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, is the second most common cause of temporary disability and the fifth most common cause of hospitalization. Persistent or frequently recurring back pain can cause great suffering for the patient and significantly reduce the quality of life.
In this article, we will tell you what diseases and conditions can cause back pain, how to examine patients with pain, 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 arises from direct tissue damage and activation of peripheral pain receptors. Neuropathic pain occurs when there is damage to the somatosensory system. Dysfunctional pain occurs due to neurodynamic disorders in the central nervous system. When examining patients with dysfunctional pain, it is usually not possible to identify organic diseases that could explain the occurrence of the pain syndrome. There are also accompanying pains, a typical example of which 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 spreads to the head;
- Cervicobrachialgia – neck pain radiating to the arm;
- Thoracalgia – pain in the middle back and chest area;
- Lumbodynia – pain in the lumbar and/or lumbosacral region;
- Lumboischialgia – pain in the lower back that radiates down the leg;
- Sacralgia – pain in the sacral area;
- Coccydynia – pain in the tailbone.
Depending on the course of the pain syndrome, a distinction is made between acute (lasting less than 4 weeks), subacute (lasting 4 to 12 weeks) and chronic (lasting more than 12 weeks) forms. In most patients seeking medical attention, back pain is acute, lasts for several days, and is easily relieved by nonsteroidal anti-inflammatory drugs and muscle relaxants. In about a third of patients, the pain persists for six weeks and becomes permanent. The chronicity of the pain syndrome can lead to the appearance in the patient of anxiety and depressive disorders, a feeling of expectation of pain, the formation of "pain behavior" and irritability. In this regard, the transition of pain into a chronic form requires a different approach to patient management, selectionmore complex therapeutic regimens including antidepressants.
Depending on which structures of the spine are involved in the pathological process, compression or reflex syndromes predominate in the clinical picture. Compression syndromes occur when altered structures of the spine compress the roots, blood vessels or spinal cord. Reflex syndromes arise from irritation of various structures in the spine. Depending 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 diseases, 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 pain corresponds to the extent of the lesion. So, pain in the neck, which sometimes radiates to the head, indicates pathological changes in the neck area, pain in the spine in the middle of the back indicates damage to the thoracic area, and in the lumbar area indicates problems in the lumbosacral spine. Pain in osteochondrosis is usually moderate, dull, constant or periodic, increases after physical activity and subsides at rest. For fear of provoking an attack, patients slowly and carefully change their posture.
With the progression of pathological changes, osteochondrosis of the spine can lead to the formation of an intervertebral hernia, which is characterized by local transient dull pain, which increases with physical activity, disappears with prolonged stay in a static position and in a lying position. Gradually the pain becomes constant, associated with severe muscle tension; some patients develop lumbago and lumboischialgia – attacks of acute, intense pain in the lumbar region and posterior thigh region.
Degenerative changes in the facet joints that connect the articular processes of adjacent vertebrae result in spondyloarthrosis, which manifests itself as local pain that occurs during movement and subsides at rest. As the disease progresses, patients experience morning stiffness and persistent dull pain in the back in the affected area, which increases with prolonged posture.
Another degenerative disease of the spine, which is accompanied by dull pain in the back, is spondylosis - a chronic pathology associated with degenerative changes in the anterior parts of the intervertebral discs, calcification of the anterior longitudinal ligament and the formation of osteophytes in the anterior and lateral partsThe spine. Pain in spondylosis is local in nature and increases towards the end of the day against the background of overwork, hypothermia and sudden movements, sometimes at night. Spondylosis is characterized by a very slow progression; If no other spinal diseases are present, the clinical manifestations may not worsen for decades.
Spinal abnormalities
Back pain is often observed in congenital anomalies of the spine, sometimes associated with neurological symptoms. Some spinal malformations remain asymptomatic for a long time and only become apparent in adolescence or even adulthood. Back pain can occur with the following diseases:
- Spina bifida.The closed form of the pathology is manifested by moderate local pain in the lumbosacral area, which is often accompanied by impaired sensitivity and reflexes, as well as muscle hypotonia.
- Sacralization.A congenital spinal anomaly in which all or part of the fifth lumbar vertebra fuses with the sacrum is quite common and is often asymptomatic, but may be associated with pain in some patients. With an early onset (around the age of 20), pain occurs after excessive physical activity, falling on the feet or jumping, which radiates to the lower extremities and is sometimes accompanied by abnormal sensations. Typically, the pain eases when lying down and increases when sitting on your heels, jumping, or standing. Late onset pain syndrome is caused by secondary changes in the joints and vertebrae. Pain occurs in middle age or older and is usually only localized in the lumbar area.
- Lumbarization.A congenital anomaly in which the first sacral vertebra partially or completely separates from the sacrum and "transforms" into an additional (sixth) lumbar vertebra is the reason for a visit to the doctor in about 2% of all cases of back pain. Signs of pathology appear even in young childrenyears. The clinical picture depends on the form of lumbarization. With the lumbar form, patients suffer from 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 ofPain in the buttocks and lower extremities. In some cases, a violation of skin sensitivity in the thigh and lumbar region is noted.
- Wedge-shaped vertebrae.Wedge-shaped vertebrae are a congenital, less commonly acquired, anomaly that can cause spinal deformity and back pain. Patients complain of increased fatigue during physical activity, malaise and pain in the back. Depending on the location of the pathology, these symptoms may include headache and shortness of breath.
Acquired spinal deformities
With minor deformities in stage I-II pathology, pain is usually absent. As the process progresses, excruciating or aching pains in the back appear, which intensify against the background of physical activity and prolonged uncomfortable posture. Pain syndrome is observed in spinal deformities such as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis and Scheuermann-Mau disease. In patients with poor posture, discomfort and mild pain in the back can also be observed, which are caused by unphysiological posture and muscle weakness.
