Isaykin A.I., Chernenko O.A., Ivanova M.A., Stitsenko A.N. Back pain caused by disorders of the intervertebral discs. Consilium Medicum. 2015; 17 (2): 52–60. DOI: 10.26442/2075-1753_2015.2.52-60
Боль в пояснице, обусловленная патологией межпозвоночных дисков
Isaykin A.I., Chernenko O.A., Ivanova M.A., Stitsenko A.N. Back pain caused by disorders of the intervertebral discs. Consilium Medicum. 2015; 17 (2): 52–60. DOI: 10.26442/2075-1753_2015.2.52-60
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.
Ключевые слова: боль в спине, дискогенная аксиальная боль, грыжа диска с радикулопатией, CTF- и MSU-классификации, Модик-1, зона высокоинтенсивного сигнала в задних отделах фиброзного кольца, лечение грыжи диска, Артрозан, Комбилипен.
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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.
Key words: back pain, discogenic axial pain, disc herniation with radiculopathy, CTF- and MSU-classification, Modic-1, zone of high signal in the posterior regions of the fibrous ring, treatment of disc herniation, Artrozan, Combilipen.
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39. Kаssis А. Antidepressants to Treat Nonspecific Low Back Pain. Am Fam Physician 2008; 78 (1): 51–2.
40. Leggett LE, Soril LJ, Lorenzetti DL et al. Radiofrequency ablation for chronic low back pain: a systematic review of randomized controlled trials. Pain Res Manag 2014; 19 (5): e146–53.
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1. Gaunt A, Herring S, O’connor F. Caring for patients who have acute and subactute low back pain. CME bulletin 2008; 7 (2): 1–8.
2. 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.
3. Podchufarova E.V., Iakhno N.N. Bol' v spine. M.: GEOTAR-Media, 2010. [in Russian]
4. Parfenov V.A., Gerasimova O.N. Lechenie nespetsificheskikh bolei v spine v ambulatornoi praktike. Sprav. poliklin. vracha. 2013; 1: 48–51. [in Russian]
5. 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.
6. Koes B, Van Tulder M, Chung-Wei CL. 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.
7. Henschke N, Maher CG, Refshauge KM 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.
8. Zhang Y et al. Clinical diagnosis for discogenic low back pain. Intern J Biol Sci 2009; 5 (70): 647.
9. DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med 2011; 12: 224–33.
10. Van Tulder K. Diagnosis and treatment of sciatica. BMJ 2007; 334: 1313.
11. Haro H. Translational research of herniated discs: current status of diagnosis and treatment. J Orthopaedic Sci 2014; 19 (40): 515–20.
12. Kim SJ, Lee TH, Lim SM. Prevalence of disc degeneration in asymptomatic korean subjects. Part 1: lumbar spine. J Korean Neurosurg Soc 2013; 53 (1): 31–8.
13. Perez FA, Jarvik JG. Evidence-based imaging and effective utilization: lessons in neuroradiology. Neuroimaging Clin N Am 2012; 22 (3): 467–76.
14. Steffens D, Hancock MJ, Maher CG et al. Does magnetic resonance imaging predict future low back pain? A systematic review. Еur J Pain 2014; 18 (6): 755–65.
15. Fardon DF 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.
16. Mysliwiec LW 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.
17. Van Rijn JC, Klemetso N, Reitsma JB 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.
18. Bogduk N et al. Why I pursue discogenic pain. International Spine 2005; 15–27.
19. Risbud MV, Shapiro IM. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat Rev Rheumatol 2014; 10 (1): 44–56.
20. Takahashi K, Aoki Y, Ohtori S. Resolving discogenic pain. Eur Spine J 2008; 17 (Suppl. 4): 428–31.
21. 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.
22. 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).
23. Lama P, Le Maitre CL, Dolan P et al. Do intervertebral discs degenerate before they herniate, or after? Bone Joint J 2013; 95-B (8): 1127–33.
24. Malik KM, Cohen SP, Walega DR, Benzon HT. Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature. Spine J 2013; 13 (11): 1675–89.
