Боль в шее: особенности диагностики и терапии

Боль в шее – довольно распространенная жалоба на приеме врача, в год частота ее возникновения составляет 10–21%. Она стоит на четвертом месте среди причин инвалидизации, почти 50% пациентов продолжают испытывать неприятные ощущения или повторные эпизоды болей. Наиболее подвержены боли в шее пожилые люди, что связанно с прогрессирующими дегенеративными изменениями фасеточных суставов и межпозвонковых дисков. Однако причины у данного симптома могут быть самые разные. Диагностика при цервикалгии направлена прежде всего на исключение симптоматических болей, связанных с  тяжелой соматической патологией, иммунными заболеваниями, инфекциями и  онкологией. Коморбидные заболевания и факторы риска могут сочетаться между собой, обусловливая полиэтиологический болевой синдром. Основными этапами в алгоритме диагностики цервикалгии являются: подробный сбор жалоб и анамнеза, физикальное обследование и неврологический осмотр, а также визуализационные методы. Визуализация и электродиагностические методы далеко не всегда оказываются информативны у пациентов с хронической цервикалгией и при дегенеративной этиологии синдрома. Проведение МРТ и  консультацию хирурга необходимо рекомендовать пациентам с  ухудшением неврологической симптоматики или длительной постоянной болью. Консервативная терапия цервикалгии подразумевает сочетание немедикаментозных (соблюдение режима, ортопедическое лечение, ЛФК, физиотерапия и т. д.) и лекарственных методов. Последние зависят от наличия нейропатического компонента боли и  длительности болевого синдрома. Терапия боли ноцицептивного характера обычно подразумевает комбинацию нестероидных противовоспалительных средств, неопиоидных анальгетиков и миорелаксантов. Тогда как при нейропатических болях препаратами первой линии являются трициклические антидепрессанты, дулоксетин, венлафаксин, прегабалин, габапентин. Успех терапии зависит от правильной индивидуальной оценки факторов возникновения боли, ее хронизации и возможных осложнений лечения. Терапевтический прогноз острой неспецифической цервикалгии обычно хороший, однако он становится менее предсказуемым, если боли приобретают хронический характер.

1. Vasseljen O., Woodhouse A., Bjørngaard J.H., Leivseth L. Natural course of acute neck and low back pain in the general population: the HUNT study. Pain. 2013;154(8):1237–1244. https://doi.org/10.1016/j.pain.2013.03.032.

2. Binder A. The diagnosis and treatment of nonspecific neck pain and whiplash. Eura Medicophys. 2007;43(1):79–89. Available at: https://www.minervamedica. it/en/journals/europa-medicophysica/article.php?cod=R33Y2007N01A0079.

3. Murray C.J., Atkinson C., Bhalla K., Birbeck G., Burstein R., Chou D. et al. The state of US health, 1990–2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591–608. https://doi.org/10.1001/jama.2013.13805.

4. Carroll L.J., Hogg-Johnson S., van der Velde G., Haldeman S., Holm L.W., Carragee E.J. et al. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;33(4 Suppl.):S75–S82. https://doi.org/10.1097/BRS.0b013e31816445be.

5. Côté P., Cassidy D.J., Carroll L.J., Kristman V. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain. 2004;112(3):267–273. https://doi.org/10.1016/j.pain.2004.09.004.

6. Cohen S.P. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015;90(2):284–299. https://doi.org/10.1016/j.mayocp.2014.09.008.

7. Guzman J., Hurwitz E.L., Carroll L.J., Haldeman S., Côté P., Carragee E.J. et al. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;33(4 Suppl.):S14–S23. https://doi.org/10.1097/BRS.0b013e3181643efb.

8. Childress M.A., Stuek S.J. Neck Pain: Initial Evaluation and Management. Am Fam Physician. 2020;102(3):150–156. Available at: https://www.aafp. org/afp/2020/0801/p150.html.

