Консервативное лечение цервикальной радикулопатии в амбулаторной практике. Клинический случай

Исайкин А.И., Керимова Е.К., Кинан Муки. Консервативное лечение цервикальной радикулопатии в амбулаторной практике. Клинический случай. Consilium Medicum. 2025;27(2):81–87. DOI: 10.26442/20751753.2025.2.203210

© ООО «КОНСИЛИУМ МЕДИКУМ», 2025 г.

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Isaikin AI, Kerimova EK, Kinan Mouki. Non-surgical treatment of cervical radiculopathy in outpatient settings. Case report. Consilium Medicum. 2025;27(2):81–87. DOI: 10.26442/20751753.2025.2.203210

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Аннотация

Цервикальная радикулопатия (ЦР) возникает при сдавлении шейных спинномозговых корешков в результате дегенеративных изменений позвоночных структур. На шейном уровне компрессия корешковых структур чаще всего обусловлена не «мягкотканным» компонентом грыжи диска в эпидуральном пространстве, а сдавлением в самом корешковом отверстии за счет спондилеза. ЦР может проявляться различными клиническими симптомами и их сочетанием в виде не только боли (обычно с «длинной» иррадиацией), но и симптомов выпадения (гипестезии, двигательных нарушений, снижения сухожильных рефлексов) в зоне иннервации соответствующих спинномозговых корешков. Используют провокационные тесты, направленные на увеличение компрессии корешка и усиление клинической симптоматики (Шпурлинга, Вальсальвы, Элвейс-тест [Upper Limb Tension Test – ULTT]), а также другие с целью уменьшения степени сдавления корешка и облегчения боли (тракции, отведения плеча). Основу диагностики составляет анализ клинической симптоматики. Корешковая компрессия маловероятна в отсутствие очаговой неврологической симптоматики. Магнитно-резонансная томография шейного отдела позвоночника без контрастирования является основным методом нейровизуализации для пациентов с впервые возникшей или нарастающей клинической картиной нетравматической ЦР в отсутствие «красных флагов тревоги». При оценке корешковой компрессии данные нейровизуализации надо интерпретировать только в контексте клинической симптоматики. Наличие тревоги, депрессии, симптомов дистресса, высоких требований на работе связано с плохим прогнозом восстановления и снижением качества жизни у пациентов с ЦР. В своей практической деятельности большинство врачей не уделяют должного внимания оценке психосоциальных факторов. Для облегчения этой оценки нами разработан телеграмм-бот. Для ЦР характерны естественное благоприятное течение и прогноз. В большинстве случаев ЦР представляет собой спонтанно регрессирующее заболевание, при котором полностью выздоравливают 83–90% пациентов. Методом выбора является консервативное лечение. Представлен клинический случай типичной ЦР. Комплексное мультидисциплинарное лечение, включающее разъяснение, образовательную программу, лечебную физкультуру, мануальную терапию, а также медикаментозную терапию (нестероидные противовоспалительные препараты, габапентин, Комбилипен), позволило достичь хорошего эффекта в виде регресса болевых ощущений, неврологической симптоматики, улучшения психоэмоционального статуса, функциональных способностей и качества жизни.

Ключевые слова: боль в шейном отделе позвоночника, цервикальная радикулопатия, витамины группы «В», мультидисциплинарный подход, мануальная терапия

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Cervical radiculopathy (CR) occurs when the cervical spinal roots are compressed due to degenerative changes in vertebral structures. At the cervical level, compression of radicular structures is most often caused not by the "soft tissue" component of the herniated disc in the epidural space but by compression in the radicular opening itself due to spondylosis. CR can present with various clinical symptoms and their combination in the form of not only pain (usually with "distant" radiation) but also symptoms of dysfunction (hypoaesthesia, motor disorders, decreased tendon reflexes) in the innervation zone of the corresponding spinal roots. Challenge tests aimed at increasing root compression and enhancing clinical symptoms (Spurling, Valsalva, and Elvey tests – Upper Limb Tension Tests, ULTT) are used, as well as other tests to reduce the root compression and relieve pain (traction, shoulder abduction). The diagnosis is based on the analysis of clinical presentation. Root compression is unlikely in the absence of focal neurological symptoms. Native magnetic resonance imaging of the cervical spine is the mainstay of neuroimaging for patients with a new or worsening clinical presentation of non-traumatic CR in the absence of "red flags." When assessing radicular compression, neuroimaging data should be interpreted only in the context of clinical presentation. The presence of anxiety, depression, distress symptoms, and high demands at work is associated with a poor prognosis of recovery and a decrease in the quality of life in patients with CR. Most doctors do not pay enough attention to assessing psychosocial factors. To facilitate this assessment, we have developed a telegram bot. The CR has a naturally favorable course and prognosis. In most cases, CR is a spontaneously resolving condition with a full recovery rate of 83-90%. The method of choice is non-surgical treatment. A case of typical CR is presented. A comprehensive multidisciplinary treatment, including clarification, an educational program, physical therapy, manual therapy, as well as drug therapy (non-steroidal anti-inflammatory drugs, gabapentin, Combilipen) is effective in regression of pain, neurological symptoms, improvement of psycho-emotional status, functional abilities, and quality of life.

