Nowadays, almost every adult experiences some form of back pain from time to time. As the body ages, various types of changes are also inevitable in the spine due to the fact that it constantly bears a considerable load.
Taking care of the spine means taking care of youth
The most common chronic diseases today are considered to be degenerative-dystrophic changes in the spine . The concept of “degenerative-dystrophic changes” implies direct destruction of vertebral tissues (degeneration) and metabolic disorders in them (dystrophy).
Such diseases are quite serious; they can cause not only the loss of a person’s normal working capacity, but also disability if medical help is not sought in time. These diseases are difficult to treat, especially in the later stages. Therefore, you need to try to protect your back as much as possible.
Changes in the spine of a degenerative-dystrophic nature manifest themselves in the form of many diseases. The main problems are:
These are just the main diseases that are caused by degenerative processes in the spine. Moreover, such changes may also combine very different variations.
Obvious risk factors for degenerative change
First of all, it must be said that the process of degenerative changes is associated in most cases with aging of the discs. It may also be caused by a deterioration in blood supply and metabolic processes in a certain area of the spinal column. All this, in turn, has its reasons. Namely:
Back pain is the main symptom of spinal problems
We can talk about the symptoms inherent in degenerative-dystrophic processes in the spine for a long time. There are many of them, and for each individual case and specific disease they are different. Although we can highlight the most basic ones. This:
Such changes in the spine, such as degenerative-dystrophic ones, occur over quite a long time.
Therefore, it is quite difficult to detect them at a very early stage. For this reason, they can often cause various complications.
This may be arthrosis, osteochondropathy, arthritis, scoliosis, intervertebral hernia, ischemia, paresis, paralysis.
Manual therapy is an effective method of treating degenerative changes
Due to the fact that degenerative processes occurring in the spine can cause various diseases, treatment is also expected to be completely different. First of all, it is aimed at eliminating the root cause . It can be conservative and surgical, as with many other diseases of the human body.
Conservative treatment of degenerative processes in the spine may include:
In some cases, a method such as percutaneous nucleotomy is used. It is a puncture biopsy aimed at reducing the volume of the affected intervertebral disc. This method is borderline between surgical and conservative treatment and has many contraindications.
Surgery is prescribed in the most difficult cases, when the disease is severely advanced, rapidly progressing, has neurological symptoms and severe pain, as well as when conservative methods are completely ineffective.
In order to prevent the development of degenerative-dystrophic processes, it is necessary to engage in their prevention.
It includes multiple measures, including avoiding excessive exercise, a sedentary lifestyle, and spinal injuries; regular gymnastics and so on.
Degenerative spinal diseases are a group of diseases that result in the loss of normal structure and function in the spine. These common disorders are associated with the effects of aging, but can also be caused by infection, tumors, muscle strains, or arthritis.
Pressure on the spinal cord and nerve roots associated with osteochondrosis can be caused by:
The discs between the bones of the spine are made of cartilage, connective tissue and water. With age, these discs can weaken and can become flattened, bulge, or break. Intervertebral disc herniation, a common cause of pain associated with degenerative disc disease, occurs when the fibrous part of the disc weakens and the disc's nucleus pushes through and puts pressure on nearby nerves. Additionally, a degenerating disc can also cause bony swelling, which can put additional pressure on the spinal cord.
Spinal stenosis, or narrowing of the spinal canal, is a condition potentially more serious than degenerative diseases. As the spinal canal contracts, the spine and nerves can become significantly compressed and irritated, causing both back pain and pain that spreads to other parts of the body, depending on the location of the pressure on the nerves.
The primary symptoms of degenerative spinal diseases are acute and/or chronic pain, weakness, limited movement and sensory loss. If osteochondrosis leads to compression or injury to the spinal cord, weakness and limited movement may increase significantly. Loss of bladder and bowel function and problems with sexual function may also occur as the problem gets worse. Specific symptoms often depend on the location of the structural problems in the spine.
The diagnosis often begins with a spine x-ray, which does not show discs, but may show other structural changes in the spine. Magnetic resonance imaging (MRI) scans are the main means of diagnosis because they can show the disc in detail and allow doctors to see the nerves and spinal canal spaces and how they are affected by the disease. Computed tomography (CT) scan may also be used. However, the diagnosis of back problems, even with MRI, can be complicated by false positives and cases in which the scans do not correlate well with the patient? symptoms.