9. Nilsen T.I., Holtermann A., Mork P.J. Physical exercise, body mass index, and risk of chronic pain in the low back and neck/shoulders: longitudinal data from the Nord-Trondelag Health Study. Am J Epidemiol. 2011;174(3):267–273. https://doi.org/10.1093/aje/kwr087.

10. Kääriä S., Laaksonen M., Rahkonen O., Lahelma E., Leino-Arjas P. Risk factors of chronic neck pain: a prospective study among middle-aged employees. Eur J Pain. 2012;16(6):911–920. https://doi.org/10.1002/j.1532-2149.2011.00065.x.

11. Bodin J., Ha C., Sérazin C., Descatha A., Leclerc A., Goldberg M., Roquelaure Y. Effects of individual and work-related factors on incidence of shoulder pain in a large working population. J Occup Health. 2012;54(4):278–288. https://doi.org/10.1539/joh.11-0262-oa.

12. Hogg-Johnson S., van der Velde G., Carroll L.J., Holm L.W., Cassidy J.D., Guzman J. et al. The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. 2009;32(2 Suppl.):S46–S60. https://doi.org/10.1016/j.jmpt.2008.11.010.

13. Holm L.W., Carroll L.J., Cassidy J.D., Hogg-Johnson S., Côté P., Guzman J. et al. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;33(4 Suppl.):S52–S59. https://doi.org/10.1097/ BRS.0b013e3181643ece.

14. Воробьева О.В. Цервикальная радикулопатия: диагностика и терапия. Эффективная фармакотерапия. Неврология и психиатрия. 2012;(2):40–44. Режим доступа: https://umedp.ru/articles/tservikalnaya_radikulopatiya_ diagnostika_i_terapiya.html. Vorobieva O.V. Cervical radiculopathy: diagnosis and therapy. Effektivnaya farmakoterapiya. Nevrologiya i psikhiatriya = Effective Pharmacotherapy. Neurology and Psychiatry. 2012;(2):40–44. (In Russ.) Available at: https://umedp.ru/articles/tservikalnaya_radikulopatiya_diagnostika_i_terapiya.html.

15. Rodine R.J., Vernon H. Cervical radiculopathy: a systematic review on treatment by spinal manipulation and measurement with the Neck Disability Index. J Can Chiropr Assoc. 2012;56(1):18–28. Available at: https://www.ncbi. nlm.nih.gov/pmc/articles/PMC3280115/.

16. Murphy D.R., Hurwitz E.L., Gregory A., Clary R. A nonsurgical approach to the management of patients with cervical radiculopathy: a prospective observational cohort study. J Manipulative Physiol Ther. 2006;29(4):279–287. https://doi.org/10.1016/j.jmpt.2006.03.005.

17. Liu R., Kurihara C., Tsai H.T., Silvestri P.J., Bennett M.I., Pasquina P.F., Cohen S.P. Classification and Treatment of Chronic Neck Pain: A Longitudinal Cohort Study. Reg Anesth Pain Med. 2017;42(1):52–61. https://doi.org/10.1097/ AAP.0000000000000505.

18. Grijalva R.A., Hsu F.P., Wycliffe N.D., Tsao B.E., Williams P., Akpolat Y.T., Cheng W.K. Hoffmann sign: clinical correlation of neurological imaging findings in the cervical spine and brain. Spine (Phila Pa 1976). 2015;40(7):475–479. https://doi.org/10.1097/BRS.0000000000000794.

19. Cook C., Roman M., Stewart K.M., Leithe L.G., Isaacs R. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction. J Orthop Sports Phys Ther. 2009;39(3):172–178. https://doi.org/10.2519/jospt.2009.2938.

20. Davies B.M., Mowforth O.D., Smith E.K., Kotter M.R. Degenerative cervical myelopathy. BMJ. 2018;360:k186. https://doi.org/10.1136/bmj.k186.

21. Childress M.A., Becker B.A. Nonoperative Management of Cervical Radiculopathy. Am Fam Physician. 2016;93(9):746–754. Available at: https://www.aafp.org/afp/2016/0501/p746.html.

