Back pain occupies a leading place among all pain syndromes, occurs in 80-100% of people and causes long-term disability in 4% of the world's population, is the second cause of temporary disability and the fifth cause of'hospitalization. . Persistent or frequently recurring back pain can cause serious suffering to patients and significantly reduce their 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 physiopathological point of view, we distinguish between nociceptive, neuropathic and dysfunctional types of pain. Nociceptive pain results from direct tissue damage and activation of peripheral pain receptors. Neuropathic pain develops in cases of damage affecting the somatosensory system. Dysfunctional pain is due to neurodynamic disorders of the central nervous system. As a rule, when examining patients with dysfunctional pain, it is not possible to identify organic diseases that can explain the appearance of pain syndrome. Added to this are associated pains, a typical example of which is back pain.
Depending on the location of the pain syndrome, the following types of back pain are distinguished:
- neck pain - neck pain;
- cervicocranialgia – neck pain spreading to the head;
- cervicobrachialgia - neck pain radiating to the arm;
- Thoracalgia – pain in the middle of the back and chest;
- lumbodynia – pain in the lumbar and/or lumbosacral region;
- lumboischialgia – pain in the lower back radiating down the leg;
- sacralgia - pain in the sacral area;
- coccydynia - pain in the coccyx.
Depending on the evolution of the pain syndrome, acute (duration less than 4 weeks), subacute (4 to 12 weeks) and chronic (more than 12 weeks) forms are distinguished. In most patients who seek medical attention, back pain is acute, persists for several days, and is easily relieved by nonsteroidal anti-inflammatory drugs and muscle relaxants. In about a third of patients, the pain lasts for six weeks and becomes persistent. The chronicity of the pain syndrome can lead to the appearance of anxiety and depressive disorders in the patient, a feeling of anticipation of pain, the formation of "pain behaviors" and irritability. In this regard, the transition of pain to a chronic form requires a different approach to patient care, the selection of more complex treatment regimens including antidepressants.
Depending on the spinal structures involved in the pathological process, compression or reflex syndromes predominate in the clinical picture of the disease. Compression syndromes develop when altered structures in the spine compress the roots, blood vessels, or spinal cord. Reflex syndromes result from irritation of various spinal structures. Based on the localization, 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 lesion. So, 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 thelumbosacral spine. Pain in osteochondrosis is usually moderate, dull, constant or periodic, intensifies after physical activity and weakens at rest. For fear of provoking an attack, patients slowly and carefully change their body position.
With the progression of pathological changes, osteochondrosis of the spine can lead to the formation of an intervertebral hernia, characterized by local dull, transient pain that intensifies during physical activity, a long stay in a static position anddisappears when lying down. Little by little, the pain becomes constant, associated with severe 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 is manifested by local pain that occurs during movements and disappears at rest. As the disease progresses, patients develop morning stiffness and a constant dull back pain in the affected area, which increases with prolonged posture.
Another degenerative disease of the spine that occurs with dull aching 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 andof the formation of osteophytes in the anterior part. and the lateral parts of the spine. The pain associated 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 very slow progression; in the absence of other spinal diseases, clinical manifestations may not worsen for decades.
Spinal abnormalities
Back pain is often seen with congenital spinal abnormalities, sometimes associated with neurological symptoms. Some spinal malformations remain asymptomatic for a long time and only appear during adolescence or even adulthood. Back pain can occur with the following pathologies:
- Spina bifida.The closed form of the 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 spinal anomaly, in which the fifth lumbar vertebra completely or partially fuses with the sacrum, is a fairly common phenomenon and is often asymptomatic, but in some patients it may be accompanied by pain. Onset early (around the age of approximately 20), the pain occurs following excessive physical activity, falling on one's feet or jumping, radiating towards the lower limbs, and sometimes associated with paresthesias. Characteristically, the pain eases when lying down and intensifies when sitting on heels, jumping or standing. Late onset of pain syndrome is caused by secondary changes in the joints and vertebrae. The pain appears in middle or old age and is usually localized only in the lumbar region.
- Lower back.A congenital anomaly, in which the first sacral vertebra is partially or completely separated from the sacrum and "transforms" into an additional (sixth) lumbar vertebra, is the reason for seeking medical attention in approximately 2% of all cases ofback pain. 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 aching 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 limbs. In some cases, a violation of skin sensitivity in the thigh and lumbar region is detected.
- Wedge-shaped vertebrae.Wedge-shaped vertebrae are a less commonly acquired congenital abnormality that can cause spinal deformity and back pain. Patients complain of increased fatigue during physical activity, discomfort and pain in the back. Depending on the location of the condition, these symptoms may include headaches and shortness of breath.
Acquired spinal malformations
With minor deformities in stages I - II of pathology, pain is usually absent. As the process progresses, shooting or aching pains in the back appear, which intensify against the background of physical activity and prolonged uncomfortable body position. Pain syndrome is observed with spinal deformities such as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. Minor back discomfort and pain caused by unphysiological posture and muscle weakness may also be seen in patients with poor posture.
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 1-2 weeks after the injury.
- Traumatic spondylolisthesis.Displacement of the vertebrae of a traumatic nature most often occurs in the lumbar region. Patients complain of moderate or severe pain in the lower back, radiating to the legs. Palpation of the spinous process is painful, the symptom of axial loading is positive.
- Compression fracture of the spine.The injury is usually caused by a jump or fall from a height. A traumatic injury is accompanied by acute pain; In cases of thoracic spine fracture, severe mid-back pain is often associated with difficulty breathing. Subsequently, the patient complains of pain at the projection of the injured vertebra, sometimes radiating towards the abdomen. The pain decreases when lying down, increases with coughing, deep breathing, movements, as well as when standing, sitting and walking.
