Cervicobrachialgia: many reasons, one problem

The article presents the results of a study devoted to identifying the role of functional disorders in the vertebral-motor segments of the cervical spine and clarifying the significance of each of the anatomical structures in the formation of the clinical picture of cervicogenic headache.

Introduction



Headache is one of the most common symptoms in the clinical practice of doctors of various specialties. It is also one of the most difficult symptoms to study and interpret.

According to the International classification of headaches of the 3rd revision (ICGB-3), today there are primary headaches (migraine, tension headache, trigeminal autonomic cephalgia, other primary headaches), a large heterogeneous group of secondary headaches, including, in particular, headaches associated with pathology of the cervical spine, and a third group, which includes headaches and facial pain associated with cranial nerve damage or other diseases. For the first time, the existence of cervicogenic headache (CGB) was mentioned in 1925, when J. A. Barre reported a disease that he called "posterior cervical sympathetic syndrome", and in 1928. his student Y. C. Lieou published his dissertation "Posterior cervical sympathetic syndrome". Then in 1949, M. Barteh-Rochaix described the clinical and radiological picture of the disease in the monograph "Cervical migraine". The term and formulation of the diagnosis of CGB was proposed in 1983 by A. Sjaastadetal, and in 1988 a corresponding section appeared in the International classification of headaches.

According to various authors, the frequency of CGB varies from 2.5 to 70%. According to N. Nilsson (1995), 70% of patients with pain in the cervical spine simultaneously experience headache, but only in 18% of cases it is considered as a consequence of neck pain. At the same time, N. Bogdak indicated that 15-20% of patients with chronic headache have cervicogenic pain. Isolated neck pain is a common occurrence. Periodically, 40-70% of adults in the population complain of pain in the cervical spine. For a long time, it was believed that headache in children is less common than in adults. However, studies in recent decades have shown that the prevalence of headaches in children is between 40% and 75% in the population. Functional disorders in the vertebral-motor segments (PDS) of the cervical spine, in particular disorders in the structures of the upper cervical spine, play a significant role in the Genesis of headache in children and adolescents.

According to most authors, CGB is a pain syndrome localized in the cervical-occipital region, which can spread to the frontotemporal region and the eye area from the homolateral side. Pain is always one-sided. A number of patients may have symptoms such as photo-and phonophobia, lacrimation, which can sometimes be regarded as a manifestation of migraine. A special feature of CGB is that it is provoked by movements in the cervical spine, and after performing certain warm-up movements in the neck, it can be stopped. For the diagnosis of BTF uses the diagnostic criteria presented in the MKGB-3:

A. Pain originating from the neck and perceived in one or more areas of the head and/or the person meets the criteria C and D.

V. Clinical, laboratory and/or neuroimaging evidence of violation or damage in the cervical spine or soft tissues of the neck that are true or possible cause of the headache.

C. the Causal Association of headache with cervical pathology is based on at least one of the following symptoms:

clinical signs confirm that the source of pain is located in the neck;

- pain
- ceases after diagnostic blockage of
- neck structures or nerve formations (with adequate comparative study with placebo).

d.Headache ceases within 3 months after successful treatment of the disorder or damage that caused the pain syndrome.

It is believed that the pathophysiological mechanisms of CGB are well studied. For several decades, the dominant role was given to degenerative-dystrophic changes in the spine, such as osteochondrosis, spondyloarthritis, spondylosis, and uncovertebral arthrosis. At the same time, there are only isolated indications of the role of functional disorders in PDS in the development of CGB. From our point of view, CGB is a heterogeneous group of headaches, which are based on functional and organic changes in various anatomical structures of the cervical spine: joints, ligaments, fascia, muscles, nerves.

The aim of the study was to identify the role of functional disorders in the PDS of the cervical spine and clarify the significance of each of the anatomical structures in the formation of the clinical picture of CGB.


Research material and methods


The study included 110 patients aged 18 to 60 years (average age-38.7+-2.3 years) in accordance with the inclusion and exclusion criteria. The criteria for inclusion in the study were: complaints of neck pain with radiation to the head, the patient's consent to participate in the study. The exclusion criteria were: isolated headache or neck pain, fever, pregnancy and lactation, as well as a history of cerebral circulatory disorders, traumatic brain injury, cancer, and blood diseases. All patients underwent clinical neurological and neuro-orthopedic examinations. Verification of the diagnosis of "CGB" was carried out according to the diagnostic criteria recommended by specialists of the International Association for the study of headache. As an additional method of examination, all patients underwent TRANS-and extracranial duplex scanning according to the generally accepted method. According to the indications of some patients, magnetic resonance imaging of the brain and cervical spine, multispiral computed tomography was performed.


Results


Women (68 people, 61.8%) and 42 men (38.2%) predominated among the surveyed. The duration of the disease at the time of treatment varied from 20 days to 11 years.

All patients complained of discomfort and/or neck pain. About a third of them noted the presence of an acoustic phenomenon (crunch) that occurs when driving. At the same time, the pain in the head area in the examined patients was unilateral in 91 (82.7%) cases. Half of the patients were concerned about limiting the amount of movement in the cervical spine. The presence of visual and auditory disorders associated with movement in the neck or head position was noted in 60% and 14.5%, respectively. Episodic vertigo was described by patients as a feeling of transient instability and unsteadiness of gait, also occurring when changing the position of the head, rotation, or hyperextension of the cervical spine (SHOP).