Keywords: cervical spine pain, cervical radiculopathy, B vitamins, multidisciplinary approach, manual therapy

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1. Iakhno NN, Abuzarova GR, Alekseev VV, et al. Bol'. Prakticheskoe rukovodstvo. Moscow: MEDpress-inform, 2022 (in Russian).
2. Bono CM, Ghiselli G, Gilbert TJ, 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. DOI:10.1016/j.spinee.2010.10.023
3. Kuijper B, Tans JT, Schimsheimer RJ, et al. Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review. Eur J Neurol. 2009;16(1):15-20. DOI:10.1111/j.1468-1331.2008.02365.x
4. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117(Pt 2):325-35. DOI:10.1093/brain/117.2.325
5. Mansfield M, Smith T, Spahr N, Thacker M. Cervical spine radiculopathy epidemiology: A systematic review. Musculoskeletal Care. 2020;18(4):555-67. DOI:10.1002/msc.1498
6. Kelsey JL, Githens PB, Walter SD, et al. An epidemiological study of acute prolapsed cervical intervertebral disc. The Journal of Bone & Joint Surgery. 2016;66(6):907-14. DOI:10.2106/00004623-198466060-00011
7. Katsuura Y, Bruce J, Taylor S, et al. Overlapping, Masquerading, and Causative Cervical Spine and Shoulder Pathology: A Systematic Review. Global Spine J. 2020;10(2):195-208. DOI:10.1177/2192568218822536
8. Jajeh H, Lee A, Charls R, et al. A clinical review of hand manifestations of cervical myelopathy, cervical radiculopathy, radial, ulnar, and median nerve neuropathies. J Spine Surg. 2024;10(1):120-34. DOI:10.21037/jss-23-39
9. Isaykin AI, Akhmedzhanova LT, Golenkova SS, et al. Cervicobrachial syndrome: diagnostic and treatment algorithms. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(3):110-6 (in Russian). DOI:10.14412/2074-2711-2024-3-110-116
10. Isaikin AI, Shmidt TE, Shor YuM. Cervical radiculopathy. Neurology, Neuropsychiatry, Psychosomatics. 2022;14(5):103-8 (in Russian). DOI:10.14412/2074-2711-2022-5-103-108
11. Guzman J, Haldeman S, Carroll LJ, et al. Clinical Practice Implications of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. Spine (Phila Pa 1976). 2008;33(Suppl. 4):S199-213. DOI:10.1097/brs.0b013e3181644641
12. McAnany SJ, Rhee JM, Baird EO, et al. Observed patterns of cervical radiculopathy: how often do they differ from a standard, "Netter diagram" distribution? Spine J. 2019;19(7):1137-12. DOI:10.1016/j.spinee.2018.08.002
13. Rainville J, Joyce AA, Laxer E, et al. Comparison of Symptoms From C6 and C7 Radiculopathy. Spine (Phila Pa 1976). 2017;42(20):1545-51. DOI:10.1097/BRS.0000000000002353
14. Peng B, Bogduk N. Cervical Discs as a Source of Neck Pain. An Analysis of the Evidence. Pain Med. 2019;20(3):446-55. DOI:10.1093/pm/pny249
15. Kang JD, Stefanovic-Racic M, McIntyre LA, et al. Toward a biochemical understanding of human intervertebral disc degeneration and herniation. Contributions of nitric oxide, interleukins, prostaglandin E2, and matrix metalloproteinases. Spine (Phila Pa 1976). 1997;22(10):1065-73. DOI:10.1097/00007632-199705150-00003
16. 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. Journal Orthopaedic Research. 2004;22(4):895-900. DOI:10.1016/j.orthres.2003.11.008
17. 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.
18. McCartney S, Baskerville R, Blagg S, McCartney D. Cervical radiculopathy and cervical myelopathy: diagnosis and management in primary care. Br J Gen Pract. 2018;68(666):44-6. DOI:10.3399/bjgp17X694361
19. Expert Panel on Neurological Imaging: McDonald MA, Kirsch CFE, et al. ACR Appropriateness Criteria(®) Cervical Neck Pain or Cervical Radiculopathy. J Am Coll Radiol. 2019;16(5S):S57-76. DOI:10.1016/j.jacr.2019.02.023
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22. Thoomes EJ, Scholten-Peeters W, Koes B, et al. The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review. Clin J Pain. 2013;29(12):1073-86. DOI:10.1097/AJP.0b013e31828441fb
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24. Wong JJ, Côté P, Quesnele JJ, et al. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 2014;14(8):1781-9. DOI:10.1016/j.spinee.2014.02.032
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28. Mallard F, Wong JJ, Lemeunier N, Côté P. Effectiveness of Multimodal Rehabilitation Interventions for Management of Cervical Radiculopathy in Adults: An Updated Systematic Review from the Ontario Protocol for Traffic Injury Management (Optima) Collaboration. J Rehabil Med. 2022;54:jrm00318. DOI:10.2340/jrm.v54.2799
29. Kjaer P, Kongsted A, Hartvigsen J, et al. National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy. Eur Spine J. 2017;26(9):2242-27. DOI:10.1007/s00586-017-5121-8
30. Côté P, Wong JJ, Sutton D, et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016;25(7):2000-22. DOI:10.1007/s00586-016-4467-7
31. Liang L, Feng M, Cui X, et al. The effect of exercise on cervical radiculopathy: A systematic review and meta-analysis. Medicine (Baltimore). 2019;98(45):e17733. DOI:10.1097/MD.0000000000017733
32. Zhu L, Wei X, Wang S. Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta-analysis. Clin Rehabil. 2016;30(2):145-55. DOI:10.1177/0269215515570382
33. Parfenov VA, Yakhno NN, Davydov OS, et al. Discogenic lumbosacral radiculopathy. Recommendations of the Russian Association for the Study of Pain (RSSP). Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2020;12(4):15-24 (in Russian). DOI:10.14412/2074-2711-2020-4-15-24
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Авторы

А.И. Исайкин, Е.К. Керимова*, Кинан Муки

ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*ekaterinakerimova29@yandex.ru

________________________________________________

Aleksei I. Isaikin, Ekaterina K. Kerimova*, Kinan Mouki

Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*ekaterinakerimova29@yandex.ru

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