Consilium MedicumConsilium MedicumConsilium MedicumConsilium Medicum2075-17532542-2170Consilium Medicum94240ArticlesСтатьиResearch ArticleBack pain caused by disorders of the intervertebral discsБоль в пояснице, обусловленная патологией межпозвоночных дисков‌‌‌IsaykinA. IИсайкинАлексей Иванович

доц. каф. нервных болезней и нейрохирургии ГБОУ ВПО Первый МГМУ им. И.М.Сеченова, куратор отд-ния боли и заболеваний периферической нервной системы Клиники нервных болезней им. А.Я.Кожевникова

alexisa68@mail.ruChernenkoO. AЧерненкоОлег Анатольевич

зав. отд-нием боли и заболеваний периферической нервной системы Клиники нервных болезней им. А.Я.Кожевникова

IvanovaM. AИвановаМария Алексеевна

врач-ординатор отд-ния боли и заболеваний периферической нервной системы Клиники нервных болезней им. А.Я.Кожевникова

StitsenkoA. NСтиценкоАлександр Николаевич

врач-ординатор отд-ния боли и заболеваний периферической нервной системы Клиники нервных болезней им. А.Я.Кожевникова

I.M.Sechenov First Moscow State Medical University of the Ministry of Health of the Russian FederationГБОУ ВПО Первый Московский государственный медицинский университет им. И.М.Сеченова Минздрава РоссииA.Ya.Kozhevnikov Clinic for Nervous DiseasesКлиника нервных болезней им. А.Я.Кожевникова15022015172VOL 17, NO2 (2015)ТОМ 17, №2 (2015)526028122021Copyright ©; 2015, Consilium MedicumCopyright ©; 2015, ООО "Консилиум Медикум"2015Consilium MedicumООО "Консилиум Медикум"https://creativecommons.org/licenses/by-nc-sa/4.0https://consilium.orscience.ru/2075-1753/article/view/94240

The article is devoted to the actual problem - the role of discogenic factor in the development of low back pain. Presented is an updated description of CTF- classification of pathological changes of discs (2014) and MSU-classification of disc herniation. We discuss the pathogenesis, clinical manifestations, diagnosis and additional differential treatment (conservative and operative) of the two most common manifestations of discogenic lumbar pathologies: axial discogenic pain and disco-radicular conflict. Emphasized is the role of inflammation in the development, maintenance of discogenic pain and regression of herniated disc. Materials presented the first evidence-based guidelines for the diagnosis and treatment of disc herniation with radiculopathy symptoms of the expert group North American Spine Society's - NASS (2012). Discussed are also the treatment of discogenic pain, selection of optimal drug groups.

Статья посвящена актуальной проблеме - роли дискогенного фактора в развитии поясничных болей. Приведены обновленная CTF-классификация описания патологических изменений дисков (2014 г.) и MSU-классификация грыж диска. Обсуждаются патогенез, клинические проявления, дополнительные методы диагностики и дифференцированное лечение (консервативное и оперативное) двух наиболее частых проявлений дискогенной патологии поясничного отдела: аксиальной дискогенной боли и диско-радикулярного конфликта. Подчеркивается роль воспаления в развитии, поддержании дискогенных болей и регрессе грыжи диска. Приведены материалы первого научно обоснованного руководства по диагностике и лечению грыжи диска с симптомами радикулопатии, разработанные экспертной группой North American Spine Society's - NASS (2012 г.). Обсуждаются вопросы терапии дискогенной боли, выбор оптимальных групп препаратов.

