Vertebrogenny stethalgia

Description:

Stethalgia – one of the most frequent complaints with which patients see a doctor. Differential diagnosis and treatment in these situations – a complex challenge. It is known that there are about 40-50 reasons of pains in a thorax. On the frequency of occurrence the cardiological reasons (stenocardia, a myocardial infarction, etc.) are in the lead, at the same time there is a high percent of patients with vertebrogenny pain.

Symptoms of the Vertebrogenny stethalgia:

Clinical syndromes of defeat of chest department of a backbone are connected with its functional and anatomic specifics. So, basic function of chest intervertebral (dugootrostchaty) joints increases at the rotational movements. The main loading at the same time falls on front departments of intervertebral disks where there are degenerative defeats more often. At various deformations of a backbone joints of heads of edges and hillocks of edges or in general a composite costovertebral joint suffer. Formation of arthroses is promoted both by diseases of bodies of a thorax, and first of all chronic obstructive diseases of lungs. An upper extremity pain and a shoulder girdle can be caused by a prelum of a neurovascular bunch various dense structures (bones, sheaves, muscles) in a thorax aperture. As the neurovascular bunch passes in close space between a clavicle and the first edge, and also scalenes on a neck, at any pathological deviation in them there can be a prelum of vessels or nerves.
The main clinical displays of vertebrogenny pathology at the chest level are dorsalgiya and pektalgiya. They are the main sources of skeletal and muscular pain syndromes. Pain carries the deep, aching, aching, burning character, is most intensive at night, amplifies at vibration, cooling, rotation of a trunk, is more rare at inclinations aside. Straightening of a trunk is followed by feeling of exhaustion of a back. The joint pain of heads and hillocks of edges amplifies at a deep breath. It is localized in intercostal spaces, being followed sometimes by breath difficulty, especially a breath. Pain can keep days and more. Provocative tests to its emergence are percussion on acanthas, zones of capsules of joints of hillocks of edges and rotation of a trunk. The syndrome of morbidity of a breast is characteristic – began zones грудино - a clavicular and mastoidal muscle. Pain from a zone of a xiphoidal shoot extends to both subclavial areas and on the anteriointernal surfaces of hands. At pathology of a synchondrosis of the VII-X edges mobility of the end of one cartilage increases that leads to its sliding and traumatization of nervous educations. At vertebrogenny irritation of receptors of the struck motive segment (receptors of a fibrous ring of an intervertebral disk, a back longitudinal sheaf, capsules of joints, autokhtonny muscles of a backbone) there are not only local pains in chest department and muscular and tonic disturbances, but also various reflex answers at distance – in the field of the cover fabrics innervatsionno connected with the struck vertebral segments. The nociceptive afferentation coming to various departments of the central nervous system starts a complex of the integrative responses which are evolutionarily directed to a functional immobilization of the struck departments. This muscular and tonic tension of juxtaspinal and ekstravertebralny skeletal muscles. The starting moment of formation of a local muscle hyper tone static work of insignificant intensity is considered for a long time. In the conditions of the constant distorted afferentation brake processes are weakened that finally leads to increase in a tone of all muscle. Except local and spinal segmental mechanisms suprasegmentarny structures – the efferent descending pathways are involved in a pathogeny of a hyper tone (reticulospinal, rubrospinalny and pyramidal). Depending on on what nervous educations the struck structures of PDS have pathological effect, distinguish myofascial, compression and reflex vertebralny syndromes.
Myofascial syndromes meet in 7–35% of cases. Their emergence is provoked by an injury of soft tissues with hemorrhage and serous and fibrous extravasates, a pathological impulsation at visceral defeats, vertebrogenny factors. Pain is caused by a muscular spasm and disturbance of microcirculation in a muscle. Emergence or strengthening of pain at reduction of muscular groups, the movement of hands and trunks is characteristic. Intensity of a pain syndrome can vary from a sensation of discomfort to the most severe pain.
Compression syndromes in chest department of a backbone are rather rare, despite rich radiological manifestation. Clinically it is shown by a girdle pain and a hypalgesia in the corresponding dermatomas at a root compression, and at a compression of a spinal cord – pain, a conduction hypalgesia and pelvic spinal disturbances. Objective disturbance of sensitivity is expressed as a hyperesthesia or a hypesthesia. It is more often broken painful and tactile, is more rare – a thermoesthesia. The muscular and joint feeling usually remains. Sensitive frustration are found in a zone of an innervation of the struck roots. Motive frustration are not so expressed and depend on localization and extent of defeat of a root, autokinesias in the acute period are limited, but paresis meets seldom. Fastsikulyation in the muscles innervated by roots can sometimes be observed. Except compression and ischemic radiculopathies intercostal neuropathies meet even more often. It is promoted by some topografoanatomichesky relations of intercostal nerves. Intercostal nerves at the beginning pass in lower parts of a thorax directly at the capsule and a head of an underlying edge. Here in connection with frequent arthroses and a periarthrosis of joints of a head of an edge there are also conditions for a neuropathy of intercostal nerves. Analgesia depth at pathology is less, than at compression radiculopathies. At girdle pains, paresthesias quite often diagnose also intercostal neuralgia. However it is necessary to know that true intercostal neuralgia is only the acute herpetic ganglioneuritis (Herpes zoster). At a compression hernia of a disk of radikulomedullyarny arteries or their branches the spondilogenny radikulomiyeloishemiya develops. Symptoms of defeat of chest segments of a spinal cord at the same time appear sharply, slowly progress for several weeks. Emergence of symptoms of damage of a spinal cord demands an in-depth kliniko-neurologic and paraclinic study. Manual therapy is contraindicated.

