Боль в спине при дегенеративных изменениях позвоночника – одна из наиболее частых причин обращения пациентов за медицинской помощью. Источником болевого синдрома могут быть изменения межпозвонковых дисков, суставов, связочного аппарата, мышц. Часто патогенетической основой боли является компрессия спинномозговых корешков, спинного мозга. Большое количество научных работ посвящено изучению патофизиологических основ возникновения болевого синдрома на фоне их механического сдавления. Однако нарушение кровоснабжения спинного мозга может быть самостоятельной причиной возникновения боли. Поэтому нельзя отрицать необходимость назначения сосудистой терапии, улучшающей микроциркуляцию и кровообращение, при хроническом болевом синдроме. В статье рассмотрены возможные патофизиологические механизмы, лежащие в основе болевого синдрома при дегенеративных изменениях позвоночника.
Ключевые слова: дегенеративные изменения позвоночника, боль в спине, патофизиологические механизмы боли, ишемия спинного мозга.
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Back pain associated with degenerative spine disease is one of the most common reason for seeking medical attention. Pain syndrome in degenerative spine disease may originate from various damaged structures, such as intervertebral disc, joints, ligaments or muscles. Compression of nerve roots or spinal cord commonly can be pathogenetic sources of pain. A large number of scientific studies are focused on researching pathophysiological sources of compression pain syndrome. However, impaired blood flow to the spinal cord can cause pain by itself. Therefore, it is important to administer vascular therapy improving microcirculation and blood flow to control сhronical pain. In this article summarizes possible pathophysiological mechanisms of pain in degenerative spine disease.
Key words: degenerative spine disease, back pain, pathophysiological mechanisms of pain, spinal cord ischemia.
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1. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 16; 390 (10100): 1211–59. DOI: 10.1016/S0140-6736(17)32154-2. PMID: 28919117
2. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet 2012; 4; 379 (9814): 482–91. DOI: 10.1016/S0140-6736(11)60610-7. PMID: 21982256
3. Manchikanti L, Singh V, Falco FJ et al. Epidemiology of low back pain in adults. Neuromodulation 2014; 17 (Suppl. 2): 3–10. DOI: 10.1111/ner.12018. PMID: 25395111
4. Braun J, Baraliakos X, Regel A, Kiltz U. Assessment of spinal pain. Best Pract Res Clin Rheumatol 2014; 28 (6): 875–87. DOI: 10.1016/j.berh.2015.04.031. PMID: 26096091
5. Allegri M, Montella S, Salici F et al. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Res 2016; 5: (F1000 Faculty Rev): 1530. DOI: 10.12688/f1000research.8105.2. PMID: 27408698
6. Minkalis AL, Vining RD. What is the pain source? A case report of a patient with low back pain and bilateral hip osteonecrosis. J Can Chiropr Assoc 2015; 59 (3): 300–10. PMID: 26500365
7. Lorenzo A, Schildt P, Lorenzo M et al. Acute low back pain management in primary care: a simulated patient approach. Fam Pract 2015; 32 (4): 436–41. DOI: 10.1093/fampra/cmv030. PMID:26060210
8. Gilchrist RV, Slipman CW, Bhagia SM. Anatomy of the intervertebral foramen. Pain Physician 2002; 5 (4): 372–8. PMID: 16886015
9. Lin JH, Chiang YH, Chen CC. Lumbar radiculopathy and its neurobiological basis. World J Anesthesiol 2014; 3 (2):162–73. DOI: 10.5313/wja.v3.i2.162
10. Kobayashi S, Mwaka ES, Baba H. Microvascular system of the lumbar dorsal root ganglia in rats. Part II: neurogenic control of intraganglionic blood flow. J Neurosurg Spine 2010; 12 (2): 203–9. DOI: 10.3171/2009.8.SPINE08895. PMID: 20121357
11. Sapunar D, Kostic S, Banozic A, Puljak L. Dorsal root ganglion – a potential new therapeutic target for neuropathic pain. J Pain Res 2012; 5: 31–8. DOI: 10.2147/JPR.S26603. PMID: 22375099
12. Kobayashi S, Mwaka ES, Baba H et al. Microvascular system of the lumbar dorsal root ganglia in rats. Part I: a 3D analysis with scanning electron microscopy of vascular corrosion casts. J Neurosurg Spine 2010; 12 (2): 197–202. DOI: 10.3171/2009.6.SPINE08894. PMID: 20121356
13. Guo W, Zhao P, Zhou W et al. Correlation studies between MRI and the symptom scores of patients with LDH before and after manipulative therapy. Zhongguo Gu Shang 2010; 23 (1): 17–9. PMID: 20191957
14. Yabuki S, Kikuchi S, Olmarker K, Myers RR. Acute effects of nucleus pulposus on blood flow and endoneurial fluid pressure in rat dorsal root ganglia. Spine (Phila Pa 1976) 1998; 23: 2517–23. PMID: 9854750
15. Sun Z, Zhang M, Zhao XH. Immune cascades in human intervertebral disc: the pros and cons. Int J Clin Exp Pathol 2013; 6 (6): 1009–14. PMID: 23696917
16. Molinos M, Almeida CR, Caldeira J. Inflammation in intervertebral disc degeneration and regeneration. J R Soc Interface 2015; 6; 12 (104): 20141191. DOI: 10.1098/rsif.2014.1191. PMID: 25673296
17. Krames ES. The role of the dorsal root ganglion in the development of neuropathic pain. Pain Med 2014; 15 (10): 1669–85. DOI: 10.1111/pme.12413. PMID: 24641192
18. Zhang JM, Jianxiong An. Cytokines, Inflammation and Pain. Int Anesthesiol Clin 2007; 45 (2): 27–37. DOI: 10.1097/AIA.0b013e318034194e. PMID: 17426506
19. Rydevik BL, Myers RR, Powell HC. Pressure increase in the dorsal root ganglion following mechanical compression. Closed compartment syndrome in nerve roots. Spine (Phila Pa 1976) 1989; 14 (6): 574–6. PMID: 2749371
20. Lawson SN. Morphological and biochemical cell types of sensoryneurons. In: Scott AS, ed. Sensory Neurons, Diversity, Development and Plasticity. NY: Oxford University Press, 1992; p. 27–59.
