Back pain occupies a leading position among all pain syndromes, occurs in 80-100% of people and causes long-term disability in 4% of the world's population, it is the second most common cause of temporary disability. and the fifth most common cause of hospitalization. . Persistent or recurrent back pain can cause severe suffering to patients and significantly reduce quality of life.
In this article we will tell you what diseases and conditions can cause back pain, how patients with pain are examined, and what treatment a doctor can prescribe.
Classification of back pain.
From a pathophysiological point of view, nociceptive, neuropathic and dysfunctional types of pain are distinguished. Nociceptive pain is produced by direct tissue damage and activation of peripheral pain receptors. Neuropathic pain develops when there is damage that affects the somatosensory system. Dysfunctional pain is formed due to neurodynamic disorders in the central nervous system. As a rule, when examining patients with dysfunctional pain, it is not possible to identify organic diseases that could explain the appearance of pain syndrome. In addition, there is associated pain, a typical example of this is back pain.
Depending on the location of the pain syndrome, there are the following types of back pain:
- cervicalgia - neck pain;
- cervicocranialgia: neck pain that extends to the head;
- cervicobrachialgia: neck pain that radiates to the arm;
- Thoracalgia: pain in the middle of the back and chest;
- lumbodynia - pain in the lumbar and/or lumbosacral region;
- lumboischialgia: lower back pain that radiates to the leg;
- sacralgia - pain in the sacral area;
- coccydynia: pain in the tailbone.
Depending on the course of the pain syndrome, acute (lasting less than 4 weeks), subacute (from 4 to 12 weeks) and chronic (more than 12 weeks) forms are distinguished. In most patients who seek medical help, back pain is acute, persists for several days, and is easily relieved with nonsteroidal anti-inflammatory drugs and muscle relaxants. In about a third of patients, the pain persists for six weeks and becomes persistent. The chronicity of pain syndrome can provoke the appearance of anxiety and depressive disorders in the patient, a feeling of anticipation of pain, the formation of "pain behavior" and irritability. In this regard, the transition of pain to a chronic form requires a different approach to the patient's treatment, the selection of more complex therapeutic regimens that include antidepressants.
Depending on which spinal structures are involved in the pathological process, compression or reflex syndromes predominate in the clinical picture of the disease. Compression syndromes develop when altered structures of the spine compress the roots, blood vessels, or spinal cord. Reflex syndromes arise as a result of irritation of various structures of the spine. Depending on the location, vertebrogenic syndromes of the cervical, thoracic and lumbosacral spine are distinguished.
Causes of back pain
Back pain is a common symptom of many orthopedic and neurological pathologies, some diseases of internal organs, metabolic disorders and tumor processes. Let's take a closer look at the most common causes of back pain.
Degenerative diseases of the spine.
Osteochondrosis of the spine is one of the most common causes of back pain. The location of the pain corresponds to the level of the injury. Therefore, pain in the neck, sometimes radiating to the head, indicates pathological changes in the cervical region, pain in the spine in the middle of the back indicates damage to the thoracic region and in the lumbar region, problems in the lumbosacral spine. Pain in osteochondrosis is usually moderate, dull, constant or periodic, intensifies after physical exertion and weakens at rest. For fear of provoking an attack, patients change their body position slowly and carefully.
With the progression of pathological changes, spinal osteochondrosis can lead to the formation of an intervertebral hernia, which is characterized by local transient dull pain that intensifies during physical activity, prolonged stay in a static position and disappears in a position lying down. Little by little, the pain becomes constant, combined with intense muscle tension; Some patients develop lumbago and lumboischialgia, attacks of sharp, intense pain in the lumbar region and the back of the thigh.
With degenerative changes in the facet joints connecting the articular processes of adjacent vertebrae, spondyloarthrosis develops, which manifests itself as local pain that arises during movements and subsides with rest. As the disease progresses, patients develop morning stiffness and constant dull pain in the back in the affected area, which increases with prolonged sitting.