Treatment for dystrophic diseases of the spine depends on the severity of the condition. In most cases, the problem is not severe enough to require invasive treatment. The first line of treatment is rest, oral pain, and physical therapy to strengthen the back muscles and improve flexibility and range of motion. Also, are minimally invasive spinal procedures, such as epidural steroid injections or pain medications, used to isolate the source of pain and provide temporary pain relief? physical therapy is more productive in patients with severe pain. Non-invasive and minimally invasive procedures will provide pain relief for the vast majority of patients.
Surgery may eventually be required as a condition of progress. Surgery is indicated for patients with severe chronic pain, nerve deficits, and loss of bladder and bowel control. Additionally, surgery may be considered in patients who have not responded to less invasive treatments and for patients who have personal structural abnormalities that can be effectively corrected.
The surgical procedures used vary depending on the type and severity of the condition. In some patients, a herniated disc can be surgically repaired to restore normal anatomy. In other patients, the disc that is causing the pain or the bone placing pressure on the spinal cord must be removed. In patients with spinal stenosis, for example, only surgery to relieve pressure on the spinal cord can provide relief within a noticeable period. The tear is removed by tissue, whether a disc or bone, then bridged through a process called spinal fusion. Metal devices are used to stabilize the spine, and then bones taken from another part of the body or from a bone bank are secured to encourage the bone to grow throughout the scale. Bone growth can be promoted with bone morphogenic protein, a biological product that stimulates the creation of new bone tissue. The results of the surgery are usually excellent, and most patients return to normal activities within a few weeks.
Degenerative diseases of the spine, their complications and treatment
Professor A.S. Nikiforov*, Ph.D. O.I. Mendel
Department of Nervous Diseases and Neurosurgery, Moscow
The main cause of dorsopathies, in particular LBP, in most cases is recognized as degenerative-dystrophic changes in the spine - osteochondrosis and spondyloarthrosis, which are characterized primarily by manifestations of degeneration of the intervertebral discs and facet joints with subsequent involvement of ligaments, muscles, tendons and fascia in the process, and in further and spinal roots and spinal nerves.
Destruction of cartilage tissue of both intervertebral discs and facet joints, which occurs during degenerative processes in the spine , is accompanied by pain. Moreover, over time, relapsing pain syndrome can become chronic and, as a rule, leads to significant biomechanical disorders.
Anatomical and physiological features of the spine
An anatomical complex consisting of one intervertebral vertebrae adjacent to it , the ligamentous apparatus connecting them and the facet joints is usually called the spinal motion segment (SMS).
The intervertebral disc (IVD) consists of a nucleus pulposus surrounded by an annulus fibrosus. The nucleus pulposus has a zlip-shaped shape and consists of an amorphous hydrophilic intercellular substance and cartilage cells - chondrocytes. In newborns, the nucleus pulposus contains up to 88% water, in an adult - about 70%. The fibrous ring is formed by bundles of intertwining collagen and elastic fibers, the ends of which grow into the marginal border of the vertebral . The intervertebral disc is delimited from the vertebral by connective tissue marginal plastics.
along the anterior surface of the spine , which is loosely connected to the forward-facing edge of the intervertebral disc and is firmly attached to the anterior surface of the vertebral . The spinal canal contains the posterior longitudinal ligament, which forms the ventral wall of the spinal canal. It is loosely connected to the posterior surface of the vertebral and tightly fused with the intervertebral discs. This ligament, massive in the central part, becomes thinner towards the edges as it approaches the intervertebral foramina. The anterior wall of the intervertebral foramina is formed by notches in the bodies of adjacent vertebrae . Their posterior wall is formed by paired lower and upper articular processes extending from the vertebral arches and moving towards each other, connecting to each other through small facet joints. The articular surfaces of the processes (faceted menisci) are covered with cartilage tissue. The connective tissue capsules of the facet joints have an internal, synovial layer. In addition to the facet joints, the arches of adjacent vertebrae are held together by massive, elastic yellow ligaments that participate in the formation of the posterior wall of the spinal canal. Spinal nerves, formed after the union of the posterior and anterior spinal roots, as well as radicular vessels pass through intervertebral All structures of the SMS are innervated mainly by the recurrent (meningeal) branches of the spinal nerves (Luschka nerves).