Back injuries
Traumatic injuries to the spine and surrounding soft tissue are another common cause of back pain. The severity 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 that radiates 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 stabbing pain; If the thoracic spine is fractured, severe pain in the middle of the back is often accompanied by difficulty breathing. The patient then complains of pain in the projection of the damaged vertebra, some of which radiates into the abdomen. The pain decreases when lying down and increases when coughing, breathing deeply, moving, standing, sitting and walking.
osteoporosis
Osteoporosis is a pathology of bone tissue, which is 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 mild pain in the spine, most commonly in the thoracic and lumbar regions, which increases with physical activity. Sometimes back pain is accompanied by 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, an increase in the morning and a decrease in its intensity after physical activity or a hot shower. During the day, the pain also increases at rest and decreases with physical activity. As the disease progresses, the pain gradually spreads to the entire 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). With vertebral osteomyelitis, the pain in the spine is usually clearly localized, has a strong bursting character, sharply increases when attempts to move and is accompanied by hyperthermia, weakness, fever and pronounced local edema.
If an infection penetrates 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 stiffness of the spinal muscles, pain when hitting the spinous processes and positive symptoms of tension. As inflammation increases, tendon reflexes decrease, resulting in paresis, paralysis and pelvic discomfort.
Infectious inflammation of the arachnoid membrane of the spinal cord leads to the development of spinal arachnoiditis, which is manifested by temporary pain in the area of innervation of the nerve roots. Gradually, pain in the spine becomes permanent and resembles the clinical picture of radiculitis. They are accompanied by sensory and movement disorders as well as a possible loss of control over the function of the pelvic organs.
Spinal neoplasms
Benign tumors of the spine are often asymptomatic or accompanied by mild, slowly progressive symptoms. The most common spinal tumors discovered in patients of all ages are hemangiomas. In around 10-15% of cases they are accompanied by locally aching back pain, which becomes worse 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 the malignant tumors of the spine, spinal sarcoma is the most commonly diagnosed. In the initial stages, the disease is characterized by mild to moderate intermittent pain that worsens at night. The intensity of the pain increases quickly. 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. The pain is initially local, dull, aching and reminiscent of the clinical picture of osteochondrosis, but progresses quickly, becomes constant and, depending on the location, can radiate into the arms or legs.
Risk factors for the development of back pain
Factors that can trigger the occurrence of back pain can be divided into correctable and non-correctable factors (heredity, age, gender). The adjustable factors include:
- Professional(work when lifting heavy objects, static load on the spine, monotonous physical work, including frequent bending and turning of the body, work accompanied by vibration processes);
- psychosocial(Muscle discomfort caused by acute and/or chronic stress);
- individual physical and somatic characteristics(scoliosis, kyphosis and other spinal deformities, weak muscle corset, monotonous stereotypical movements);
- Poor diet and gastrointestinal diseases(malabsorption of B vitamins, consumption of foods high in purine bases, obesity);
- 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, unfavorable movements or an acute stressful situation are enough to develop 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 discusses with the patient all the circumstances that lead to the pain occurring.
historiography
Although patients describe pain differently, a careful history can provide clues to pathophysiological mechanisms underlying the pain syndrome.
Therefore, 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, which are accompanied by damage to the joints of the spine, ligaments and muscles. Burning, stabbing pain that radiates to the extremities and is accompanied by sensory disturbances can be caused by compressive radiculopathy.
Pain associated with damage to internal organs is often not clearly localized, may be accompanied by nausea, skin discoloration and excessive sweating, is often cramp-like in nature and radiates to the other half of the body.
It should be noted that low back pain without irradiation of the limb in patients under 50 years of age (without a history of malignant neoplasm, without clinical signs of systemic disease and without neurological deficit) occurs with a probability of up to 99% caused by musculoskeletal diseases, for example myofascial pain syndrome or joint pain. -Band 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. So, the presence of fever, local pain and an increase in local temperature in the paravertebral area may indicate an infectious lesion of the spine, causeless weight loss, a history of malignant tumors, persistent pain at rest - a malignant neoplasm of the spinal column, accompanying uveitisand arthralgia - spondyloarthritis.
Patient examination
A physical examination for back pain in most cases makes it possible to establish the source and pathogenesis of the pain syndrome and to suspect 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, deformities and asymmetries of the limbs, assesses the condition of the spine, clarifies the presence and nature of motor, sensory and trophic disorders and changes in theTendon 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 help 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 recommended to undergo general and biochemical blood tests, as well as urine tests.
In some cases, imaging techniques 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 extent of damage to the structures of the spinal cord and peripheral nervous system, including clarifying the type of radiculopathy, electroneuromyography is performed.
Treatment of back pain
The main goals of treating patients with back pain are to relieve pain, prevent chronification of the disease, create conditions for comprehensive 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 that mainly affect the nociceptive component of pain, including massage, therapeutic exercises and manual therapy.
During the acute phase, excessive physical activity is excluded, but instead of prolonged bed rest, these patients are shown an early return to the usual level of activity in order to prevent the development of chronic pain syndrome. Strict immobilization is recommended for the first three days. A fixation belt is used for acute pain in the lower back, and a neck brace is used for pain in the neck. However, long-term fixation of the cervical or lumbar spine is not recommended except in selected cases, such as vertebral fractures or the presence of lumbar spondylolisthesis.
When the pain syndrome resolves, patients are prescribed physiotherapeutic procedures: ultrasound, magnetic therapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, manual therapy is carried out depending on the indications.
In case of vertebral instability, spinal compression, intervertebral hernia or neoplasia, the patient may be recommended surgical treatment. The type and extent of the surgical procedure are determined individually by the treating doctor or a medical association. 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.