Another degenerative disease of the spine that presents with dull pain in the back is spondylosis, a chronic pathology that is accompanied by degenerative changes in the anterior parts of the intervertebral discs, calcification of the anterior longitudinal ligament and formation of osteophytes in the anterior part. . and lateral parts of the spine. Pain with spondylosis is local in nature, intensifies towards the end of the day, against the background of overload, hypothermia, sudden movements, sometimes at night. Spondylosis is characterized by a very slow progression; In the absence of other spinal diseases, clinical manifestations may not worsen for decades.
Spinal column anomalies.
Back pain is often seen with congenital anomalies of the spine, sometimes combined with neurological symptoms. Some malformations of the spinal column are asymptomatic for a long time and manifest only in adolescence or even in adulthood. Back pain can occur with the following pathologies:
- Spina bifida.The closed form of pathology is manifested by moderate local pain in the lumbosacral region, which is often accompanied by sensory and reflex disorders and muscle hypotension.
- Sacralization.A congenital anomaly of the spine, in which the fifth lumbar vertebra completely or partially fuses with the sacrum, is a fairly common phenomenon and is usually asymptomatic, but in some patients it may be accompanied by pain. Early onset (at the age of about 20 years), pain appears after excessive physical activity, falling or jumping, radiates to the lower extremities and is sometimes combined with paresthesia. Characteristically, the pain decreases when lying down and intensifies when sitting on the heels, jumping, or standing. The late onset of pain syndrome is caused by secondary changes in the joints and vertebrae. The pain appears in middle age or old age and is usually located only in the lumbar region.
- Lumbalization.A congenital anomaly, in which the first sacral vertebra partially or completely separates from the sacrum and "converts" into an additional (sixth) lumbar vertebra, is the reason for a doctor's visit in approximately 2% of all cases of pain backwards. Signs of pathology appear at a young age. The clinical picture depends on the form of lumbarization. In the lumbar form, patients are bothered by pain in the lower back and along the spine, which is relieved by taking NSAIDs. A characteristic feature of the sciatic form is the radiation of pain to the buttocks and lower extremities. In some cases, a violation of skin sensitivity is detected in the thigh and lumbar region.
- Wedge-shaped vertebrae.Wedge-shaped vertebrae are a congenital, less commonly acquired, anomaly that can cause deformation of the spine and back pain. Patients complain of increased fatigue during physical activity, discomfort and pain in the back. Depending on the location of the pathology, these symptoms may include headaches and difficulty breathing.
Acquired spinal deformities
With minor deformities in stages I-II of pathology, pain is usually absent. As the process progresses, an annoying or aching pain occurs in the back, which intensifies against the background of physical activity and a prolonged uncomfortable body position. Pain syndrome is observed with spinal deformities such as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, and Scheuermann-Mau disease. In patients with poor posture, minor discomfort and pain in the back caused by non-physiological postures and muscle weakness can also be observed.
back injuries
Traumatic injuries to the spine and surrounding soft tissues are another common cause of back pain. The intensity of the pain depends on the severity of the injury:
- Injury.When a bruise occurs, back pain is usually local and moderate in nature, subsides after a few days and disappears completely between 1 and 2 weeks after the injury.
- Traumatic spondylolisthesis.Displacement of vertebrae of a traumatic nature most often occurs in the lumbar region. Patients complain of moderate or severe pain in the lower back, which radiates to the legs. Palpation of the spinous process is painful, the axial loading symptom is positive.
- Compression fracture of the spine.The injury is usually caused by a jump or fall from a height. Traumatic injury is accompanied by acute pain; with a fracture in the thoracic spine, severe pain in the middle back is often combined with shortness of breath. Subsequently, the patient complains of pain in the projection of the damaged vertebra, which sometimes radiates to the abdomen. The pain decreases when lying down, increases when coughing, breathing deeply, moving, as well as when standing, sitting and walking.
