Back pain takes 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, is the second most common cause of temporary disability and the fifth cause of hospitalization. . Persistent or frequently recurring back pain can cause severe suffering to patients and significantly reduce their quality of life.
In this article, we will explain to you what diseases and conditions can cause back pain, how patients with back pain are examined, and what treatment a doctor can prescribe.
Classification of back pain
From the pathophysiological point of view, nociceptive, neuropathic and dysfunctional types of pain are distinguished. Nociceptive pain occurs as a result of direct tissue damage and activation of peripheral pain receptors. Neuropathic pain develops when damage affects the somatosensory system. Dysfunctional pain is formed due to neurodynamic disturbances in 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 pain syndrome. In addition, there is associated pain, a typical example of which is back pain.
Depending on the location of the pain syndrome, the following types of back pain are distinguished:
- cervicalgia - neck pain;
- cervicocranialgia - neck pain spreading over the head;
- cervicobrachialgia - neck pain radiating to the arm;
- Thoracalgia - pain in the middle of the back and chest region;
- lumbodynia - pain in the back and / or lumbosacral region;
- lumboischialgia - lower back pain radiating to the leg;
- sacralgia - pain in the sacral region;
- coccydynia - pain in the tailbone.
According to the course of the pain syndrome, acute (lasting less than 4 weeks), subacute (4-12 weeks) and chronic (more than 12 weeks) forms are distinguished. In the majority of patients who seek medical attention, back pain is acute, lasts for several days, and is easily relieved with nonsteroidal anti-inflammatory drugs and muscle relaxants. In about a third of patients, the pain lasts for six weeks and is persistent. The chronicity of the pain syndrome can lead to the appearance of anxiety and depressive disorders in the patient, the feeling of waiting for pain, the emergence of "pain behavior" and irritability. In this regard, the transition of pain into a chronic form requires a different approach to patient management, the selection of more complex therapeutic regimens, including antidepressants.
Depending on which structures of the spine are involved in the pathological process, the clinical picture of the disease is dominated by compression or reflex syndromes. Compression syndromes develop when the altered structures of the spine compress the roots, blood vessels, or spinal cord. Reflex syndromes are caused by irritation of various structures of the spine. Vertebrogenic syndromes of the cervical, thoracic and lumbosacral spine are distinguished by localization.
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 localization of pain corresponds to the level of the lesion. Thus, pains in the neck sometimes spreading to the head indicate pathological changes in the neck, pains in the spine in the middle of the back indicate damage to the thoracic region, and problems in the lumbar spine. Pain during osteochondrosis is usually moderate, dull, constant or periodic, intensifies after physical activity 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 increases during physical activity, stays in a static position for a long time, and disappears in a lying position. Gradually, the pain becomes stable, combined with severe muscle tension; some patients develop lumbago and lumboischialgia - sharp intense pain attacks in the lumbar region and the back of the thigh.
Spondyloarthrosis develops with degenerative changes in the facet joints connecting the articular processes of adjacent vertebrae, which manifests itself as local pain that occurs during movements and decreases with rest. As the disease progresses, patients develop morning stiffness and constant dull back pain in the affected area, which increases with prolonged standing.
Another degenerative disease of the spine, which occurs with dull aching pain in the back, is spondylosis - a chronic pathology accompanied by degenerative changes in the anterior parts of the intervertebral discs, calcification of the anterior longitudinal ligament, and the formation of osteophytes in the anterior part. and lateral parts of the spine. Pain with spondylosis is local, towards the end of the day, it intensifies against the background of overload, hypothermia, sudden movements, sometimes at night. Spondylosis is characterized by very slow progress, in the absence of other spinal diseases, clinical manifestations may not worsen for decades.
Anomalies of the spine
Back pain is often observed with congenital anomalies of the spine, sometimes combined with neurological symptoms. Some malformations of the spine are asymptomatic for a long time and manifest only in 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, often accompanied by sensory and reflex disorders and muscle hypotension.
- Sacralization.Congenital spinal anomalies in which the fifth lumbar vertebra is completely or partially fused with the sacrum are quite common and are often asymptomatic, but may be accompanied by pain in some patients. At an early onset (about 20 years old), the pain spreads to the lower limbs and is sometimes combined with paresthesia after excessive physical activity, after falling or jumping. Characteristically, the pain decreases when lying down and intensifies when sitting on the heel, jumping or standing. Late onset of pain syndrome is caused by secondary changes in joints and vertebrae. The pain appears in middle or old age and is usually localized only in the lumbar region.