In humans, the spinal column experiences a lot of stress. This is due to the fact that most of a person’s life is in an upright position, and besides, he lifts and carries heavy objects. Particularly pronounced pressure falls on the IVD of the lumbar and cervical spine , which also have significant mobility. In 15 each MPS, which performs the function of an articular joint, the main point of support is the nucleus pulposus. Due to the elasticity of the nucleus pulposus, part of the energy of the pressure it experiences is transferred to the fibrous ring, thus causing its tension. Both the IVD and the paired facet joints, as well as the associated muscles and ligamentous apparatus, do a lot of work aimed at ensuring statics and mobility of the spine . At the same time, they are normally adapted to mechanical loads and range of motion that are determined by the degree of severity.
The IVD, which functions as a kind of joint, and the facet joints, which are part of the PDS, have much in common both in function and in the structure of their constituent tissues. The cartilage tissue of the IVD and facet joints consists of intercellular substance, which forms its matrix, and cartilage cells - chondrocytes, which play a key role in maintaining the balance between anabolic and catabolic processes in cartilage. At the same time, the proteoglycans of the IVD and the cartilage tissue of the facet joints, represented by chondroitin sulfates, are homologous to the proteoglycans of the cartilage of the peripheral joints. The above allows us to recognize that it is probable that the processes of degeneration in the intervertebral discs and in the facet joints, as well as in the peripheral joints, do not have fundamental differences [12].
The term "osteochondrosis" was proposed in 1933 by the German orthopedist Hildebrandt to refer to involutional changes in the musculoskeletal system. In the 60-90s of the last century, spinal was recognized as the main cause of pain in the spine and paravertebral tissues, as well as radicular syndromes.
The elastic properties of the IVD normally provide significant mitigation of shocks and shocks that occur during walking, jumping and other movements. However, over the years, the disc “wears out” and gradually loses its elasticity. of the intervertebral that occurs in people over 20 years of age , after which the blood supply to the disc is subsequently carried out only due to diffusion from the vessels of the parenchyma of the adjacent vertebral , while it may be insufficient to ensure regenerative processes in the disc. In the process of IVD, first of all, dehydration of the nucleus pulposus occurs, a decrease in its turgor, which increases the load on the fibrous ring, gradually causes its stretching, disintegration, the formation of cracks in it and over time leads to protrusion of IVD tissue beyond the edges of the bodies adjacent vertebrae to it . In this case, another microtrauma or (not always significant) additional load on the SMS may be accompanied by an increase in the severity of IVD protrusion.
Protrusion of the IVD forward is accompanied by tension in the anterior longitudinal ligament. At the level of the protruding disc, this ligament stretches and takes on an arched shape. vertebrae adjacent to the disc . As a result, gradual ossification of the anterior longitudinal ligament occurs, which is manifested by the formation of anterior osteophytes, which have the form of beak-shaped bone growths directed towards each other. This process is usually painless, since the anterior longitudinal ligament is poor in pain receptors. However, its increasing ossification over time increasingly limits the mobility of the spinal column.
Protrusion of the IVD backwards leads to displacement in the same direction (like a drawer being pulled out) of the fragment of the posterior longitudinal ligament fused to the disc. The growing osteophytes, emanating from the posterior sections of the marginal border of the vertebral bodies, stretch in the horizontal direction along the surfaces of the intervertebral disc protruding towards the spinal canal, and at the same time turn out to be parallel to each other. Such changes in the spine , along with the narrowing of the intervertebral space that usually occurs simultaneously and the sometimes resulting penetration of IVD fragments into the parenchyma of the vertebral bodies (Schmorl's hernias), are obligate signs of osteochondrosis.
Schmorl's hernias, protrusion of the IVD forward and the formation of anterior coracoid osteophytes usually do not cause pain, whereas when the IVD is displaced backward, irritation of the posterior longitudinal ligament, rich in pain receptors, occurs, which leads to pain syndrome (local pain and tenderness).