Osteoporosis
Osteoporosis is a pathology of bone tissue, which is accompanied by a decrease in mass, a decrease in resistance and an increase in bone fragility. In most cases, the disease is asymptomatic and is detected during radiological examination. However, some patients with osteoporosis may experience mild pain in the spine, most often in the thoracic and lumbar region, which intensifies with physical activity. Sometimes back pain is combined with pain in the ribs and hip joints.
Inflammatory and infectious diseases.
Dull pain and a feeling of stiffness in the lower back may be the first signs of ankylosing spondylitis, a chronic inflammatory disease of the spine and joints. A characteristic feature of this pathology is the appearance of pain at night, intensification in the morning and decrease in intensity after physical activity or a hot shower. During the day, pain also increases at rest and decreases during physical activity. As the disease progresses, pain gradually spreads throughout the spine, its mobility is limited, and thoracic kyphosis forms.
Back pain can occur due to post-traumatic or postoperative osteomyelitis, an inflammation of the bone marrow that affects all elements of the bone (periosteum, spongy and compact substance). In vertebral osteomyelitis, pain in the spine usually has a clear localization, has an intense and explosive character, sharply intensifies when trying to move and is combined with hyperthermia, weakness, fever and pronounced local edema.
When the infection penetrates into the subdural space of the spinal cord, a spinal epidural abscess can form, which manifests itself as diffuse back pain and an increase in body temperature to high values. Patients experience local stiffness of the spinal muscles, pain on percussion of the spinous processes, and positive symptoms of tension. With increased inflammation, a decrease in tendon reflexes is observed, paresis, paralysis and pelvic disorders occur.
Infectious inflammation of the arachnoid membrane of the spinal cord leads to the development of spinal arachnoiditis, which is manifested by transient pain in the area of innervation of the nerve roots. Gradually, the pain in the spine becomes permanent, reminiscent of the clinical picture of radiculitis, is accompanied by sensory and motor disorders, and a possible loss of control over the functioning of the pelvic organs.
Spinal neoplasms
Benign tumors of the spine are usually asymptomatic or accompanied by mild symptoms that progress slowly. The most common spinal tumors detected in patients of any age are hemangiomas. In about 10-15% of cases, they are accompanied by local pain in the back, which increases after physical activity and at night. The cause of the development of pain in spinal hemangioma is irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Among malignant tumors of the spine, the most common diagnosis is spinal sarcoma. In the initial stage, the disease is characterized by mild or moderate intermittent pain, which worsens at night. The intensity of the pain increases rapidly. Depending on the location of the tumor, patients experience pain in their arms, legs, and internal organs.
Pain in the spine can also be a sign of metastasis of neoplasms of internal organs. At first, the pain is local, dull, aching, reminiscent of the clinical picture of osteochondrosis, but it progresses rapidly, becomes constant and, depending on the location, can radiate to the arms or legs.
Risk factors for developing back pain
The factors that can trigger the appearance of back pain can be divided into correctable and non-correctable (heredity, age, sex). Adjustable factors include:
- professional(work associated with lifting heavy objects, static loads on the spine, monotonous physical work, including frequent bending forward and turning the body, work accompanied by vibration processes);
- psychosocial(muscular discomfort caused by being under conditions of acute and/or chronic stress);
- individual physical and somatic characteristics(scoliosis, kyphosis and other spinal deformities, weak muscle corset, monotonous stereotyped movements);
- Poor nutrition and gastrointestinal diseases.(malabsorption of B vitamins, consumption of foods with a large amount of purine bases, excess body weight);
- bad habits(smoking, alcohol abuse).
These risk factors are quite common, but can be eliminated or limited depending on the duration of exposure. Against the background of such predisposing factors, hypothermia, uncomfortable movements or an acute stressful situation are enough for the formation of pain syndrome.
Examination of patients with back pain.
The main tasks of a neurologist when examining a patient with acute or chronic back pain are to establish an accurate topical diagnosis and the etiology of the pain syndrome. At the initial appointment, the doctor talks to the patient and discovers all the circumstances surrounding the onset of pain.
story take
Although patients describe pain differently, a careful history can suggest pathophysiological mechanisms underlying the pain syndrome.