Reasons of the Vertebrogenny stethalgia:

As a rule, primary vertebrogenny pains in a thorax are connected with degenerative and dystrophic changes of a backbone (a dorsopatiya, a spondylosis and a spondylarthrosis). Their development is connected with genetic predisposition, age, influence of risk factors. Degenerative and dystrophic changes lead to emergence of functional blockade and other disturbances of biomechanics of a rachis. It can serve as a releaser of diseases of the internals segmentarno connected with the struck department of a backbone.
At the same time it is necessary to consider that internals have no strict segmented innervation. So, for example, the stomach, a liver, kidneys, a pancreas receive an innervation from the same celiac texture. All physiological and pathological reactions are not limited only to one segment, and pass into zones of the next metameres. Besides, pathology of a backbone serves as the reason of multilateral disorders of nervous control and a trophicity of various internals that leads to development of functional disturbances and organic pathology and can cause a somatopathy. Many domestic and foreign authors claim that in development of vertebrogenny defeats the main place is taken by an uneven fitness of muscles. For example, dominance of sgibatel over razgibatel promotes the shift and an incomplete dislocation in intervertebral joints. Shift or loss of intervertebral disks in the form of protrusions or hernias of an intervertebral disk in combination with local reactive changes are the reasons of infringement and damage of roots of intervertebral nerves. The backbone affected as a result of osteochondrosis creates numerous receptors a flow of a pathological impulsation which in combination with adverse influence of mechanical overloads forms spazmirovanny sites in muscles therefore the condensed tyazh containing painful dense small knots, or trigger points (trigger points) develop. These trigger points cause development of the so-called myofascial pain syndromes causing disease severity of patients.
Secondary vertebrogenny pains meet at damage of a backbone various diseases (infectious, oncological, injuries, etc.). Traumatic and infectious diseases, an ankylosing spondylarthritis (Bekhterev's disease) meet more often, is more rare – tumors and an idiopathic spondylopathy (a youthful dorsal kyphosis, or Shayermana-Mau's disease).
Dorsopatiya are the most frequent reason of primary vertebrogenny pains. Dorsopatiya – group of diseases of a musculoskeletal system and connecting fabric which leading symptom complex is the somatalgia and extremities of not visceral etiology. Discussing questions of a stethalgia, it should be noted that a dorsopatiya — difficult cascade process. Genetic predisposition, microtraumatization, the wrong motive stereotype lead to a degeneration of the vertebral motive segment (VMS). The deformations of fabrics arising under the influence of statodinamichesky loadings are the reason of constant irritation of pain receptors. Gradually mechanical stability of PDS is recovered due to regional growths (osteophytes), fibrosis of disks and the capsule, an anchylosis of facet joints, a thickening of sheaves. Sometimes it leads to spontaneous remitting, a thicket they cause a stenosis of the vertebral channel. The osteophytes directed towards the spinal channel can injure roots, causing or strengthening a pain syndrome. Pathological impulses follow from a longitudinal ligament, a fibrous ring, a periosteum of vertebras, other sheaves and joint capsules through a back root in a back horn of a spinal cord, causing at the same time reflex painful phenomena, can switch to front and side horns. Further they follow to striated muscles, causing their reflex tension (La Défense), a muscular and tonic reflex, vasomotor and other visceral reflexes; to unstriated muscles, including vascular; to visceral bodies (vasomotor and other visceral reflexes). Under the influence of a long impulsation of fabric, especially ischemic, undergo dystrophic changes. It touches first of all the ligaments which are attached to bone ledges, especially in the zones close to joints. These dystrophic changes define as a neuroosteofibrosis.