22. Matsumoto M., Fujimura Y., Suzuki N., Nishi Y., Nakamura M., Yabe Y., Shiga H. MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg Br. 1998;80(1):19–24. https://doi.org/10.1302/0301- 620x.80b1.7929.

23. Fennessy J., Wick J., Scott F., Roberto R., Javidan Y., Klineberg E. The Utility of Magnetic Resonance Imaging for Detecting Unstable Cervical Spine Injuries in the Neurologically Intact Traumatized Patient Following Negative Computed Tomography Imaging. Int J Spine Surg. 2020;14(6):901–907. https://doi.org/10.14444/7138.

24. MacDermid J.C., Walton D.M., Bobos P., Lomotan M., Carlesso L. A Qualitative Description of Chronic Neck Pain has Implications for Outcome Assessment and Classification. Open Orthop J. 2016;10:746–756. https://doi.org/10.2174/1874325001610010746.

25. Bono C.M., Ghiselli G., Gilbert T.J., Kreiner D.S., Reitman C., Summers J.T. et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011;11(1):64–72. https://doi.org/10.1016/j.spinee.2010.10.023.

26. Radhakrishnan K., Litchy W.J., O’Fallon W.M., Kurland L.T. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117(Pt 2):325–335. https://doi. org/10.1093/brain/117.2.325.

27. Gross A., Langevin P., Burnie S.J., Bédard-Brochu M.S., Empey B., Dugas E. et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;(9):CD004249. https://doi.org/10.1002/14651858.CD004249.pub4.

28. Vernon H., Humphreys K., Hagino C. Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials. J Manipulative Physiol Ther. 2007;30(3):215–227. https://doi.org/10.1016/j.jmpt.2007.01.014.

29. Bronfort G., Evans R., Anderson A.V., Svendsen K.H., Bracha Y., Grimm R.H. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med. 2012;156(1 Pt 1):1–10. https://doi.org/10.7326/0003-4819-156-1-201201030-00002.

30. Barreto T.W., Svec J.H. Chronic Neck Pain: Nonpharmacologic Treatment. Am Fam Physician. 2019;100(3):180–182. Available at: https://www.aafp. org/afp/2019/0801/p180.html.

31. Trinh K., Graham N., Irnich D., Cameron I.D., Forget M. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2016;(5):CD004870. https://doi. org/10.1002/14651858.CD004870.pub4.

32. Young I.A., Michener L.A., Cleland J.A., Aguilera A.J., Snyder A.R. Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Phys Ther. 2009;89(7):632–642. https://doi. org/10.2522/ptj.20080283.

33. Berger A.A., Liu Y., Mosel L., Champagne K.A., Ruoff M.T., Cornett E.M. et al. Efficacy of Dry Needling and Acupuncture in the Treatment of Neck Pain. Anesth Pain Med. 2021;11(2):e113627. https://doi.org/10.5812/aapm.113627.

34. Gattie E.R., Cleland J.A., Snodgrass S.J. Dry Needling for Patients with Neck Pain: Protocol of a Randomized Clinical Trial. JMIR Res Protoc. 2017;6(11):e227. https://doi.org/10.2196/resprot.7980.

35. Gattie E., Cleland J.A., Snodgrass S. The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017;47(3):133–149. https://doi.org/10.2519/jospt.2017.7096.

36. Kroeling P., Gross A., Graham N., Burnie S.J., Szeto G., Goldsmith C.H. et al. Electrotherapy for neck pain. Cochrane Database Syst Rev. 2013;(8):CD004251. https://doi.org/10.1002/14651858.CD004251.pub5.

37. Finnerup N.B., Attal N., Haroutounian S., McNicol E., Baron R., Dworkin R.H. et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162–173. https://doi. org/10.1016/S1474-4422(14)70251-0.

38. Duehmke R.M., Derry S., Wiffen P.J., Bell R.F., Aldington D., Moore R.A. Tramadol for neuropathic pain in adults. Cochrane Database Syst Rev. 2017;6(6):CD003726. https://doi.org/10.1002/14651858.CD003726.pub4.