Therefore, the development of acute pain with a clear localization, which is well relieved by the intake of analgesics and is not accompanied by a violation of surface sensitivity, is characteristic of nociceptive pain syndromes associated with damage to the joints of the the spine, ligaments and muscles. Burning, stabbing pain that radiates to the extremities and is accompanied by sensory disturbances may be caused by compressive radiculopathy.
Pain associated with damage to internal organs often does not have a clear localization, may be accompanied by nausea, skin discoloration, excessive sweating, is often spasmodic in nature and radiates to the opposite half of the body.
It should be noted that low back pain without irradiation to the limb in patients under 50 years of age (in the absence of a history of malignancy, clinical signs of systemic disease and neurological deficit) with a probability of up to 99% is caused by musculoskeletal disorders, for For example, myofascial pain syndrome or joint pain. -Ligamentous dysfunction.
However, even during the first examination of the patient, the doctor pays attention to signs that indicate that back pain may be a symptom of a more serious pathology. Therefore, the presence of fever, local pain and an increase in local temperature in the paravertebral region may indicate an infectious lesion of the spine, unexplained weight loss, a history of malignant tumors, persistence of pain at rest - a neoplasm malignant of the spine. spine, concomitant uveitis and arthralgia - spondyloarthritis.
Patient examination
A physical examination for back pain in most cases makes it possible to establish the origin and pathogenesis of the pain syndrome, to suggest or accurately determine the nature of the underlying pathological process.
During a neurological examination, the doctor pays attention to the patient's posture, posture and gait, monitors contractures, deformities and asymmetries of the limbs, evaluates the condition of the spine, clarifies the presence and nature of motor, sensory and trophic. disorders and changes in tendon reflexes. Based on the survey data and the results of the examination, the neurologist prescribes additional tests to the patient.
Instrumental and laboratory diagnosis.
Instrumental and laboratory research methods help to make differential diagnoses, confirm or refute the suspected diagnosis.
When examining patients with back pain, X-ray spondylography with functional testing, computed tomography, and magnetic resonance imaging are informative. For acute back pain, patients are recommended to take general and biochemical blood tests and urine tests.
In some cases, neuroimaging methods, such as computed tomography and magnetic resonance imaging, come to the fore. Radioisotope scintigraphy is used to diagnose local inflammatory or metastatic processes. The diagnosis of osteoporosis is based on densitometry. To determine the level of damage to the structures of the spinal cord and peripheral nervous system, including to clarify the nature of radiculopathy, electroneuromyography is performed.
Back pain treatment
The main goals of treating patients with back pain are to relieve pain, prevent the disease from becoming chronic, provide conditions for a full course of rehabilitation measures, and prevent relapse of exacerbations.
The basis of conservative treatment of pain syndrome consists of non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotropic vitamins and some other non-pharmacological methods that mainly affect the nociceptive component of pain, including massage, therapeutic exercises and manual therapy.
During the acute period, excessive physical activity is excluded, but instead of prolonged bed rest, these patients are shown an early return to the usual level of activity to prevent the formation of chronic pain syndrome. Strict immobilization is recommended for the first three days. For acute pain in the lower back a fixation belt is used, for neck pain a cervical collar is used. However, long-term fixation of the cervical or lumbar spine is not recommended, except in selected cases, such as vertebral fracture or presence of lumbar spondylolisthesis.
As the pain syndrome returns, patients are prescribed physiotherapeutic procedures: ultrasound, magnetotherapy, electrical stimulation, reflexology, physiotherapy and massage are recommended, and manual therapy is performed as indicated.
In case of vertebral instability, compression of the spinal column, intervertebral hernia or neoplasms, surgical treatment may be recommended to the patient. The type and scope of surgical intervention is selected individually by the treating doctor or medical council. After the operation, antibacterial and analgesic agents, neurotropic vitamins and other drugs are used, and rehabilitation measures are carried out, including physiotherapy techniques, massage and physiotherapy.