Back pain ranks first among all pain syndromes, occurring in 80–100% of people and causing long-term disability in 4% of the world's population, being the second most common cause of temporary disability and the fifth most common cause of hospitalization. . Persistent or frequently recurring back pain can cause severe suffering to patients and significantly reduce quality of life.
In this article we will tell you the diseases and conditions that can cause back pain, how sick patients are examined, and the treatment that can be prescribed by a doctor.
Classification of back pain
From a pathophysiological point of view, nociceptive, neuropathic and non-functional types of pain are distinguished. Nociceptive pain occurs through direct tissue damage and activation of peripheral pain receptors. Neuropathic pain develops when there is damage affecting the somatosensory system. Dysfunctional pain is formed as a result of 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 occurrence of pain syndromes. In addition, there is associated pain, 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 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 - lower back pain radiating to the legs;
- sacralgia - pain in the sacral area;
- coccydynia - pain in the coccyx.
According to the course of the pain syndrome, acute (lasting less than 4 weeks), subacute (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. Chronic pain syndrome can lead to the appearance of anxiety and depression disorders in patients, feelings of anticipation 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, the selection of a more complex therapeutic regimen including antidepressants.
Depending on the spinal structure involved in the pathological process, compression or reflex syndrome dominates in the clinical picture of this disease. Compression syndrome develops when the modified spinal structure compresses the roots, blood vessels or spinal cord. Reflex syndrome arises as a result of irritation of various spinal structures. Based on localization, vertebrogenic syndromes of the cervical, thoracic and lumbosacral spine are distinguished.
Causes of back pain
Pain in the back is a common symptom of many orthopedic and neurological pathologies, some internal organ diseases, 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 pain in the back. The localization of pain corresponds to the level of the lesion. 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 - a problem in the lumbosacral spine. Pain in osteochondrosis is usually moderate, dull, constant or periodic, intensifies after physical activity and weakens during rest. For fear of provoking an attack, the patient changes their body position slowly and carefully.
With the development of pathological changes, osteochondrosis of the spine can cause the formation of intervertebral hernia, which is characterized by local temporary dull pain that increases during physical activity, stays for a long time in a static position and disappears in a lying position. Gradually, the pain becomes constant, combined with severe muscle tension; some patients experience lumbago and lumboischialgia - attacks of acute severe pain in the lumbar region and posterior thigh.
With degenerative changes in the facet joints that connect the articular processes of adjacent vertebrae, spondyloarthrosis develops, which manifests itself as local pain that occurs during movement and subsides with rest. As the disease progresses, the patient experiences morning stiffness and constant dull pain in the back in the affected area, which increases with prolonged posture.
Another degenerative disease of the spine that occurs with dull pain in the back is spondylosis - a chronic pathology accompanied by degenerative changes in the anterior part of the intervertebral disc, calcification of the anterior longitudinal ligament and the formation of osteophytes in the anterior. and the side of the spine. Pain with spondylosis is local, increasing 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.
Anomalies of the spinal column
Back pain is often observed with congenital anomalies of the spine, sometimes combined with neurological symptoms. Some spinal deformities are asymptomatic for a long time and manifest only in adolescence or adulthood. Pain in the back 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 disturbances, and muscle hypotension.
- Consecration.Congenital spinal anomalies, in which the fifth lumbar vertebra is completely or partially fused with the sacrum, are a relatively common occurrence and often asymptomatic, but in some patients it may be accompanied by pain. In the early onset (at the age of about 20 years), the pain occurs after excessive physical activity, falls on the foot or jumps, radiates to the lower part of the leg, and is sometimes combined with paresthesia. Characteristically, the pain decreases when lying down and increases when sitting on 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 or old age and is usually localized only in the lumbar region.