A feeling of pain is usually the first sign of spinal , for which the patient consults a doctor. At this stage, when examining the patient, pain in the spinous processes and paravertebral points at the level of discopathy is revealed, as well as tension (“defense”) of the paravertebral muscles, leading to limited mobility of the spine and its straightening. All these clinical manifestations not only signal a pathological process, but also help clarify its location and nature. Depending on the level of the affected PDS, the clinical picture revealed in such cases can be characterized as cervicalgia, lumbodynia, or thoracalgia, which is rare in osteochondrosis. Exacerbations of clinical manifestations of osteochondrosis usually occur under the influence of provoking factors and alternate with remissions. Over time, the hernial protrusion of the IVD towards the spinal canal increases. The next exacerbation, caused by additional protrusion of the IVD, may be accompanied by perforation of the posterior longitudinal ligament. In such cases, the IVD tissue penetrates the idural space and usually irritates the posterior (sensitive) spinal root. In this case, radicular pain , usually radiating along the corresponding peripheral nerves, and tension symptoms appear (symptoms of Neri, Lasegue, etc.). Especially often in cases where the lower lumbar SMS are affected by osteochondrosis, in a patient who previously suffered from exacerbations of the disease that occurred like lumbodynia, after perforation of a posterolateral hernia of the posterior longitudinal ligament, signs of lumbar ischialgia appear. Along with irritation of the spinal root, the cause of radicular pain (usually in cases where it becomes particularly protracted) can be an autoimmune, inflammatory process that occurs as aseptic epiduritis [5|.
Sometimes in patients with a herniated intervertebral disc, during the next exacerbation of the disease, a vascular-radicular conflict occurs, leading to ischemia of the compressed spinal nerve with the development in the corresponding zone of decreased sensitivity in a certain dermatome and muscle strength in the corresponding myotome. If the victim is the radicular-medullary artery, that is, the radicular artery involved in the blood supply to the spinal cord, then a clinical picture of acute myelischemia or chronic discirculatory myelopathy may occur, usually at the cervical or lumbosacral level, usually dooming the patient to disability. In the latter case, due to compression and stenosis of the Adamkiewicz or Deproj-Hutteron artery, the development of syndromes - “intermittent claudication” of the spinal cord or cauda equina is characteristic.
The diagnosis of osteochondrosis is facilitated by the results of spondylography, which usually reveals changes in the configuration of the spine , narrowing of the intervertebral spaces, and the development of marginal osteophytes emanating from the vertebral . During spondylography, vertebral (various variants of spondylolisthesis) and congenital anomalies of the spine , in particular, vertebral , sacralization of L, or lumbarization of the S vertebra, which are factors provoking the development of osteochondrosis. Imaging examination methods are very informative when diagnosing osteochondrosis. In this case, on a CT scan you can see the intervertebral disc and the degree of its protrusion into the spinal canal. The results of MRI are especially clear, allowing one to judge not only the condition of the vertebrae and intervertebral disc, but also their relationship to other structures of the SMS, as well as to the spinal nerve roots, spinal nerves and the dura mater.
For some time now, neurologists have begun to pay more and more attention to the fact that local back pain, radicular syndrome and vascular-radicular disorders can occur in the absence of a herniated intervertebral disc. In such cases, the main cause of local pain, radicular or vascular-radicular syndromes is often the development of deforming spondyloarthrosis, the basis of which is arthrosis of the intervertebral facet joints. It is believed that spondyloarthrosis is the main cause of dorsalgia in 20% of degenerative-dystrophic pathologies of the spine , and in people over 65 years of age in 65% (4).
Osteochondrosis and spondylosis deformans are provoked by identical pathogenetic factors, primarily physical overload of the posterior sections of the SMS; in this case, a possible cause of such overload may be a static disorder of the spine . Spondyloarthrosis deformans, as a rule, is combined with osteochondrosis and often manifests itself at an early stage of its development, and sometimes significantly ahead of the clinical manifestations of discopathy. Spondylosis, like osteochondrosis, most often develops at the level of the cervical or lumbar SMS.
Arthrosis of the facet joints can be one of the manifestations of common osteoarthritis. In the degenerative-dystrophic process in the spine, the biochemical changes that occur in the facet joint have much in common with similar changes in the intervertebral disc caused by osteochondrosis. At the early stage of spondyloarthrosis, the cartilage thickens, and subsequently it thins; gradually the entire joint is involved in the process, including its synovial membrane, capsule, ligaments, as well as nearby muscles.
In the clinical picture of spondyloarthrosis, local pain and tenderness, usually bilateral, predominantly paravertebral localization, accompanied by manifestations of myofascial syndrome at the level of the affected SMS, can be leading for a long time. This syndrome is characterized by severe tension and soreness of certain muscle bundles and fascia, especially significant within the trigger zones, irritation of which provokes pain reactions.