Treatment of the Vertebrogenny stethalgia:

The basic principles of medicamentous therapy of a vertebrogenny stethalgia are the early beginning, removal of a pain syndrome, a combination of pathogenetic and symptomatic therapy. Medicamentous therapy consists of non-steroidal anti-inflammatory drugs – NPVP (both single — for stopping of an attack, and course reception) and the central muscle relaxants.
For treatment of a stethalgia the adequate analgesia has paramount value. NPVP remain means of the first choice for removal of a pain syndrome. When using traditional NPVP antiinflammatory, febrifugal and anti-anginal effects are sometimes combined with ulcerogenic gastrotoksichesky action and can lead to injury of a mucous membrane of digestive tract, a renal failure, etc. This risk is connected with the main mechanism of action of NPVP – not selective braking of biosynthesis of prostaglandins in different bodies. Though now already about 100 NPVP of various classes are known, search of new representatives of this group continues. It is connected with the need for the drugs having as an optimum ratio of anesthetic and antiinflammatory action, and high degree of safety.
One of modern drugs of this group which is optimum combining the expressed analgetic effect with the minimum quantity of side effects and complications is Ksefokam (lornoksika). Drug represents NPVP with the expressed analgetic action owing to inhibition of synthesis of prostaglandins, oppression of isoenzymes of cyclooxygenase and suppression of formation of free radicals from the activated leukocytes and leukotrienes. Drug actively stimulates development of endogenous dinorfinum and endorphine that is the additional physiological mechanism of stopping of pain syndromes of any intensity and localization. The drug elimination half-life makes about 4 h of a blood plasma that there is much less same period at other NPVP of group of oksikam. Thanks to such short plasma elimination half-life of blood Ksefokam has smaller expressiveness of side effects as during the period between introductions of doses recovery of physiological level of prostaglandins necessary for protection mucous a stomach is possible and maintenance of a normal blood-groove in kidneys, at the same time there are no cumulation and risk of overdose. Absolute bioavailability of drug makes 97%, the maximum concentration it in plasma is reached in 15 min. after intramuscular introduction, and extent of linkng with proteins of plasma makes 99% that, however, does not interfere with its active penetration into a joint. Drug is completely metabolized in a liver under the influence of R-450 cytochrome with formation pharmacological of inactive metabolites, about 1/3 who are brought by kidneys with urine, and 2/3 – a liver and intestines, at the same time enteropechenochny circulation is absent. Such double way of excretion reduces load of these bodies and improves Ksefokam's portability therefore at easy and moderate degree of a liver and/or renal failure of correction of his dose it is not required. Pharmacokinetic processes at elderly people and young people when using drug proceed approximately equally therefore any dose adjustment of drug at elderly is also not required. Generally, unlike other NPVP, Ksefokam possesses low gepato-, nefro-and a gematotoksichnost, good gastrointestinal tolerance, his allergic potential was also recognized as low.
For the purpose of achievement of bystry analgesic effect without use of a parenteral (intramuscular) way of the introduction characteristic of "standard" NPVP, the company developed drug Ksefokam Rapid. It is the tableted drug which is intended for bystry and effective treatment of an acute pain. All tableted NPVP forms existing today are dissolved and soaked up in a small intestine of the person that considerably increases time prior to effect of drug. The pharmacokinetics Ksefokama Rapid at oral administration is similar to an intramuscular way of administration of the anesthetizing non-narcotic drug.  Time of the beginning of the anesthetizing effect of drug is reduced from 30-40 to 10–15 min., i.e. practically in
3 times. It is reached thanks to unique structure and a design of a new tablet Ksefokam Rapid. Lornoksikam who is contained in a tablet Ksefokam Rapid is placed in the microgranules covered with buffer substance. A covering of granules, reacting with a gastric juice, creates an alkalescent environment in which it to lornoksika is quickly dissolved and soaked up in blood.