medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2021-12-420-425medsovet-6379Research ArticleДИССЕРТАНТDISSERTANTАмбулаторное ведение пациентов с дискогенной пояснично-крестцовой радикулопатиейOutpatient management of patients with discogenic lumbosacral radiculopathyhttps://orcid.org/0000-0002-9372-3018ПрокоповичВ. С.ProkopovichV. S.

аспирант кафедры нервных болезней и  нейрохирургии,

119991, Москва, ул. Трубецкая, д. 8, стр. 2

Postgraduate Student, Head of the Department of Nervous Diseases and Neurosurgery, 

8, Bldg. 2, Trubetskaya St., Moscow, 119991

prokopovichvlad@yandex.ruПервый Московский государственный медицинский университет имени И.М. Сеченова (Сеченовский университет)РоссияSechenov First Moscow State Medical University (Sechenov University)Russian Federation202119092021012420425Copyright © Прокопович В.С., 20212021Прокопович В.С.Prokopovich V.S.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/6379

Введение. Дискогенная пояснично-крестцовая радикулопатия (ДПКР) встречается реже, чем поясничные скелетно-мышечные боли, но имеет более плохой прогноз и чаще сопровождается длительной инвалидностью. Большинство пациентов с ДПКР могут эффективно лечиться в условиях поликлиники, однако неясно, насколько в реальной амбулаторной практике используются эффективные консервативные методы терапии ДПКР. Цель. Проанализировать амбулаторное ведение пациентов с ДПКР, которые прошли хирургическое лечение (поясничную микродискэктомию) в связи с неэффективностью консервативной терапии. Материалы и методы. 90 пациентов (мужчины – 33, женщины – 57, средний возраст – 59,78 ± 12 лет) перенесли хирургическое лечение (микродискэктомию) в  связи с  неэффективностью консервативного ведения ДПКР. Длительность заболевания до операции колебалась от 2 до 14 нед. и составила в среднем 6 ± 3 нед. Результаты. Пациенты не были информированы о благоприятном течении ДПКР, возможности естественного (без хирургического вмешательства) регресса грыжи диска, а также целесообразности сохранять все виды активности, избегать длительного постельного режима. Только половине пациентов проводилась лечебная гимнастика. В качестве обезболивания 94,4% пациентов получали нестероидные противовоспалительные средства, 92,2% – миорелаксанты, 79,8% – комплекс витаминов группы В, при этом не использовались эпидуральные блокады с анестетиками и кортикостероидами. Относительно широко применялись неэффективные методы терапии ДПКР: паравертебральные блокады анальгетиками (42,2%), внутривенное капельное введение актовегина и (или) пентоксифиллина (26,7%), магнитотерапия и (или) лазеротерапия (36,7%). Выводы. В амбулаторной практике пациенты с ДПКР не получают эффективное консервативное лечение, что может быть причиной относительно раннего (через 6 нед.) направления на хирургическое лечение. Врачи поликлиники плохо информированы об эффективных консервативных методах терапии ДПКР. 

Disсоgenic lumbosacral radiculopathy (DLSR) is less common than lumbar musculoskeletal pains, but has a worse forecast and is more often accompanied by a long disabilities. Most patients with DLSR can effectively be treated under polyclinic conditions, but it is not clear how effective conservative methods of DLSR therapy are used in real outpatient practice. This study was carried out in order to analyze the outpatient maintenance of patients with DLSR, which were surgical treatment (lumbar microdiskectomy) due to the ineffectiveness of conservative therapy.

Materials and methods

Materials and methods. 90 patients (33 men, 57 women, average age – 59.78 ± 12) years suffered surgical treatment (microdiskectomy) due to the ineffectiveness of conservative DLSR. The duration of the disease to operation ranged from 2 to 14 weeks and was an average of 6 ± 3 weeks.

Results

Results. Patients were not informed about the favorable course of the DLSR, the possibilities of natural (without surgical intervention) of the regression of the disk hernia, as well as expediency to maintain all types of activity, avoid a long bed mode. Only half of the patients were conducted by therapeutic gymnastics. 94.4% of patients received non-steroidal anti-inflammatory funds, 92.2% – muscle relaxant, 79.8% – a complex of vitamins of group B, and epidural blockade with anesthetics and corticosteroids were not used. Relatively widely used ineffective methods of therapy of the DLSR: paravertebral blockade of analgesics (42.2%), intravenous drip administration of actovegin and/or pentoxyfalline (26.7%), magnetotherapy and/or laser and therapy (36.7%).