In most cases, the development of deforming spondyloarthrosis is accompanied by a feeling of awkwardness, discomfort in the spine , static disorder, and limited mobility. A crunching sound that occurs during movements in the affected SMS is characteristic. As the disease , pain in the affected SMS becomes more frequent and intensifies, and hardening and soreness of the paravertebral muscles that are part of the corresponding myotomes is determined. The development of spondyloarthrosis is accompanied by flattening of the physiological curves of the spine . Exacerbation of pain is often provoked by prolonged standing, as well as an attempt to straighten the spine , especially if it is combined with its rotation. Changes in the position of the torso with spondyloarthrosis can cause a temporary dulling of pain, which sometimes prompts the patient to frequently change position, thus trying to reduce the feeling of discomfort and pain in the spine . In some cases, the pain subsides when bending forward and while walking.
Increasing narrowing of the intervertebral foramen leads to irritation of the spinal nerve passing through it and to the development of radicular syndrome, characterized by pain radiating along the course of a certain peripheral nerve, and also leads to the possible extinction of the reflex, in the formation of the arc of which this nerve takes part, and the appearance of tension symptoms. Exacerbation of clinical manifestations of snondyloarthrosis usually has an intermittent course.
Spondylography for deforming spondyloarthrosis reveals straightening of the physiological curves of the spine , deformation of the contours of the facet joints, sclerosis of the subchondral areas of bone tissue, and a decrease in the lumen of the intervertebral foramina. Particularly pronounced signs of deforming spondyloarthrosis are detected in the SDS at the level of the cervical (C4-C5 and C5-C6) and lumbosacral (L4-L5, and L5-S1) spine .
Pharmacological treatment of osteochondrosis
and deforming spondyloarthrosis and their complications
When treating spondylogenic dorsopathy in the acute period, the main goal is to relieve pain and restore the biomechanics of the spine . Carrying out such treatment makes it possible to prevent the development of a pathological motor stereotype in the patient and, if possible, to begin rehabilitation measures earlier.
In the process of treating moderate pain caused by degenerative diseases and their complications , in most cases you can use the proposed O.S. Levin |1| approximate algorithm:
Days 1-2 of treatment - strict bed rest, use of analgesics, which should be administered hourly, without waiting for the pain to worsen; It is also advisable to use muscle relaxants;
Days 2-10 - semi-bed rest, same pharmacotherapy plus moderate exercise, physiotherapy;
Days 10-20 - active motor mode, possibly with partial restrictions, analgesics - as needed, therapy , massage, in the absence of contraindications - elements of manual therapy;
Day 20-40 - active motor regimen, therapy , restorative exercise.
It should be borne in mind that prolonged bed rest can contribute to the transformation of acute pain into a chronic one, and also increases the likelihood of the patient developing various psycho-emotional disorders. Therefore, if back pain is moderate and is not associated with signs of damage to the spinal roots, radicular vessels and spinal nerve, in most cases there is no need to prolong strict bed rest. Treatment must be accompanied by an explanation to the patient of the essence of the disease and psychotherapeutic influences. The patient should be taught to move, while avoiding the provocation of pain and a significant increase in the load on the spine . a certain place in treatment .
for therapeutic measures for degenerative processes in the spine is more complex if pain and static-dynamic disorders become chronic. In diseases , the presence of pain is the basis for the use of non-narcotic analgesics. For moderate pain, the simple analgesic paracetamol can be used. If treatment is not effective enough, as is the case in the case of intense pain, non-steroidal anti-inflammatory drugs (NSAIDs) are indicated. NSAIDs are among the most effective drugs for the treatment of diseases of the musculoskeletal system, primarily in terms of their analgesic activity. All NSAIDs inhibit the activity of the enzyme cyclooxygenase (COX), which results in inhibition of the synthesis of prostaglandins, prostacyclins and thromboxanes. This determines both their main properties and side effects. There are two isoforms of COX: structural isoenzyme (COX-1). regulating the production of PGs involved in ensuring the normal (physiological) functional activity of cells, and an inducible isoenzyme (COX-2), the expression of which is regulated by immune mediators (cytokines) involved in the development of the immune response and inflammation. According to J. Vane's hypothesis, the anti-inflammatory, analgesic and antipyretic effects of NSAIDs are associated with their