21. Kobayashi S, Mwaka ES, Meir A et al. Vasomotion of Intraradicular Microvessels in Rat. Spine 2009; 34 (10): 990–7. DOI: 10.1097/BRS.0b013e3181a100bf
22. Kobayashi S, Takeno K, Miyazaki T et al. Effects of Arterial Ischemia and Venous Congestion on the Lumbar Nerve Root in Dogs. J Orthop Res 2008; 26 (11): 1533–40. DOI: 10.1002/jor.20696 PMID: 18536056
23. Dubový P. Wallerian degeneration and peripheral nerve conditions for both axonal regeneration and neuropathic pain induction. Ann Anat 2011; 193 (4): 267–75. DOI: 10.1016/j.aanat.2011.02.011. PMID: 21458249
24. Olmarker K. Spinal nerve root compression. Acta Orthopaedica Scand 1991; 62: 1–27. DOI: 10.3109/17453679109153920
25. Beggs S, Salter MW. Stereological and somatotopic analysis of the spinal microglial response to peripheral nerve injury. Brain Behav Immun 2007; 21: 624–33. DOI: 10.1016/j.bbi.2006.10.017. PMID: 17267172
26. Otoshi K, Kikuchi S, Konno S, Sekiguchi M. The reactions of glial cells and endoneurial macrophages in the dorsal root ganglion and their contribution to pain-related behavior after application of nucleus pulposus onto the nerve root in rats. Spine (Phila Pa 1976) 2010; 35: 264–71. DOI: 10.1097/BRS.0b013e3181c67f1e. PMID: 20042951
27. Gilchrist RV, Slipman CW, Isaac Z et al. Vascular Supply to the Lumbar Spine: An Intimate Look at the Lumbosacral Nerve Roots. Pain Physician 2002; 5 (3): 288–93. PMID: 16902656
28. Watanabe R, Parke WW. Vascular and neural pathology of lumbosacral spinal nerve roots in spinal stenosis. J Neurosurg 1986; 64: 64–70. DOI: https://doi.org/10.3171/jns.1986.64.1.0064
29. Hoyland JA, Freemont AJ, Jayson MI. Intervertebral foramen venous obstruction. A cause of periradicular fibrosis? Spine (Phila Pa 1976) 1989; 14 (6): 558–68. PMID: 2749370
30. Konovalov A.N., Grin' A.A., Dreval' O.N. et al. Clinical recommendations for the diagnosis and treatment of degenerative stenosis of the spinal canal at the lumbosacral level. Discussed and approved at the Plenum of the Board of the Association of neurosurgeons of Russia, Kazan 2015. Moscow, 2015. (in Russian).
31. Takahashi K, Kagechika K, Takino T et al. Changes in epidural pressure during walking in patients with lumbar spinal stenosis. Spine (Phila Pa 1976) 1995; 15; 20 (24): 2746–9. PMID: 8747254
32. Kobayashi S. Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis. World J Orthop 2014; 18; 5 (2): 134–45. DOI: 10.5312/wjo.v5.i2.134. PMID: 24829876
33. Sluka KA, Winter OC, Wemmie JA. Acid-sensing ion channels: A new target for pain and CNS diseases. Curr Opin Drug Discov Devel 2009; 12 (5): 693–704. PMID: 19736627
34. Wu WL, Cheng CF, Sun WH et al. Targeting ASIC3 for pain, anxiety, and insulin resistance. Pharmacol Ther 2012; 134 (2): 127–38. DOI: 10.1016/j.pharmthera.2011.12.009. PMID: 22233754.
35. North RA. P2X3 receptors and peripheral pain mechanisms. J Physiol 2004; 15; 554 (Part 2): 301–8. DOI: 10.1113/jphysiol.2003.048587. PMID: 12832496
36. Harvey VL, Dickenson AH. Mechanisms of pain in nonmalignant disease. Curr Opin Support Palliat Care 2008; 2 (2): 133–9. DOI: 10.1097/SPC.0b013e328300eb24. PMID: 18685411.
37. Chien SQ, Li C, Li H et al. Sympathetic Fiber Sprouting in Chronically Compressed Dorsal Root Ganglia Without Peripheral Axotomy. J Neuropathic Pain Symptom Palliation 2005; 1 (1): 19–23. DOI: 10.1300/J426v01n01_05. PMID: 17387381
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