Therapy of spinal canal stenosis involves the impact on the following pathogenetic mechanisms:
1) microfracture neurovascular structures due to their constant compression, friction, tension in a narrow spinal or radicular channel;
2) hypoxia of nerve roots due to chronic venous insufficiency, arterial spasm, microcirculation disorders with the development of peri-and intraneural edema, axonal damage;
3) secondary metabolic disorders due to hypoxia, with the formation of chemicals that cause irritation of pain receptors;
4) demyelination, degeneration roots, ganglia, peri – and intraneural fibrosis, arachnoiditis, peridural autoimmune origin;
5) formation of a pathological system with the presence of excitation generators in the intervertebral and paravertebral ganglia with persistent hyperexcitability of the motor neuron, segmental and suprasegmental apparatus of the autonomic nervous system;
6) impaired liquor circulation, hypertension in the epidural and subarachnoid spaces;
7) instability of the spine, weakness of the muscular corset.
Stenosis of the spinal canal as a whole is characterized by a chronic course. In the clinical picture for years prevails moderately pronounced pain syndrome, limited mobility of the spine, there are elements of intermittent claudication. Decompensation is often associated with the progression of disc disease, the development of spondylarthrosis, instability of the spine as a result of inactivity, detrenirovannosti muscles. Mild spinal injury, weight lifting often provoke severe persistent pain syndrome, and the disease can take a progredient course. Early diagnosis, carrying out a complex of medical and sanitary measures relating to changes in the patient’s lifestyle, his rational employment make it possible in most cases to exclude the growth of neurological deficit, to maintain a high quality of life of people with spinal stenosis of various Genesis and localization.
The most important task in this category of patients is to strengthen the muscular corset that fixes the spine, which is facilitated by regular exercise therapy with the inclusion of a complex of isometric flexor and extensor exercises to strengthen and normalize the tone of the paravertebral muscles. The posture with the straightened back, a slight inclination of a trunk forward is developed. Swimming, Cycling, skiing are recommended. Contraindicated sharp movements with extension, rotation of the trunk, neck, rhythmic gymnastics, contact sports, weightlifting. We have repeatedly observed cases of deterioration of patients as a result of excessive persistent performance of not properly prescribed exercises with aggravation, overextension, excessive rotation of the spine. Limited range of motion, no pain during exercise, moderate load-the main principles of exercise therapy in this category of patients. They can not work with a long stay on their feet, with a forced working posture (doctor, surgeon, dentist, computer operator, Secretary-typist), with frequent turns of the head, torso, lifting weights, in the workplace with adverse temperature factors. Women need to pick up and constantly wear shoes with the optimal height of the heel, as the change of shoes violates the compensatory posture and can cause a relapse of the disease.
Treatment of severe pain or severe intermittent claudication begins with the appointment of strict bed rest for 10-14 days. The spine is immobilized by a rational pose, a fixing soft collar, a corset. Parenterally administered drugs that provide analgesic effect and neurovegetative blockade (analgesics, neuroleptics, tranquilizers, ganglioblockers, antihistamines, anesthetics).
Pathogenetic therapy consists in application of venotonic (aescusan, troxevasin, anavenol), vasodilator drugs (trental, ksantinola nicotinate, no-Spa), of normalizing the microcirculation (heparin, reoglumann, sermion, Cavinton, had chimes). In the first 3-5 days, powerful diuretics (mannitol, lasix) are administered. It is advisable to prescribe antihypoxants (LIPOSTABIL, vitamin E) and antioxidants (Actovegin, Emoxipine).
Calcitonin (miacalcin, calcimar), in addition to effects on bone and cartilage, has a Central analgesic effect via receptors in the hypothalamus, reduces venous congestion in the epidural and subarachnoid spaces. By suppressing prostaglandin synthesis, calcitonin exhibits anti-inflammatory effects. The drug is administered subcutaneously for 100 ME daily for 5 days, then every other day for 3 weeks. In parallel, the patient takes calcium salts and vitamin D(500 ME) inside.