ability to inhibit COX-2, while the most common side effects (damage to the gastrointestinal tract, kidneys, impaired platelet aggregation) are associated with suppression of COX-1 activity. Currently, there are two classes of NSAIDs in the doctor's arsenal - non-selective NSAIDs and selective NSAIDs (COX-2 inhibitors). Of the drugs in the group of non-selective NSAIDs, derivatives of acetic acid - diclofenac - are most often used. ketorolac, arylpropionic acid derivatives - ibuprofen, nairoxen, ketoprofen, oxicam derivatives - niroxicam, dornoxicam. Selective NSAIDs include nimesulide, meloxicam, and celecoxib. However, despite the undoubted clinical effectiveness, the use of NSAIDs has its limitations. It is known that even short-term use of NSAIDs in small doses can lead to the development of side effects, which in general occur in approximately 25% of cases, and in 5% of patients can pose a serious threat to life. There is a particularly high risk of side effects in elderly and senile people, who make up more than 60% of NSAID users. The relative risk of severe gastrointestinal complications is significantly higher when taking those drugs (indomethacin and piroxicam) that have low selectivity for COX-2. To reduce the risk of side effects, in particular, damage to the mucous membrane of the digestive tract, it is advisable to treat HPBIIs, which are selective COX-2 inhibitors [6,1]. It is also known that NSAIDs are more selective for COX-2 than COX-1. also exhibit less nephrotoxic activity. When prescribing NSAIDs to a patient, one should also keep in mind the existence of the opinion that at least some of them can have a negative effect on metabolic processes in cartilage tissue [9], and this, in turn, can aggravate the course of the disease.
In the acute stage of dorsopathy, in some cases it is necessary to resort to the use of narcotic analgesics - tramadol or its combination with paracetamol [2,10]. In addition, in the acute phase of the disease, paravertebral blockades with local analgesics (solutions of novocaine, lidocaine, their combination with hydrocortisone, vitamin B12) can be very effective. The block is usually performed on both sides, sometimes at the level of several SMS, with the needle directed to the location of the facet joints. In hospital settings, in cases of complicated osteochondrosis, epidural blockades can be performed with the administration of similar medicinal solutions [7]. A certain therapeutic effect can also be expected from the use of local medications containing painkillers and anti-inflammatory drugs in the form of ointments, gels, creams, etc. For dorsopathies accompanied by severe tension in the paravertebral muscles, the use of muscle relaxants, such as tolperisone and tizanidine, is quite effective. Also, due to their good muscle relaxant and tranquilizing effects, benzodiazepine derivatives in medium therapeutic doses (diazepam, clonazepam, tetrazepam) can be used in short courses. In most cases, treatment with muscle relaxants must be combined with HIIBP therapy. In such cases, some advantages of the drug tizanidine should be taken into account, since, in addition to relaxing striated muscles, it also has a moderate gastroprotective effect. Fluniritine maleate has a combined analgesic and muscle relaxant effect, which does not cause ulcerogenic complications .
An undoubted achievement of modern pharmacotherapy has been the introduction into clinical practice of a new group of drugs, the so-called slow-acting anti-inflammatory or structure-modifying agents (also known as “chondroprotectors”). The use of chondroprotectors is advisable in the treatment of degenerative- dystrophic manifestations characteristic of osteochondrosis and spondyloarthrosis, as well as in arthrosis of peripheral joints. The most studied chondroprotectors are glucosamine and chondroitin sulfate. As stated in the 2003 European League Against Rheumatism Recommendation, “while the evidence base in favor of two active substances, glucosamine sulfate and chondroitin sulfate, is steadily growing, then for other drugs in this group it is extremely weak or absent” [13].
Chondroitin sulfate (CS) is the main component of the extracellular matrix of many biological tissues, including cartilage, bone, skin, ligaments and tendons. According to its chemical structure, cholesterol is a sulfated glycosaminoglycan isolated from the cartilage of birds and cattle. Its molecule is represented by long polysaccharide chains consisting of repeating compounds of the disaccharide M-acetylgalactosamine and glucuronic acid. Most N-acetylgalactosamine residues are sulfated at the 4th and 6th positions: chondroitin-6-sulfate and chondroitin-6-sulfate. These types of cholesterol differ from each other in molecular weight and, thus, have differences in purity and bioavailability. Articular cartilage has a high cholesterol content in aggrecan, which is of great importance in creating osmotic pressure, which keeps the matrix and collagen network of cartilage tissue under tension (5|.