- Lumbarization.Congenital anomaly, in which the first sacral vertebra is partially or completely separated from the sacrum and "turns" into an additional (sixth) lumbar vertebra, is the reason to visit the doctor in about 2% of all cases of back pain. Signs of pathology appear at a young age. The clinical picture depends on the form of lumbarization. In the lumbar form, the patient is bothered by pain in the lower back and along the spine, which is relieved by taking NSAIDs. A characteristic feature of the sciatica form is the radiating pain in the back and lower legs. In some cases, a violation of skin sensitivity in the thigh and lumbar region is detected.
- The spine is wedge-shaped.Wedge-shaped vertebrae are congenital anomalies, less commonly acquired, 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 pathology, these symptoms may include headache and shortness of breath.
Acquired spinal deformities
With a small defect in the I-II stage of pathology, pain is usually absent. As the process progresses, back pain or pain in the back occurs, which increases 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. Discomfort and minor pain in the back caused by non-physiological posture and muscle weakness can also be observed in patients with poor posture.
Back injury
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:
- injury.When a contusion occurs, the back pain is usually local and moderate, subsides after a few days and disappears completely 1-2 weeks after the injury.
- Traumatic spondylolisthesis.Traumatic vertebral displacement 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, symptoms of axial load are positive.
- Vertebral compression fracture.Injuries are usually caused by jumping or falling from a height. Traumatic injuries are accompanied by sharp pain; with a fracture of the thoracic spine, severe pain in the middle of the back is often combined with difficulty breathing. After that, the patient complains of pain in the projections of the damaged vertebrae, sometimes radiating to the abdomen. Pain decreases when lying down, increases with coughing, deep breathing, movement, as well as 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 detected during an X-ray examination. However, some patients with osteoporosis may experience minor pain in the spine, most often in the thoracic and lumbar regions, which increases with 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 may be the first sign of ankylosing spondylitis, a chronic inflammatory disease of the spine and joints. The characteristic feature of this pathology is the appearance of pain at night, intensification in the morning and a decrease in intensity after physical activity or a hot bath. During the day, the pain also increases during rest and decreases during physical activity. As the disease progresses, pain gradually spreads throughout the spine, mobility is limited, and thoracic kyphosis is formed.
Back pain can occur as a result of post-traumatic or post-operative osteomyelitis - inflammation of the bone marrow, which affects all bone elements (periosteum, spongy and compact material). With vertebral osteomyelitis, pain in the spine usually has a clear localization, is of an intense bursting nature, increases sharply when trying to move, and is combined with hyperthermia, weakness, fever, and significant local edema.
When the infection penetrates the subdural space of the spinal cord, a spinal epidural abscess can form, which manifests itself as a diffuse back pain and an increase in body temperature to high values. The patient experiences localized stiffness in the spinal muscles, pain on percussion of the spinous process, 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 temporary pain in the area of innervation of the nerve root. 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 possible loss of control over the function of the pelvic organs.
Neoplasm of the spine
Benign tumors of the spine are often asymptomatic or accompanied by mild and slow-growing symptoms. The most common spinal tumor detected in patients of any age is hemangioma. In about 10-15% of cases, they are accompanied by localized pain in the back, which increases after physical activity and at night. The cause of the development of pain in spinal hemangioma is the irritation of the pain receptors of the periosteum and posterior longitudinal ligament.
Among the malignant tumors of the spine, sarcoma of the spine is the most frequently diagnosed. In the early stages, the disease is characterized by mild or moderate intermittent pain, worsening at night. The intensity of the pain increased rapidly. Depending on the location of the tumor, patients experience pain in the arms, legs, and internal organs.
Pain in the spine can also be a sign of metastases of internal organ neoplasms. At first, the pain is local, dull, aching, reminiscent of the clinical picture of osteochondrosis, but quickly develops, becomes constant, and depending on the location, can radiate to the arms or legs.