- Lumbarization.Congenital anomaly, in which the first sacral vertebra partially or completely separates from the sacrum and "turns" into an additional (sixth) lumbar vertebra, is the reason for consulting doctors in about 2% of all cases of back pain. Pathological symptoms appear at a young age. The clinical picture depends on the form of lumbarization. In the lumbar form, patients suffer from aching pain along the lower back and spine, which is relieved by taking NSAIDs. A characteristic feature of the sciatica form is the radiation of pain to the hips and lower extremities. In some cases, a violation of skin sensitivity is detected in the thighs and lower back.
- Wedge-shaped vertebrae.Wedge-shaped vertebrae are a congenital, less common acquired anomaly that can cause spinal deformity and back pain. Patients complain of increased fatigue, restlessness, and back pain during physical activity. Depending on the location of the pathology, these symptoms can be headache and shortness of breath.
Acquired spinal deformities
In the I-II stages of pathology, there is usually no pain with minor deformations. As the process progresses, back nagging or aching pain occurs, which intensifies against the background of physical activity and long-term uncomfortable body position. Pain syndrome is observed with pathological kyphosis and lordosis of the spine, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. Discomfort and minor back pain caused by non-physiological posture and muscle weakness can also be observed in patients with poor posture.
Back injuries
Traumatic injuries to the spine and surrounding soft tissues are another common cause of back pain. The severity of the pain depends on the severity of the injury:
- injuryWhen a bruise occurs, back pain is usually local and moderate, decreases after a few days and disappears completely 1-2 weeks after the injury.
- Traumatic spondylolisthesis.Displacement of traumatic vertebrae occurs most often in the lumbar region. Patients complain of moderate or severe pain in the lower back, spreading to the legs. Palpation of the spinous process is painful, the axial load symptom is positive.
- Compression fracture of the spine.The injury is usually caused by jumping or falling from a height. Traumatic injury is accompanied by acute pain; with a fracture of the thoracic spine, severe pain in the middle of the back is often combined with difficulty in breathing. Later, the patient complains of pain in the projection of the damaged vertebra, sometimes spreading to the abdominal cavity. The pain decreases when lying down, increases during coughing, deep breathing, movements, as well as standing, sitting and walking.
Osteoporosis
Osteoporosis is a pathology of bone tissue, accompanied by a decrease in mass, a decrease 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 often in the chest and lower back, which is aggravated by physical activity. Sometimes back pain is combined with pain in the ribs and hip joints.
Inflammatory and infectious diseases
Dull pain and stiffness in the lower back can be the first symptoms 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, its intensification in the morning and its decrease in intensity after physical activity or a hot shower. During the day, the pain increases during rest and decreases during physical activity. As the disease progresses, pain gradually spreads to the entire spine, its mobility is limited, chest kyphosis is formed.
Back pain can occur due to post-traumatic or postoperative osteomyelitis - inflammation of the bone marrow that affects all elements of the bone (periosteum, spongy and compact substance). With vertebral osteomyelitis, pain in the spine usually has a clear localization, has the character of an intense burst, sharply intensifies when trying to move, and is combined with hyperthermia, weakness, fever and obvious local edema.
When the infection penetrates into the subdural space of the spinal cord, a spinal epidural abscess can develop, which manifests itself as diffuse back pain and elevated body temperature. Local stiffness of spinal muscles, pain on percussion of spinal processes, positive signs of tension are observed in patients. With increasing 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, they are accompanied by sensory disturbances and motor disturbances and a possible loss of control over the work of the pelvic organs.
Neoplasms of the spine
Benign tumors of the spine are often asymptomatic or present with mild, slowly progressive symptoms. Hemangiomas are the most common spinal tumors in patients of any age. In about 10-15% of cases, it is accompanied by local aching pain in the back, which increases after physical activity and at night. The reason for the development of pain in spinal hemangioma is the irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Spinal sarcoma is most often diagnosed among malignant tumors of the spine. At the initial stage, the disease is characterized by mild or moderate pain that worsens at night. The intensity of the pain increases rapidly. Depending on the location of the tumor, patients feel pain in the 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, painful, reminiscent of the clinical picture of osteochondrosis, but quickly develops, becomes stable and, depending on the location, can spread to the arms or legs.