Conclusion

Conclusion. In an outpatient practice, patients with DLSR do not receive effective conservative treatment, which may be a reason for the early (after 6 weeks) directions for surgical treatment. Polyclinic doctors are poorly informed about the effective conservative methods of DLSR therapy.

грыжи межпозвоночного дискамагнитно-резонансная томография позвоночниканестероидные противовоспалительные средствакомплекс витаминов группы Вэпидуральное введение анестетиков и кортикостероидовпротивоэпилептические средствалечебная гимнастикамиорелаксантыdiscogenic lumbosacral radiculopathythe hernia of the intervertebral diskmagnetic resonance tomography of the spinenon-steroidal anti-inflammatory agentsa complex of vitamins of group Bepidural administration of anesthetics and corticosteroidsanti-epileptic agentsmedical gymnasticsmuscle relaxantsReferencesChou R., Qaseem A., Snow V., Casey D., Cross J.T. Jr, Shekelle P. et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–491. https://doi.org/10.7326/0003-4819-147-7-200710020-00006.Chou R., Qaseem A., Snow V., Casey D., Cross J.T. Jr, Shekelle P. et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–491. https://doi.org/10.7326/0003-4819-147-7-200710020-00006.Konstantinou K., Dunn K.M. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine. 2008;33(22):2464–2472. https://doi.org/10.1097/BRS.0b013e318183a4a2.Konstantinou K., Dunn K.M. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine. 2008;33(22):2464–2472. https://doi.org/10.1097/BRS.0b013e318183a4a2.Ropper A.H., Zafonte R.D. Sciatica. N Engl J Med. 2015;372(13):1240–1248. https://doi.org/10.1056/NEJMra1410151.Ropper A.H., Zafonte R.D. Sciatica. N Engl J Med. 2015;372(13):1240–1248. https://doi.org/10.1056/NEJMra1410151.Парфенов В.А., Исайкин А.И. Боли в поясничной области. М.; 2018. 200 с. Режим доступа: https://static-ru.insales.ru/files/1/8037/5726053/original/boli_v_pojasn_oblasti.pdf.Parfenov V.A., Isaikin A.I. Lumbar Pain. Moscow; 2018. 200 р. (In Russ.) Available at: https://static-ru.insales.ru/files/1/8037/5726053/original/boli_v_pojasn_oblasti.pdf.Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 301 Acute and Chronic Diseases and Injuries in 188 Countries, 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743–800. https://doi.org/10.1016/S0140-6736(15)60692-4.Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 301 Acute and Chronic Diseases and Injuries in 188 Countries, 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743–800. https://doi.org/10.1016/S0140-6736(15)60692-4.Suri P., Rainville J., Hunter D.J., Li L., Katz J.N. Recurrence of Radicular Pain or Back Pain after Nonsurgical Treatment of Symptomatic Lumbar Disk Herniation. Arch Phys Med Rehabil. 2012;93(4):690–695. https://doi.org/10.1016/j.apmr.2011.11.028.Suri P., Rainville J., Hunter D.J., Li L., Katz J.N. Recurrence of Radicular Pain or Back Pain after Nonsurgical Treatment of Symptomatic Lumbar Disk Herniation. Arch Phys Med Rehabil. 2012;93(4):690–695. https://doi.org/10.1016/j.apmr.2011.11.028.National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. London: National Institute for Health and Care Excellence; 2016. Available at: https://www.ncbi.nlm.nih.gov/books/NBK401577/.National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. London: National Institute for Health and Care Excellence; 2016. Available at: https://www.ncbi.nlm.nih.gov/books/NBK401577/.Qaseem A., Wilt T.J., McLean R.M., Forciea M.A. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514–530. https://doi.org/10.7326/M16-2367.Qaseem A., Wilt T.J., McLean R.M., Forciea M.A. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7): 514–530. https://doi.org/10.7326/M16-2367.Stochkendahl M.J., Kjaer P., Hartvigsen J., Kongsted A., Aaboe J., Andersen M. et al. National Clinical Guidelines for Non-Surgical Treatment of Patients with Recent Onset Low Back Pain or Lumbar Radiculopathy. Eur Spine J. 2018;27(1):60–75. https://doi.org/10.1007/s00586-017-5099-2.Stochkendahl M.J., Kjaer P., Hartvigsen J., Kongsted A., Aaboe J., Andersen M. et al. National Clinical Guidelines for Non-Surgical Treatment of Patients with Recent Onset Low Back Pain or Lumbar Radiculopathy. Eur Spine J. 2018;27(1):60–75. https://doi.org/10.1007/s00586-017-5099-2.Парфенов В.А., Яхно Н.Н., Давыдов О.С., Кукушкин М.Л., Чурюканов М.В., Головачева В.А. и др. Дискогенная пояснично-крестцовая радикулопатия. Рекомендации Российского общества по изучению боли (РОИБ). Неврология, нейропсихиатрия, психосоматика. 2020;12(4):15–24. https://doi.org/10.14412/2074-2711-2020-4-15-24.Parfenov V.A., Yakhno N.N., Davydov O.S., Kukushkin M.L., Churyukanov M.V., Golovacheva V.A. et al. Discogenic Lumbosacral Radiculopathy. Recommendations of the Russian Association for the Study of Pain (RSSP). Nevrologiya, neyropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2020;12(4):15–24. (In Russ.) https://doi.org/10.14412/2074-2711-2020-4-15-24.Vroomen P.C., de Krom M.C., Wilmink J.T., Kester A.D., Knottnerus J.A. Lack of Effectiveness of Bed Rest for Sciatica. N Engl J Med. 1999;340(6):418– 423. https://doi.org/10.1056/NEJM199902113400602.Vroomen P.C., de Krom M.C., Wilmink J.T., Kester A.D., Knottnerus J.A. Lack of Effectiveness of Bed Rest for Sciatica. N Engl J Med. 1999;340(6): 418–423. https://doi.org/10.1056/NEJM199902113400602.Pinto R.Z., Maher C.G., Ferreira M.L., Ferreira P.H., Hancock M., Oliveira V.C. et al. Drugs for Relief of Pain in Patients with Sciatica: Systematic Review and Meta-Analysis. BMJ. 2012;344:e497. https://doi.org/10.1136/bmj.e497.Pinto R.Z., Maher C.G., Ferreira M.L., Ferreira P.H., Hancock M., Oliveira V.C. et al. Drugs for Relief of Pain in Patients with Sciatica: Systematic Review and Meta-Analysis. BMJ. 2012;344:e497. https://doi.org/10.1136/bmj.e497.Rasmussen-Barr E., Held U., Grooten W.J., Roelofs P.D., Koes B.W., van Tulder M.W., Wertli M.M. Non-Steroidal Anti-Inflammatory Drugs for Sciatica. Cochrane Database Syst Rev. 2016;(10):CD012382. https://doi.org/10.1002/14651858.cd013581.Rasmussen-Barr E., Held U., Grooten W.J., Roelofs P.D., Koes B.W., van Tulder M.W., Wertli M.M. Non-Steroidal Anti-Inflammatory Drugs for Sciatica. Cochrane Database Syst Rev. 2016;(10):CD012382. https://doi.org/10.1002/14651858.cd013581.Chou R., Hashimoto R., Friedly J., Fu R., Bougatsos C., Dana T. et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-Analysis. Ann Intern Med. 2015;163(5): 373–381. https://doi.org/10.7326/M15-0934.Chou R., Hashimoto R., Friedly J., Fu R., Bougatsos C., Dana T. et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-Analysis. Ann Intern Med. 2015;163(5): 373–381. https://doi.org/10.7326/M15-0934.Chou R., Deyo R., Friedly J., Skelly A., Hashimoto R., Weimer M. et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493–505. https://doi.org/10.7326/M16-2459.Chou R., Deyo R., Friedly J., Skelly A., Hashimoto R., Weimer M. et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493–505. https://doi.org/10.7326/M16-2459.Гуща А.О., Коновалов Н.