Glucosamia (G) - glucosamine sulfate or glucosamine hydrochloride, is a natural amino monosaccharide. The source of their production is chitin, isolated from the shell of crustaceans. G is synthesized in the body in the form of glucosamine 6-phosphate. In joints and intervertebral discs, it is included in the structure of the glycosaminoglycan molecules, heparan sulfate, keratan sulfate and hyaluronan. It is necessary for the biosynthesis of glycolipids, glycoproteins, glycosaminoglycans (mucopolysaccharides), hyaluronate and proteoglycans. G is an essential component of the cell membrane of predominantly mesodermal structures and plays an important role in the formation of cartilage, ligaments, tendons, synovial fluid, skin, bones, noggen, heart valves and blood vessels.
During the period from 1984 to 2000, more than 20 controlled studies of CS and G were carried out. This made it possible to establish that they not only have an analgesic effect, but prolong it up to 6 months after discontinuation of the drug, while the functional state of the joints and general motor activity improves patients. In addition, against the background of their long-term use, it is possible to slow down or prevent the increase in structural changes in cartilage tissue, which allows one to speak about the modifying effect of cholesterol and I" on cartilage tissue. Their safety during treatment does not differ from placebo 11,5,9]. Taking into account the fact that cholesterol and I' do not have identical pharmacological effects on cartilage metabolism, to increase the effectiveness of the treatment of degenerative joint diseases, it was considered advisable to combine these drugs.
In 2002-2005 In 16 US medical centers under the auspices of the National Institutes of Health, a randomized, double-blind, placebo-controlled study of the effects of celecoxib, CS, G and their combination (CS+G) was conducted, as well as comparing them with placebo in patients with osteoarthritis of the knee joints [15]. The results of this study indicate that the combination of cholesterol + G was the most effective analgesic pharmacological agent in patients with osteoarthritis of the knee joints with severe and moderate pain [16].
In Russia, the most studied of the combined chondroprotective drugs is ARTRA; it contains 500 mg of chondroitin sulfate and 500 mg of glucosamine hydrochloride, and is available in tablets taken orally. In 2005, an open randomized clinical trial of the drug ARTRA was conducted in clinical institutions in Russia in 203 patients (main group) with osteoarthritis of the knee joints[9]. was taken by patients 1 tablet 2 times a day during the first month of treatment tablet once a day. In parallel, patients were prescribed diclofenac at a dose of 100 mg per day with the condition of a possible reduction in dosage or discontinuation once an analgesic effect is achieved. The patients were observed for 9 months (of which 6 months were treatment) and followed up 3 months after the end of therapy to assess the duration of the treatment . In the control group (172 similar patients), treatment was carried out for the same time only with diclofenac (50 mg 1-2 times a day). As a result of the study of the drug ARTRA, the authors came to the following conclusions:
1. ARTRA has an analgesic and anti-inflammatory effect - it reduces pain and stiffness in the affected joints.
2. ARTRA improves functional status; joints - increases their mobility.
3. ARTRA allows you to reduce the dose or discontinue NSAIDs, which the patient could not refuse to take before.
A. ARTRA is highly safe and well tolerated.
5. The combined use of ARTRA and NSAIDs for osteoarthritis can increase the effectiveness and safety of treatment .
6. ARTRA has a lasting therapeutic effect during the interval between courses of treatment .
The studies mentioned above, and a number of other experimental and clinical studies, confirmed the higher effectiveness of combined drugs compared to monoprenarates of CS and G. Thus, the experiment found that when using a combined drug of CS, there is an increase in the production of glycosaminoglycans by chondrocytes by 96.6 %, and when using monotherapy only by 32% [1,13].
Most of the clinical studies studying the effect of cholesterol and G on degenerative changes in the musculoskeletal system are associated with the study of their effect in osteoarthritis of peripheral joints, mainly the knee. Currently, in world practice, CS and I" are increasingly used in the treatment of degenerative diseases of the spine . In one of the latest publications, Wini J, van Blitterwijk et al. (2003) convincingly substantiate the feasibility of using CS and G in the treatment of manifestations of the degenerative process in MIL The authors also provide a clinical example demonstrating the effectiveness of using a combination of cholesterol and G for 2 years to restore Mil/I in a patient with symptoms of its degeneration ... The positive result of treatment was confirmed not only clinically, but also by MPT data [16].