back paindiscogenic axial paindisc herniation with radiculopathyCTF- and MSU-classificationModic-1zone of high signal in the posterior regions of the fibrous ringtreatment of disc herniationArtrozanCombilipenболь в спинедискогенная аксиальная больгрыжа диска с радикулопатиейCTF- и MSU-классификацииМодик-1зона высо- коинтенсивного сигнала в задних отделах фиброзного кольцалечение грыжи дискаАртрозанКомбилипенGaunt A, Herring S, O’connor F. Caring for patients who have acute and subactute low back pain. CME bulletin 2008; 7 (2): 1-8.Van Tulder M, Becker A, Trudy B et al. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006; 15 (Suppl. 2): S169-S191.Подчуфарова Е.В., Яхно Н.Н. Боль в спине. М.: ГЭОТАР-Медиа, 2010.Парфенов В.А., Герасимова О.Н. Лечение неспецифических болей в спине в амбулаторной практике. Справ. поликлин. врача. 2013; 1: 48-51.Chou R, Qaseem A, Snow V 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): 478-91.Koes B, Van Tulder M, Chung-Wei C.L. An updated overview of clinical guidelines for the management of non - specific low back pain in primary care. Eur Spine J 2010; 19: 2075-94 for Clinical Management of Chronic Spinal Pain. Pain Physician 2009; 12: E225-E264.Henschke N, Maher C.G, Refshauge K.M et al. Prevalence of and screening for serious spinal pathology in patient presenting to primary care settings with acute low back pain. Arthriris & Rheumatism 2009; 60 (10): 3072-80.Zhang Y et al. Clinical diagnosis for discogenic low back pain. Intern J Biol Sci 2009; 5 (70): 647.De Palma M.J, Ketchum J.M, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med 2011; 12: 224-33.Van Tulder K. Diagnosis and treatment of sciatica. BMJ 2007; 334: 1313.Haro H. Translational research of herniated discs: current status of diagnosis and treatment. J Orthopaedic Sci 2014; 19 (40): 515-20.Kim S.J, Lee T.H, Lim S.M. Prevalence of disc degeneration in asymptomatic korean subjects. Part 1: lumbar spine. J Korean Neurosurg Soc 2013; 53 (1): 31-8.Perez F.A, Jarvik J.G. Evidence - based imaging and effective utilization: lessons in neuroradiology. Neuroimaging Clin N Am 2012; 22 (3): 467-76.Steffens D, Hancock M.J, Maher C.G et al. Does magnetic resonance imaging predict future low back pain? A systematic review. Еur J Pain 2014; 18 (6): 755-65.Fardon D.F et al. Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J 2014; 14 (11): 2525-45.Mysliwiec L.W et al. MSU classification for herniated lumbar discs on MRI: toward developing objective criteria for surgical selection. Eur Spine J 2010; 19 (70): 1087-93.Van Rijn J.C, Klemetso N, Reitsma J.B et al. Symptomatic and asymptomatic abnormalities in patients with lumbosacra radicular syndrome: Clinical examination compared with MRI. Clin Neurol Neurosurg 2006; 108 (6): 553-7.Bogduk N et al. Why I pursue discogenic pain. International Spine 2005; 15-27.Risbud M.V, Shapiro I.M. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat Rev Rheumatol 2014; 10 (1): 44-56.Takahashi K, Aoki Y, Ohtori S. Resolving discogenic pain. Eur Spine J 2008; 17 (Suppl. 4): 428-31.Aoki Y, Nakajima A, Ohtori S et al. Increase of nerve growth factor levels in the human herniated intervertebral disc: can annular rupture trigger discogenic back pain? Arthritis Res Ther 2014; 16 (4): R159.Ohtori S, Inoue G, Miyagi M, Takahashi K. Pathomechanisms of discogenic low back pain in humans and animal models. Spine J 2014.i: S1529-9430 (14).Lama P, Le Maitre C.L, Dolan P et al. Do intervertebral discs degenerate before they herniate, or after? Bone Joint J 2013; 95-B (8): 1127-33.Malik K.M, Cohen S.P, Walega D.R, Benzon H.T. Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature. Spine J 2013; 13 (11): 1675-89.Hancock M.J, Maher C.G, Latimer J, Bogduk N. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007; 16 (10): 1539-50.Sugiura K, Tonogai I, Matsuura T. Discoscopic findings of high signal intensity zones on magnetic resonance imaging of lumbar intervertebral discs. Case Rep Orthop 2014; 2014: 245952.Sheng-Yun L, Letu S, Jian C et al. Comparison of Modic Changes in the Lumbar and Cervical Spine, in 3167 Patients with and without Spinal Pain. PLoS One 2014; 15: 9 (12).Albert H.B, Lambert P, Rollason J et al. Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? Eur Spine J 2013; 22 (4): 690-6.Urquhart D.M, Zheng Y, Cheng A.C et al. Could low - grade bacterial infection contribute to low back pain? A systematic review. BMC Med 2015; 13 (1): 13.Yrjämä M, Tervonen O, Vanharanta H. Ultrasonic imaging of lumber discs combinedwith vibration pain provocation compared with discography in the diagnosis of internal anular fissures of the lumbar spine. Spine (Phila Pa 1976) 1996; 21: 571-5.Dagenais S, Tricco A.C, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010; 10 (6): 514-29.Wood H. Pain: Paracetamol is not superior to placebo for acute low back pain. Nat Rev Neurol 2014; 10 (9): 486.Williams C.M, Maher C.G, Latimer J еt al. Efficacy of paracetamol for acute low - back pain: a double - blind, randomised controlled trial. Lancet 2014; pii: S0140- 6736(14)60805-9.Roelofs P.D, Deyo R.A, Koes B.W. Non - steroidal anti - inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; 1: CD000396.European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006; 15 (Suppl. 2): S192-300.White A.P, Arnold P.M, Norvell D.C et al. Pharmacologic management of chronic low back pain: synthesis of the evidence. Spine (Phila Pa 1976) 2011; 36 (21 Suppl.): S131-43.Батышева Т.Т., Отческая О.В., Хозова А.А. и др. Эффективность применения комбинации препаратов артрозан и комбилипен у пациентов с острой болью в нижней части спины. Журн. неврологии и психиатрии им. С.С.Корсакова. 2011; 9 (2): 41-5.Chou R. Pharmacological management of low back pain. Drugs 2010; 70 (4): 387-402.Kаssis А. Antidepressants to Treat Nonspecific Low Back Pain. Am Fam Physician 2008; 78 (1): 51-2.Leggett L.E, Soril L.J, Lorenzetti D.L et al. Radiofrequency ablation for chronic low back pain: a systematic review of randomized controlled trials. Pain Res Manag 2014; 19 (5): e146-53.Lu Y, Guzman J.Z, Purmessur D et al. Nonoperative management of discogenic back pain: a systematic review. Spine (Phila Pa 1976) 2014; 39 (16): 1314-24.Kallewaard J.W, Terheggen M.A, Groen G.J. Discogenic low back pain. Pain Pract 2010; 10 (6): 560-79.Wang X, Wanyan P, Tian J.H, Hu L. Meta - analysis of randomized trials comparing fusion surgery to non - surgical treatment for discogenic chronic low back pain. J Back Musculoskelet Rehabil 2014.Bydon M1, De la Garza-Ramos R, Macki M et al. Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta - analysis of randomized controlled trials. J Spinal Disord Tech 2014; 27 (5): 297-304.Saltychev M, Eskola M, Laimi K. Lumbar fusion compared with conservative treatment in patients with chronic low back pain: a meta - analysis. Int J Rehabil Res 2014; 37 (1): 2-8.Kreiner D.S et al. Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. 2012.Sun Z, Xu-Hong Z.M.Z. Immune cascades in human intervertebral disc: the pros and cons. Int J Clin Exp Pathol 2013; 6 (6): 1009-14.Stafford M.A, Peng P, Hill D.A. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. Br J Anaesth 2007; 99 (4): 461-73.Sun Z. et al. Immune cascades in human intervertebral disc: the pros and cons. Int J Clin Exp Pathol 2013; 6 (6): 1009.Weiler C, Nerlich A.G, Bachmeier .BE, Boos N. Expression and distribution of tumor necrosis factor alpha in human lumbar intervertebral discs: a study in surgical specimen and autopsy controls. Spine (Phila Pa 1976) 2005; 30 (1): 44-53.Schistad E.I, Espeland A, Pedersen L.M et al. Association between baseline IL-6 and 1-year recovery in lumbar radicular pain. Eur J Pain 2014; 18 (10): 1394-401.Legrand E, Bouvard B, Audran M et al. Spine Section of the French Society for Rheumatology. Sciatica from disk herniation: Medical treatment or surgery? Joint Bone Spine 2007; 74 (6): 530-5.Macki M, Hernandez-Hermann M, Bydon M. Spontaneous regression of sequestrated lumbar discherniations: Literature review. Clin Neurol Neurosurg 2014; 120: 136-41.Chiu C.C, Chuang T.Y, Chang K.H et al. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil 2014.Martínez-Quiñones J.V, Aso-Escario J, Consolini F, Arregui-Calvo R. Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases. Neurocirugia (Astur) 2010; 21 (2): 108-17.Yukawa Y, Kato F, Matsubara Y et al. Serial magnetic resonance imaging follow - up study of lumbar disc herniation conservatively treated for average 30 months: relation between reduction of herniation and degeneration of disc. J Spinal Disord 1996; 9 (3): 251-2.Mochida K, Komori H, Okawa A. Regression of cervical discherniation observed on magnetic resonance images. Spine (Phila Pa 1976) 1998; 23 (9): 990-5.Yoshida M, Nakamura T, Sei A et al. Intervertebral disc cells produce tumor necrosis factor alpha, interleukin-1beta, and monocyte chemoattractant protein-1 immediately after herniation: an experimental study using a new hernia model. Spine (Phila Pa 1976) 2005; 30 (1): 55-61.Kato T, Haro H, Komori H, Shinomiya K. Sequential dynamics of inflammatory cytokine, angiogenesis inducing factor and matrix degrading enzymes during spontaneous resorption of the herniated disc. J Orthop Res 2004; 22 (4): 895-900.Karppinen J et al. Tumor necrosis factor - a monoclonal antibody, infliximab, used to manage severe sciatica. Spine 2003; 28 (8): 750-3.Sabnis A.B, Diwan A.D. The timing of surgery in lumbar disc prolapse: A systematic review. Indian J Orthop 2014; 48 (2): 127-35.Fu Q-G, Carstens E, Stelzer В, Zimmermann M. В vitamins suppress spinal dorsal horn nociceptive neurons in the cat. Neurosci Lett 1988; 95: 192-7.Wang Z.B, Gan Q, Rupert R.L et al. Thiamine, pyridoxine, cyanocobalamin and their combination inhibit thermal, but not mechanical hyperalgesia in rats with primary sensory neuron injury. Pain 2005; 116: 168-9.Bartoszyk G.D, Wild A. B-vitamins potentiate the antinociceptive effect of diclofenac in carrageenan - induced hyperalgesia in the rat tail pressure test. Neurosci Lett 1989; 101: 95-100.Vetter G, Bruggemann G, Letko M et al. Verkurzung der Diclofenac - therapie gegen Diclofenac 50 mg plus B-vitamine, bei schmerzhaften wirbelsau - lenerkrankungen mit degenerativen Veranderungen. Z Rheumatol 1988; 47: 351-62.Franca D.S, Souza A.L, Almeida K.R et al. В vitamins induce an antinociceptive effect in the acetic acid and formaldehyde models of nociception in mice. Eur J Pharmacol 2001; 421: 157-64.Rocha-Gonzalez H.I, Teran-Rosales F, Reyes-Garcia G et al. В vitamins increase the analgesic effect of diclofenac in the rat. Proc West Pharmacol Soc 2004; 47: 84-7.Zhang M, Han W, Hu S, Xu H. Methylcobalamin: a potential vitamin of pain killer. Neural Plast 2013; 2013: 424651.Данилов А.Б. Применение витаминов группы В при болях в спине: новые анальгетики? Рус. мед. журн. 2008; 16: (Спецвыпуск): 35-9.Левин О.С., Мосейкин И.А. Комплекс витаминов группы B в лечении дискогенной пояснично - крестцовой радикулопатии. Журн. неврологии и психиатрии им. С.С.Корсакова. 2009; 10: 30-5.Fleischmann R, Iqbal I, Slobodin G. Meloxicam et al. Expert Opin Pharmacother 2002; 3 (10): 1501-12.Hawkey C, Kahan A, Steinbrück K et al. Gastrointestinal tolerability of meloxicam compared to diclofenac in osteoarthritis patients. International MELISSA Study Group. Meloxicam Large - scale International Study Safety AssessmentBr J Rheumatol. 1998; 37 (9): 937-45.Rostom A., Goldkind L., Laine L. Nonsteroidal Anti-Inflammatory Drugs and Hepatic Toxicity: A Systematic Review of Randomized Controlled Trials in Arthritis Patients. Clin Gastroenterol Hepatol 2005; 3: 489-98.