Osteoporosis
Osteoporosis is a pathology of bone tissue which is accompanied by a reduction in mass, a reduction in strength and an increase in bone fragility. In most cases, the disease is asymptomatic and is detected during an x-ray examination. However, some patients with osteoporosis may experience minor pain in the spine, most commonly in the thoracic and lumbar region, which increases with physical activity. Sometimes back pain is associated 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 a decrease in its 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, the pain gradually spreads throughout the spine, its mobility is limited and thoracic kyphosis is formed.
Back pain can occur due to post-traumatic or postoperative osteomyelitis - inflammation of the bone marrow, which affects all elements of the bone (periosteum, spongy and compact substance). With vertebral osteomyelitis, pain in the spine usually has a clear localization, is intense and bursting in nature, sharply intensifies when attempting movement and is associated with hyperthermia, weakness, fever andpronounced local edema.
When the infection enters the subdural space of the spinal cord, a spinal epidural abscess may form, which is manifested by diffuse back pain and an increase in body temperature to high values. Patients experience local rigidity 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 zone of innervation of the nerve roots. Gradually, pain in the spine becomes permanent, reminiscent of the clinical picture of radiculitis, it is accompanied by sensory and motor disorders, and a possible loss of control over the functioning of the pelvic organs.
Spinal tumors
Benign spinal tumors are often asymptomatic or accompanied by mild symptoms that progress slowly. The most common spinal tumors detected in patients of any age are hemangiomas. In approximately 10 to 15% of cases, they are accompanied by painful local pain in the back, which worsens 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, spinal sarcoma is most often diagnosed. In the initial stage, the disease is characterized by intermittent mild or moderate pain, worsening 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 metastases of neoplasms to internal organs. At first, the pain is local, dull, aching, reminiscent of the clinical picture of osteochondrosis, but progresses quickly, becomes constant and, depending on the location, can radiate to the arms or legs.
Risk factors for developing back pain
Factors that can trigger the appearance of back pain can be divided into correctable and non-correctable factors (heredity, age, gender). Adjustable factors include:
- professional(work associated with lifting heavy objects, static loads on the spine, monotonous physical work, including bending forward and frequently turning the body, work accompanied by vibration processes);
- psychosocial(muscle distress caused by being under conditions of acute and/or chronic stress);
- individual physical and somatic characteristics(scoliosis, kyphosis and other deformities of the spine, weak muscular corset, monotonous stereotyped movements);
- Poor diet and gastrointestinal diseases(malabsorption of B vitamins, consumption of foods rich in purine bases, excess weight);
- bad habits(smoking, alcohol abuse).
These risk factors are quite common, but can be eliminated or limited by the duration of exposure. Against the background of such predisposing factors, hypothermia, awkward movements or an acute stressful situation are enough for the formation of a 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 etiology of the pain syndrome. At the first appointment, the doctor talks with the patient and learns all the circumstances of the onset of pain.
History taking
Although patients describe pain differently, a careful history may suggest pathophysiological mechanisms underlying the pain syndrome.
Thus, the development of acute pain with a clear localization, well relieved by taking analgesics and not accompanied by a violation of surface sensitivity, is characteristic of nociceptive pain syndromes associated with damage to the jointsof the spine, ligaments and muscles. Burning, shooting 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, can be accompanied by nausea, skin discoloration, excessive sweating, is often spasmodic in nature and radiates to the opposite halffrom the body.
It should be noted that low back pain without irradiation of 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 to99% are caused by musculoskeletal disorders, for example myofascial pain syndrome or joint pain.
However, even during the first examination of the patient, the doctor is attentive to signs that back pain may be a symptom of a more serious pathology. So, the presence of fever, local pain and an increase in local temperature in the paravertebral region may indicate an infectious lesion of the spine, causeless weight loss, a history of malignant tumors, persistence of painat rest - a malignant tumor of the spine. column, concomitant uveitis and arthralgia - spondyloarthritis.
Patient examination
A physical examination of back pain in most cases allows you to establish the source 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, checks for contractures, deformations and asymmetries of the limbs, assesses the condition of the spine, specifies the presence and naturemotor, sensory and trophic disorders. disorders and changes in tendon reflexes. Based on the survey data and examination results, the neurologist prescribes additional tests to the patient.
Laboratory and instrumental diagnostics
Laboratory and instrumental research methods make it possible to carry out differential diagnosis, confirm or refute the suspected diagnosis.
When examining patients with back pain, X-ray spondylography with functional tests, computed tomography and magnetic resonance imaging are informative. In case of acute back pain, patients are advised to carry out general and biochemical blood tests and urine tests.
In some cases, neuroimaging methods such as computed tomography and magnetic resonance imaging are emphasized. 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 treatment of patients with back pain are to relieve pain, prevent the disease from becoming chronic, provide conditions for a comprehensive program of rehabilitation measures, and prevent relapse of exacerbations.
The basis of conservative treatment of pain syndrome consists of nonsteroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotropic vitamins and other non-drug methods, mainly affecting the nociceptive component of pain, including massage, exercisestherapeutics and manual therapy.
During the acute period, excessive physical activity is excluded, but instead of prolonged bed rest, such patients benefit from a rapid return to the usual level of activity in order 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 the presence of lumbar spondylolisthesis.
As the pain syndrome subsides, physiotherapeutic procedures are prescribed to patients: ultrasound, magnetotherapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is carried out according to indications.
In cases of spinal instability, spinal compression, intervertebral hernia or neoplasms, surgical treatment may be recommended to the patient. The type and extent of surgical intervention is selected individually by the attending physician or a medical council. After the operation, antibacterial and analgesic agents, neurotropic vitamins and other drugs are used and rehabilitation measures are carried out, including physiotherapeutic techniques, massage and physiotherapy.