Thus, today it seems quite justified the possibility of using combination drugs containing cholesterol + G, in particular, the drug ARTRA, in the treatment of degenerative diseases of the joints, including the joints of the spine . Chondroprotective drugs have a positive effect on the metabolism in the cartilage tissue of the intervertebral disc and intervertebral joints, helping to slow down the progression of osteochondrosis and spondyloarthrosis, increase the hydrophilicity of the intervertebral disc, have a delayed anti-inflammatory and analgesic effect and, most importantly, do not cause significant side effects. Moreover, the analgesic effect obtained during a course of treatment with chondroprotectors usually lasts for a long time (up to 6 months), while the effectiveness of the analgesic effect of NSAIDs manifests itself only during treatment with drugs of this group. In addition, chondroprotectors make it possible to preserve cartilage tissue and even have a positive effect on the ability to restore it, or at least provide a significant slowdown in the further development of the degenerative process. Today, two schemes for the use of CS and G are accepted: they are prescribed in intermittent courses of varying durations (from 3 to 6 months) or taken by the patient continuously in maintenance doses.
Surgical treatment for degenerative diseases of the spine has to be resorted to in no more than 5% of cases. The operation is absolutely indicated for sequestration of the intervertebral disc (cases when a fragment of the disc herniation is separated from the rest of its mass and turns out to be a kind of foreign body in the epidural space). The feasibility of neurosurgical assistance to the patient is likely (but it should be discussed with a neurosurgeon) in case of compression of the radicular-medullary artery, especially the arteries of Adamkiewicz and Deproge-Hutteron, in the acute phase (pressure of the spinal nerve during vascular-radicular conflict.
Osteochondrosis often develops in individuals with a corresponding genetic predisposition. The development of osteochondrosis is facilitated by static-dynamic overloads, which occur not only during heavy physical work, but also during prolonged stay in a non-physiological position, leading to uneven load on individual fragments of the intervertebral disc and the SMS as a whole. At the same time, the degree of general physical development of a person is very significant, especially the state of the back and abdominal muscles, which make up the so-called “muscle corset.” Muscle weakness, as a result of a sedentary lifestyle, muscle detraining. Excess body weight and poor development of the “muscle corset” contribute to the occurrence in the spine of manifestations characteristic of osteochondrosis and snodyloarthrosis.
In order to prevent premature degenerative -destructive changes in the spine , excessive static-dynamic overloads should be avoided, while at the same time, systematic, adequate physical activity (morning exercises, jogging, swimming, sports games, etc.) is indicated. At the same time, we must strive to ensure that nutrition is sufficient, but not excessive. Some attention should be paid to the design of the workplace (height of table, chair, workbench, etc.). When walking and during sedentary work, correct posture is necessary, and you must constantly “keep your back.” In the case of work associated with prolonged stay in a fixed position, breaks are desirable, during which it is advisable to perform at least a few simple physical exercises.
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Degenerative diseases of the spine are the most common chronic diseases of the spine associated with changes in the intervertebral discs, joints, ligaments, and bone tissue of the spine.
With age, discs wear out and cease to perform the main function of a shock absorber. Bones and ligaments become deformed.
At first, the changes occur unnoticed, and begin to cause concern only when deformed discs, vertebrae and ligaments begin to put pressure on the nerve endings and spinal cord.
The disease most often affects people of working age, and degenerative diseases of the spine lead to significant loss of work and often disability.
Most often, a hernia occurs in the lower cervical and lower lumbar spine.
Treatment is selected after conducting the necessary examination and making a clear diagnosis.
Today, there are various ways to treat diseases.
Conservative treatment includes the use of various drugs that inhibit the degeneration of cartilage and connective tissue, which leads to a decrease in inflammation and increased joint mobility.
Sometimes patients need surgical treatment, the main goal of which is to relieve the patient of pain and return him to a full life.
During surgical treatment, it is necessary to eliminate compression of the spinal cord and its roots.
There are various surgical options.
The traditional method is to remove the disc and then form a permanent fusion of two adjacent vertebrae.
Recently, minimally invasive surgical intervention has become widespread, which is performed with special minimally invasive instruments. The surgeon makes a small incision in the back and inserts micro-instruments. This technique allows for minimal trauma to the muscles and nerves surrounding the damaged area of the spine. This technology allows the surgeon to reach the pinched disc with high precision and remove it.
Modern spinal systems make it possible to choose the appropriate solution for each patient and relieve him of pain, returning him to a full life.
In each specific case, an individual approach to the patient is applied, so be sure to consult with a specialist.
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