39. Ghasemi M., Masaeli A., Rezvani M., Shaygannejad V., Golabchi K., Norouzi R. Oral prednisolone in the treatment of cervical radiculopathy: A randomized placebo controlled trial. J Res Med Sci. 2013;18(1 Suppl.):S43–S46. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743318/.

40. Alentado V.J., Lubelski D., Steinmetz M.P., Benzel E.C., Mroz T.E. Optimal duration of conservative management prior to surgery for cervical and lumbar radiculopathy: a literature review. Global Spine J. 2014;4(4):279–286. https://doi.org/10.1055/s-0034-1387807.

41. Lavelle E.D., Lavelle W., Smith H.S. Myofascial trigger points. Anesthesiol Clin. 2007;25(4):841–851. https://doi.org/10.1016/j.anclin.2007.07.003.

42. Chen C.K., Nizar A.J. Myofascial pain syndrome in chronic back pain patients. Korean J Pain. 2011;24(2):100–104. https://doi.org/10.3344/kjp.2011.24.2.100.

43. Manchikanti L., Kaye A.D., Boswell M.V., Bakshi S., Gharibo C.G., Grami V. et al. A Systematic Review and Best Evidence Synthesis of the Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. Pain Physician. 2015;18(4):E535–582. Available at: https://www.painphysicianjournal.com/linkout?issn=&vol=18&page=E535.

44. Langevin P., Peloso P.M., Lowcock J., Nolan M., Weber J., Gross A. et al. Botulinum toxin for subacute/chronic neck pain. Cochrane Database Syst Rev. 2011;(7):CD008626. https://doi.org/10.1002/14651858.CD008626.pub2.

45. Antman E.M., Bennett J.S., Daugherty A., Furberg C., Roberts H., Taubert K.A. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007;115(12): 1634–1642. https://doi.org/10.1161/CIRCULATIONAHA.106.181424.

46. Grosser T., Fries S., FitzGerald G.A. Biological basis for the cardiovascular consequences of COX-2 inhibition: therapeutic challenges and opportunities. J Clin Invest. 2006;116(1):4–15. https://doi.org/10.1172/JCI27291.

47. Suleyman H., Cadirci E., Albayrak A., Halici Z. Nimesulide is a selective COX-2 inhibitory, atypical non-steroidal anti-inflammatory drug. Curr Med Chem. 2008;15(3):278–283. https://doi.org/10.2174/092986708783497247.

48. Caiazzo E., Ialenti A., Cicala C. The relatively selective cyclooxygenase-2 inhibitor nimesulide: What’s going on? Eur J Pharmacol. 2019;848:105–111. https://doi.org/10.1016/j.ejphar.2019.01.044.

49. Kress H.G., Baltov A., Basiński A., Berghea F., Castellsague J., Codreanu C. et al. Acute pain: a multifaceted challenge – the role of nimesulide. Curr Med Res Opin. 2016;32(1):23–36. https://doi.org/10.1185/03007995.2015.1100986.

50. Helin-Salmivaara A., Saarelainen S., Grönroos J.M., Vesalainen R., Klaukka T., Huupponen R. Risk of upper gastrointestinal events with the use of various NSAIDs: a case-control study in a general population. Scand J Gastroenterol. 2007;42(8):923–932. https://doi.org/10.1080/00365520701192326.

51. Laporte J.R., Ibáñez L., Vidal X., Vendrell L., Leone R. Upper gastrointestinal bleeding associated with the use of NSAIDs: newer versus older agents. Drug Saf. 2004;27(6):411–420. https://doi.org/10.2165/00002018-200427060-00005.

52. Castellsague J., Pisa F., Rosolen V., Drigo D., Riera-Guardia N., Giangreco M. et al. Risk of upper gastrointestinal complications in a cohort of users of nimesulide and other nonsteroidal anti-inflammatory drugs in Friuli Venezia Giulia, Italy. Pharmacoepidemiol Drug Saf. 2013;22(4):365–375. https://doi.org/10.1002/pds.3385.