А., Древаль О.Н., Гринь А.А., Диндихадзэ Р.С., Арестов С.О. и др. Клинические рекомендации по диагностике и лечению грыж межпозвонковых дисков пояснично-крестцового отдела. М.; 2014. 20 с. Режим доступа: http://www.mst.ru/information/manual/lumbar_disc_herniation.pdf.Gushcha A.O., Konovalov N.A., Dreval O.N., Grin A.A., Dindikhadze R.S., Arestov S.O. et al. Clinical Guidelines for the Diagnosis and Treatment of Herniated Discs of Lumbosacral. Moscow; 2014. 20 p. (In Russ.) Available at: http://www.mst.ru/information/manual/lumbar_disc_herniation.pdf.Clark R.B.A., Weber R.P, Kahwati L. Surgical Management of Lumbar Radiculopathy: a Systematic Review. J Gen Intern Med. 2020;35(3):855–864. https://doi.org/10.1007/s11606-019-05476-8.Clark R.B.A., Weber R.P, Kahwati L. Surgical Management of Lumbar Radiculopathy: a Systematic Review. J Gen Intern Med. 2020;35(3):855–864. https://doi.org/10.1007/s11606-019-05476-8.Jacobs W.C., van Tulder M., Arts M., Rubinstein S.M., van Middelkoop M., Ostelo R. et al. Surgery versus Conservative Management of Sciatica due to a Lumbar Herniated Disc: A Systematic Review. Eur Spine J. 2011;20(4):513–522. https://doi.org/10.1007/s00586-010-1603-7.Jacobs W.C., van Tulder M., Arts M., Rubinstein S.M., van Middelkoop M., Ostelo R. et al. Surgery versus Conservative Management of Sciatica due to a Lumbar Herniated Disc: A Systematic Review. Eur Spine J. 2011;20(4):513–522. https://doi.org/10.1007/s00586-010-1603-7.Sun Z., Zhang M., Zhao X.H., Liu Z.H., Gao Y., Samartzis D. et al. Immune Cascades in Human Intervertebral Disc: the pros and cons. Int J Clin Exp Pathol. 2013;6(6):1009–1014. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657352/.Sun Z., Zhang M., Zhao X.H., Liu Z.H., Gao Y., Samartzis D. et al. Immune Cascades in Human Intervertebral Disc: the pros and cons. Int J Clin Exp Pathol. 2013;6(6):1009–1014. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657352/.Chiu C.C., Chuang T.Y., Chang K.H., Wu C.H., Lin P.W., Hsu W.Y. The Probability of Spontaneous Regression of Lumbar Herniated Disc: A Systematic Review. Clin Rehabil. 2015;29(2):184–195. https://doi.org/10.1177/0269215514540919.Chiu C.C., Chuang T.Y., Chang K.H., Wu C.H., Lin P.W., Hsu W.Y. The Probability of Spontaneous Regression of Lumbar Herniated Disc: A Systematic Review. Clin Rehabil. 2015;29(2):184–195. https://doi.org/10.1177/0269215514540919.Guinto F.C., Hashim H., Stumer M. CT Demonstration of Disk Regression after Conservative Therapy. AJNR. 1984;5(5):632–633. Available at: https://pubmed.ncbi.nlm.nih.gov/6435432/.Guinto F.C., Hashim H., Stumer M. CT Demonstration of Disk Regression after Conservative Therapy. AJNR. 1984;5(5):632–633. Available at: https://pubmed.ncbi.nlm.nih.gov/6435432/.Macki M., Hernandez-Hermann M., Bydon M., Gokaslan A., McGovern K., Bydon A. Spontaneous Regression of Sequestrated Lumbar Discherniations: Literature Review. Clin Neurol Neurosurg. 2014;120: 136–141. https://doi.org/10.1016/j.clineuro.2014.02.013.Macki M., Hernandez-Hermann M., Bydon M., Gokaslan A., McGovern K., Bydon A. Spontaneous Regression of Sequestrated Lumbar Discherniations: Literature Review. Clin Neurol Neurosurg. 2014;120:136–141. https://doi.org/10.1016/j.clineuro.2014.02.013.Ash L.M., Modic M.T., Obuchowski N.A., Ross J.S., Brant-Zawadzki M.N., Grooff P.N. Effects of Diagnostic Information, per se, on Patient Outcomes in Acute Radiculopathy and Low Back Pain. AJNR Am J Neuroradiol. 