Risk factors for the development of back pain
Factors that trigger the appearance of back pain can be divided into correctable and non-correctable (heredity, age, gender). Modifiable factors include:
- professional(work related to 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(muscle tension caused by being under acute and/or chronic stress conditions);
- individual physical and somatic characteristics(scoliosis, kyphosis and other deformations of the spine, weak muscle corset, monotonous stereotypical movements);
- Malnutrition 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 by exposure time. Against the background of such predisposing factors, hypothermia, clumsy movement or an acute stressful situation are sufficient for the occurrence of pain syndrome.
Examination of patients with back pain
When examining a patient with acute or chronic back pain, the main tasks of a neurologist are to establish an accurate topical diagnosis and etiology of the pain syndrome. At the initial appointment, the doctor talks to the patient, revealing all the circumstances related to the occurrence of pain.
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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, which is well relieved by taking analgesics and is not accompanied by a violation of surface sensitivity, is characteristic of nociceptive pain syndromes associated with damage to the spine, ligaments and joints of muscles. Burning, shooting pain that spreads to the extremities and is accompanied by sensory disturbances can cause 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 and spreads to the opposite half of the body.
It should be noted that in patients younger than 50 years of age (in the absence of malignant neoplasms in the anamnesis, clinical signs of systemic disease, and neurological deficiency), back pain without radiation to the environment is up to 99%. caused by disorders of the musculoskeletal system, such as myofascial pain syndrome or joint pain. - ligament dysfunction.
But even during the first examination of the patient, the doctor pays attention to the signs that indicate that back pain may be a sign of a more serious pathology. Thus, fever, local pain and local temperature increase in the paravertebral region may indicate infectious damage to the spine, unexplained weight loss, history of malignant tumors, persistence of pain at rest - malignant neoplasm of the spine. column, accompanying uveitis and arthralgia - spondyloarthritis.
Patient examination
Physical examination for back pain in most cases allows to determine the source and pathogenesis of the pain syndrome, to suggest or accurately determine the nature of the main pathological process.
During the neurological examination, the doctor pays attention to the posture, posture and gait of the patient, checks the contractures, deformations and asymmetries of the limbs, evaluates the condition of the spine, and clarifies the presence and nature of motor disorders, sensory and trophic disorders. disorders and changes in tendon reflexes. Based on the survey data and examination results, the neurologist prescribes additional tests for the patient.
Laboratory and instrumental diagnostics
Laboratory and instrumental research methods help to make a differential diagnosis, to confirm or refute a suspected diagnosis.
X-ray spondylography, computed tomography and magnetic resonance imaging with functional tests are informative when examining patients with back pain. For acute back pain, patients are advised to have 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. Diagnosis of osteoporosis is based on densitometry. Electroneuromyography is performed to determine the level of damage to the structures of the spinal cord and peripheral nervous system, including to clarify the nature of radiculopathy.
Treatment of back pain
The main goals of treatment of patients with back pain are to relieve pain, prevent the disease from becoming chronic, create conditions for a full course of rehabilitation measures, and prevent recurrence of exacerbations.
The basis of conservative treatment of pain syndrome is non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotropic vitamins and some other non-drug methods, which mainly affect the nociceptive component of pain, including massage, therapeutic exercises, manual therapy.
In the acute period, excessive physical activity is excluded, but instead of long-term bed rest, such patients are advised to return to their usual level of activity early to prevent the development of chronic pain syndrome. Strict immobilization is recommended for the first three days. A fixation belt is used for acute pains in the lumbar region, and a neck collar is used for pains in the neck. However, long-term fixation of the cervical or lumbar spine is not recommended except in selected cases, such as in the presence of a vertebral fracture or lumbar spondylolisthesis.
As the pain syndrome recedes, physiotherapeutic procedures are prescribed to patients: ultrasound, magnetic therapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, manual therapy is performed according to the instructions.
In the case of spinal instability, compression of the spinal column, intervertebral hernia or neoplasms, the patient may be recommended surgical treatment. The type and degree of surgical intervention is selected individually by the attending physician or medical board. After the operation, antibacterial and analgesics, neurotropic vitamins and other drugs are used, rehabilitation measures, including physiotherapeutic methods, massage, and physical therapy are carried out.