It should be noted that the change in the volume of specific types of traffic in the SHOP is an important diagnostic criterion. In the cervical region, movements are performed around all three axes: flexion-extension, lateroflexion, and rotation. Approximately half of the flexion and extension (flexion - extension) occurs in the head joint-C0I-CI-CII, i.e. between the occiput, Atlas and axis. The rest of the movement is distributed between the underlying vertebrae, with the greatest amplitude at the level of the CV-CVI-CVII segments. In lateroflexion all the cervical segments participate evenly. To measure the volume of lateroflexia, the angle between the interclavicular and interorbital lines is taken, which is normally 35-45°.

Half of the rotational movements occur between the Atlas and the axis, the rest are evenly distributed between the underlying vertebrae. In this case, isolated rotation or lateroflexion is impossible due to the orientation of the articular surfaces of the vertebrae in space. Rotation is necessarily accompanied by lateroflexia, and lateroflexia of the cervical spine is necessarily combined with rotation movement and a slight shift in the type of sliding. The volume of rotational movements directly depends on the severity of cervical lordosis. Thus, with preserved cervical lordosis, the rotation of the neck is accompanied by a friendly rotation of the thoracic spine to the level of ThIV. With straightened cervical lordosis (achieved by a slight tilt of the head), only the cervical segments take part in rotation. When the neck is fully flexed, when the chin is close to the sternum, rotation occurs at the level of PDS C-CII. With a decrease in the volume of flexion while maintaining the approach of the chin to the neck, the PDS CII-CII is included in the rotational movement. With the maximum extension of the cervical spine, rotation occurs at the PDS CVI-CVII level. In accordance with the biomechanical tasks performed, the SHOP is divided into upper-level and lower-level departments.


Discussion



The effectiveness of CGB treatment depends directly on the complexity of the approach, there is no single effective drug or treatment method. An integrated approach involves the use of rational pharmacotherapy, injectable methods of treatment, manual therapy, physical therapy, physical therapy methods, taking into account the leading mechanisms of development of CGB in each individual patient. Non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, and, in some cases, anticonvulsants are used in the pharmacotherapy of CGB. Non-drug treatments include cognitive behavioral therapy, biofeedback, massage, and physical therapy. Since biomechanical disorders in the cervical spine play an important role in the pathogenesis of CGB, it is necessary and appropriate to include manual therapy techniques in the complex of therapeutic measures.

According to current recommendations, the first choice method for the treatment of CGB is manual therapy using low-speed, high-amplitude techniques, post-isometric relaxation, and physical therapy. A number of controlled clinical trials have shown high efficiency of these methods. We used soft-tissue, relaxation and mobilization techniques. Manipulations were carried out in the presence of indications, using special techniques that allow for a narrowly directed impact on the blocked joint with a vector that depends on the direction of blocking. In cases of acute course of the disease at its onset, when the patient clearly indicates the presence of a provoking factor in the cervical spine (inadequate movement) and for a short period from the onset of the disease to the moment of seeking medical help, the object of manual treatment was PDS of the cervical spine, the muscles of the back of the neck, the upper arms and the suboccipital area. With a longer acute period, in addition to the listed zones, the upper thoracic spine and upper ribs were added. In the presence of a chronic process in the acute stage or its stable course, a complete neuroorthopedic examination of the patient was performed in order to identify the connection of CGB with an inadequate motor stereotype and its subsequent correction. At the same time, biomechanical changes that are pathogenic in nature were most often detected in the pelvic region. Before manual therapy, all patients were required to undergo an x-ray examination in standard projections, which was supplemented with x-ray images with functional tests in case of suspected instability of the SHOP. Immediately before the first session, testing was performed to identify possible contraindications to manual therapy. For this purpose, tests were used: Spurling, vertebral artery, extensor and flexor compression, Valsalva. Patients with suspected pathology of the upper cervical spine (long-standing rotational subluxation C-CII, dysplasia of the joint complex at the same level) underwent multispiral computed tomography. To exclude the pathology of neural structures (Arnold - Chiari anomaly, root compression), individual patients were given magnetic resonance imaging of the brain and cervical spine. The duration of the treatment course ranged from 2-3 sessions for acute pathology to 10-12 sessions for the treatment of chronic process. The effectiveness was evaluated based on a combination of subjective data (reduction or disappearance of pain, stiffness, improvement of the patient's well-being) and the results of an objective study (increase in movement volume, decrease in muscle hypertonicity).

In addition, in order to restore the optimal motor stereotype and motor activity of the muscular apparatus of the cervical spine in patients with CGB, the kinesiotaping method was used. This method allows you to limit painful and excessive loads of the cervical spine, fix the affected muscle and its fascia, and create a reverse proprioceptive connection. Clinical studies have shown that the mechanism of action of kinesiotape is based on the creation of favorable conditions for sanogenetic processes: reduction of pain, improvement of microcirculation, restoration of functional activity of muscles and normalization of joint function. Kinesiotape tasks include structural correction, sensorineural stimulation, and lymphatic drainage. For the treatment of patients with CGB, we used kinesiotaping in complex treatment in combination with medication and manual therapy, but it can also be used as an independent method. Indications for using this method are: myofascial pain syndromes, vertebrogenic diseases of the nervous system, post-traumatic pain syndromes, deformities of the spine and peripheral joints, impaired lymphodynamics. Contraindications for use are: individual intolerance, open wounds and trophic ulcers, eczema, I trimester of pregnancy.


Conclusions



Cervicogenic headache is a heterogeneous group of headaches, one of the main causes of which is functional blockage in the PDS of the cervical spine. The clinical picture of CGB depends on the level of localization of functional blockage. Functional blocking of the PDS of the cervical spine is accompanied by the development of myofascial trigger zones in the neck and suboccipital muscles.

Treatment of CGB should be pathogenetically determined, complex and include rational pharmacotherapy, injectable methods of treatment, manual therapy, physical therapy, physiotherapy and kinesiotaping, which allows you to influence the leading mechanisms of CGB development in each individual patient.