Physiotherapy treatment for exacerbations involves the use of geodinamicheskikh, sinusoidal modulated currents, ultrasound, darsonvalization limbs. Highly effective magnetotherapy, laseropuncture in vegetative-vascular disorders, acupuncture.
Glucocorticoid therapy occupies a special place in the treatment of severe cases of the disease with prolonged pain syndrome, paresis of the feet, pelvic disorders, severe intermittent claudication syndrome. Glucocorticoids suppress autoimmune inflammation, improve axonal conductivity, have a neurotrophic effect, have a unique property of causing lysis of fat and connective tissue at the injection site and thus create a reserve space for neurovascular structures in the stenosis zone.
Epidural injections of glucocorticoids are carried out 1 time a week. A mixture of 0.5% novocaine solution with 1.0 ml of hormone (metipred-40, kenalog-40 or diprospan) is injected into the sacral canal, 3 injections are administered for the course of treatment. At cervical and thoracic level, the drug is administered periduralna. In the root canal at any level, it is enough to introduce 0.5 ml of glucocorticoid. The amount of novocaine or other anesthetic depends on the level of stenosis, to achieve segments LII—LIV 30— 50 ml, for LIV—SI — 10-20 ml with epidural administration; peridural and in the root canal is injected no more than 5 ml. You cannot enter periduralna anesthetics in a concentration of 2% and above. With absolute constitutional stenosis, 20 ml of anesthetic administered epidurally can cause high conduction blockade at the thoracic level with respiratory disorders.
Patients with pronounced pain syndrome, with evidence of radiculoischemia shown pulse therapy intravenous administration of 250-500 mg of medrol in the morning daily, the course of 3-5 injections.
The effect of hormonal therapy can be enhanced by parallel ULTRASOUND diathermy (1.5 W/ cm for 10 min) daily paravertebral to the stenosis area, for a course of 20-30 procedures.
Manual therapy is limited to work on the muscles (postisometric relaxation, massage, including segmental and point) to normalize tone, improve blood circulation, reduce the excitability of the neuromuscular apparatus, as well as spinal traction with root canal stenosis. Manipulation of the spine is contraindicated, as it can cause severe neurological complications.
Hyperbaric oxygenation and hypobarotherapy are the methods of pathogenetic therapy of spinal canal stenosis. Hyperbaric oxygenation (HBO) is prescribed for exacerbations, severe intermittent claudication syndrome in order to normalize Central and peripheral hemodynamics, relieve pain and autonomic disorders. Patients with chronic disease shows courses hypobarotherapy contributing to compensation dysgenesia disorders, normalization of immunogenesis.
In remission after 1-2 months after the exacerbation, recommended heat treatments, radon and hydrogen sulfide baths, phonophoresis of hydrocortisone, troksevazin, massage, physical therapy. Repeated courses of vasoregulatory therapy with the inclusion of venotonics, funds, normalizing microcirculation, and calcium channel blockers (eg, nimotop) for 1-2 months.
In chronic forms of the disease, it is advisable to prescribe immunoregulatory therapy with tactivin (thymalin) by 1.0 ml in the evening for 10 days of 2-3 courses a year. If the clinical picture is dominated by symptoms of overstimulation of the nervous system (fasciculations, cramps, simpatolitiki syndrome with dysesthesiae), the comprehensive therapy should include neuro leptic (eglonil, aralen, frenolon), anticonvulsants (tegretol, a phenytoin, phenobarbital), drugs (xanax, amitriptyline). Shown Vita mines group B, C, E in combination with biostimulants (rumalon, Cerebrolysin, vitreous), adaptogens (pantocrine, ginseng, apilak) and nootropics (piracetam, encephabol).
As our experience shows, persistent stage-by-stage management of the above-described complex of therapeutic and preventive measures, rational employment can prevent the progression of the disease, restore and preserve the ability to work in 75% of patients with spinal canal stenosis; in 25% of cases, rehabilitation is possible only after surgery.