Risk factors for back pain
Factors that can trigger the appearance of back pain can be divided into correctable and non-correctable (heredity, age, gender). Adjustable factors include:
- professional(labor associated with lifting heavy objects, static loads on the spine, boring physical work, including frequent bending forward and turning the body, work accompanied by vibration processes);
- psychosocial(muscle distress caused by acute and/or chronic stress conditions);
- individual physical and somatic characteristics(scoliosis, kyphosis and other spinal deformities, weak muscle corset, boring stereotyped movements);
- Poor nutrition and gastrointestinal disease(malabsorption of B vitamins, consumption of food with a large amount of purine bases, overweight);
- 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 acute stress conditions are enough to form a pain syndrome.
Examination of patients with back pain
The main task of the neurologist when examining patients with acute or chronic back pain is to establish an accurate topical diagnosis and the etiology of the pain syndrome. At the initial appointment, the doctor talks with the patient, finding out all the circumstances surrounding the occurrence of pain.
History taking
Although patients describe pain differently, a careful history can suggest the pathophysiological mechanisms underlying the pain syndrome.
Therefore, the development of acute pain with clear localization, which is well relieved by taking analgesics and is not accompanied by a violation of surface sensitivity, is a characteristic of nociceptive pain syndrome associated with damage to spinal joints, ligaments and muscles. Burning, shooting pain that radiates down the leg 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, changes in skin color, excessive sweating, is often spasmodic and radiates to the opposite half of the body.
It should be noted that low back pain without radiation in the limbs in patients under the age of 50 (if there is no history of malignant neoplasms, clinical signs of systemic diseases and neurological deficits) with a probability of up to 99% is due to musculoskeletal disorders, for example, myofascial pain syndromeor joint pain. -ligament dysfunction.
However, even during the first examination of the patient, the doctor pays attention to the signs that indicate that the back pain may be a symptom of a more serious pathology. Therefore, the presence of fever, local pain and increased local temperature in the paravertebral area may indicate an infectious lesion of the spine, unexplained weight loss, a history of malignant tumors, persistent pain at rest - malignant neoplasm of the spine. column, concomitant uveitis and arthralgia - spondyloarthritis.
Patient examination
Physical examination for back pain in most cases makes it possible to establish the source and pathogenesis of the pain syndrome, to suggest or precisely determine the nature of the underlying pathological process.
During the neurological examination, the doctor pays attention to the posture, posture, and gait of the patient, examines contractures, deformities and asymmetries of the limbs, assesses the condition of the spine, explains the presence and nature of motor, 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 carry out a differential diagnosis, confirm or deny a suspected diagnosis.
When examining patients with back pain, X-ray spondylography with functional tests, computed tomography and magnetic resonance imaging are informative. For acute back pain, patients are advised to perform general and biochemical blood tests and urine tests.
In some cases, neuroimaging methods such as computed tomography and magnetic resonance imaging are highlighted. 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 spinal cord and peripheral nervous system, including to clarify the nature of radiculopathy, electroneuromyography is performed.
Back pain treatment
The main objective of treating patients with back pain is to relieve pain, prevent the disease from becoming chronic, provide conditions for full recovery, and prevent recurrence of exacerbations.
The basis of conservative treatment of pain syndrome consists of non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotrophic vitamins and some other non-drug methods, especially those affecting the nociceptive pain component, including massage, therapeutic exercises, manual therapy.
During the acute period, excessive physical activity is excluded, but instead of long-term bed rest, such patients are shown to return early to a normal activity level 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 pain in the neck, a cervical collar is used. However, long-term fixation of the cervical or lumbar spine is not recommended, except in selected cases, such as a fracture of the spine or the presence of lumbar spondylolisthesis.
When the pain syndrome subsides, the patient is prescribed physiotherapeutic procedures: ultrasound, magnetic therapy, electrical stimulation, reflexology, exercise therapy and recommended massage, and manual therapy is performed according to the indications.
In the case of vertebral instability, compression of the spinal column, intervertebral hernia, or neoplasm, the patient may be recommended surgical treatment. The type and level of surgical intervention is selected individually by the attending physician or medical council. After the operation, antibacterial and analgesic agents, neurotrophic vitamins and other drugs are used, and rehabilitation measures are carried out, including physiotherapeutic techniques, massage, and physical therapy.