2008;29(6):1098–1103. https://doi.org/10.3174/ajnr.A0999.Ash L.M., Modic M.T., Obuchowski N.A., Ross J.S., Brant-Zawadzki M.N., Grooff P.N. Effects of Diagnostic Information, per se, on Patient Outcomes in Acute Radiculopathy and Low Back Pain. AJNR Am J Neuroradiol. 2008;29(6):1098–1103. https://doi.org/10.3174/ajnr.A0999.Fernandez M., Hartvigsen J., Ferreira M.L., Refshauge K.M., Machado A.F., Lemes Í.R. et al. Advice to Stay Active or Structured Exercise in the Management of Sciatica: A Systematic Review and Meta-Analysis. Spine. 2015;40(18):1457–1466. https://doi.org/10.1097/BRS.0000000000001036.Fernandez M., Hartvigsen J., Ferreira M.L., Refshauge K.M., Machado A.F., Lemes Í.R. et al. Advice to Stay Active or Structured Exercise in the Management of Sciatica: A Systematic Review and Meta-Analysis. Spine. 2015;40(18):1457–1466. https://doi.org/10.1097/BRS.0000000000001036.Rubinstein S.M., de Zoete A., van Middelkoop M., Assendelft W.J.J., de Boer M.R., van Tulder M.W. Benefits and Harms of Spinal Manipulative Therapy for the Treatment of Chronic Low Back Pain: Systematic Review and Meta-Analysis of Randomised Controlled Trials. BMJ. 2019;364:l689. https://doi.org/10.1136/bmj.l689.Rubinstein S.M., de Zoete A., van Middelkoop M., Assendelft W.J.J., de Boer M.R., van Tulder M.W. Benefits and Harms of Spinal Manipulative Therapy for the Treatment of Chronic Low Back Pain: Systematic Review and MetaAnalysis of Randomised Controlled Trials. BMJ. 2019;364:l689. https://doi.org/10.1136/bmj.l689.Van Tulder M.W., Touray T., Furlan A.D., Solway S., Bouter L.M. Muscle Relaxants for Non-Specific Low Back Pain. Cochrane Database Syst Rev. 2003;(2):CD004252. https://doi.org/10.1002/14651858.cd004252.Van Tulder M.W., Touray T., Furlan A.D., Solway S., Bouter L.M. Muscle Relaxants for Non-Specific Low Back Pain. Cochrane Database Syst Rev. 2003;(2):CD004252. https://doi.org/10.1002/14651858.cd004252.Enke O., New H.A., New C.H., Mathieson S., McLachlan A.J., Latimer J. et al. Anticonvulsants in the Treatment of Low Back Pain and Lumbar Radicular Pain: A Systematic Review and Meta-Analysis. CMAJ. 2018;190(26): E786–E793. https://doi.org/10.1503/cmaj.171333.Enke O., New H.A., New C.H., Mathieson S., McLachlan A.J., Latimer J. et al. Anticonvulsants in the Treatment of Low Back Pain and Lumbar Radicular Pain: A Systematic Review and Meta-Analysis. CMAJ. 2018;190(26):E786– E793. https://doi.org/10.1503/cmaj.171333.Calderon-Ospina C.A., Nava-Mesa M.O., Arbeláez Ariza C.E. Effect of Combined Diclofenac and B Vitamins (Thiamine, Pyridoxine, and Cyanocobalamin) for Low Back Pain Management: Systematic Review and Meta-analysis. Pain Med. 2020;21(4):766–781. https://doi.org/10.1093/pm/pnz216.Calderon-Ospina C.A., Nava-Mesa M.O., Arbeláez Ariza C.E. Effect of Combined Diclofenac and B Vitamins (Thiamine, Pyridoxine, and Cyanocobalamin) for Low Back Pain Management: Systematic Review and Meta-analysis. Pain Med. 2020;21(4):766–781. https://doi.org/10.1093/pm/pnz216.Иванова М.А., Парфенов В.А., Исайкин А.И. Хирургические и консервативные методы лечения дискогенной поясничной радикулопатии. Неврология, нейропсихиатрия, психосоматика. 2019;11(2S):40–45. https://doi.org/10.14412/2074-2711-2019-2S-40-45.Ivanova M.A., Parfenov V.A., Isaikin A.O. Surgical and Medical Treatments for Discogenic Low Back Radiculopathy. Nevrologiya, neyropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2019;11(2S):40– 45. (In Russ.) https://doi.org/10.14412/2074-2711-2019-2S-40-45.

The authors declare that there are no conflicts of interest present.