25. Hancock MJ, Maher CG, 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.
26. 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.
27. 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).
28. Albert HB, 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.
29. Urquhart DM, Zheng Y, Cheng AC et al. Could low-grade bacterial infection contribute to low back pain? A systematic review. BMC Med 2015; 13 (1): 13.
30. Yrjämä M, Tervonen O, Vanharanta H. Ultrasonic imaging of lumber discs combined with 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.
31. Dagenais S, Tricco AC, 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.
32. Wood H. Pain: Paracetamol is not superior to placebo for acute low back pain. Nat Rev Neurol 2014; 10 (9): 486.
33. Williams CM, Maher CG, 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.
34. Roelofs PD, Deyo RA, Koes BW. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; 1: CD000396.
35. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006; 15 (Suppl. 2): S192–300.
36. White AP, Arnold PM, Norvell DC et al. Pharmacologic management of chronic low back pain: synthesis of the evidence. Spine (Phila Pa 1976) 2011; 36 (21 Suppl.): S131–43.
37. Batysheva T.T., Otcheskaia O.V., Khozova A.A. i dr. Effektivnost' primeneniia kombinatsii preparatov artrozan i kombilipen u patsientov s ostroi bol'iu v nizhnei chasti spiny. Zhurn. nevrologii i psikhiatrii im. S.S.Korsakova. 2011; 9 (2): 41–5. [in Russian]
38. Chou R. Pharmacological management of low back pain. Drugs 2010; 70 (4): 387–402.
39. Kаssis А. Antidepressants to Treat Nonspecific Low Back Pain. Am Fam Physician 2008; 78 (1): 51–2.
40. Leggett LE, Soril LJ, Lorenzetti DL et al. Radiofrequency ablation for chronic low back pain: a systematic review of randomized controlled trials. Pain Res Manag 2014; 19 (5): e146–53.
41. Lu Y, Guzman JZ, Purmessur D et al. Nonoperative management of discogenic back pain: a systematic review. Spine (Phila Pa 1976) 2014; 39 (16): 1314–24.
42. Kallewaard JW, Terheggen MA, Groen GJ. Discogenic low back pain. Pain Pract 2010; 10 (6): 560–79.
43. Wang X, Wanyan P, Tian JH, 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.
44. 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.
45. 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.
46. Kreiner DS et al. Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. 2012.
47. Sun Z, Xu-Hong ZMZ. Immune cascades in human intervertebral disc: the pros and cons. Int J Clin Exp Pathol 2013; 6 (6): 1009–14.
48. Stafford MA, Peng P, Hill DA. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. Br J Anaesth 2007; 99 (4): 461–73.
49. Sun Z. et al. Immune cascades in human intervertebral disc: the pros and cons. Int J Clin Exp Pathol 2013; 6 (6): 1009.
50. Weiler C, Nerlich AG, 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.
51. Schistad EI, Espeland A, Pedersen LM et al. Association between baseline IL-6 and 1-year recovery in lumbar radicular pain. Eur J Pain 2014; 18 (10): 1394–401.
52. 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.
53. Macki M, Hernandez-Hermann M, Bydon M. Spontaneous regression of sequestrated lumbar discherniations: Literature review. Clin Neurol Neurosurg 2014; 120: 136–41.
54. Chiu CC, Chuang TY, Chang KH et al. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil 2014.
55. Martínez-Quiñones JV, 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.
56. 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.
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1 ГБОУ ВПО Первый Московский государственный медицинский университет им. И.М.Сеченова Минздрава России. 119991, Россия, Москва, ул. Трубецкая, д. 8, стр. 2;
2 Клиника нервных болезней им. А.Я.Кожевникова. 119021, Россия, Москва, ул. Россолимо, д. 11, стр. 1
*alexisa68@mail.ru
1 I.M.Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation. 119991, Russian Federation, Moscow, ul. Trubetskaia, d. 8, str. 2;
2 A.Ya.Kozhevnikov Clinic for Nervous Diseases. 119435, Russian Federation, Moscow, ul. Rossolimo, d. 11, str. 1
*alexisa68@mail.ru