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 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, there are painful, neuropathic and dysfunctional types of pain. Nociception occurs through direct tissue damage and activation of peripheral nociceptors. Neuropathic pain develops when there is damage affecting 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 could explain the appearance of the pain syndrome. In addition, there is associated pain, a typical example of which is low back pain.
Depending on the location of the pain syndrome, there are the following types of back pain:
- neck pain - pain in the neck.
- cervicocranial pain - pain in the neck that spreads to the head.
- cervicobrachial pain - pain in the neck that radiates to the arm.
- Thoracic pain - pain in the middle of the back and chest area.
- lumbodynia - pain in the lumbar and/or lumbar and lumbar region.
- low back pain - pain in the lower back that radiates to the leg.
- sacral lust - pain in the sacral area.
- coccydynia - pain in the tail.
Depending on the course of the pain syndrome, acute (lasting less than 4 weeks), subacute (4 to 12 weeks) and chronic (more than 12 weeks) are distinguished. In most patients who seek medical attention, 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 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 behavior" and irritability. In this regard, the transition of pain into a chronic form requires a different approach to patient management, the choice of more complex treatment 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 compressive or reflex syndromes. Compression syndromes develop when the damaged structures of the spine compress the roots, blood vessels or spinal cord. Reflex syndromes arise as a result of irritation of various spinal structures. Based on localization, spondylogenic 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, certain 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. Pain localization corresponds to the level of damage. Thus, pain in the neck, which sometimes radiates 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 lumbar region - problems in the lumbosacral spine. Pain in osteochondrosis is usually moderate, dull, constant or intermittent, intensifies after physical activity and subsides at rest. For fear of provoking an attack, patients change their body position slowly and carefully.
With the progress of pathological changes, vertebral osteochondrosis can lead to the formation of an intervertebral hernia, which is characterized by local transient dull pain that intensifies during physical activity, long-term stay in a static position and disappears in a lying position. Gradually, the pain becomes constant, combined with strong muscle tension; some patients develop low back and lumbago - attacks of acute severe pain in the lumbar region and the back of the thigh.
With degenerative changes in the facet joints that connect the articular processes of adjacent vertebrae, spondyloarthritis develops, which manifests itself as local pain that occurs during movements and subsides with rest. As the disease progresses, patients develop morning stiffness and constant dull back pain in the affected area, which increases with prolonged posture.
Another degenerative disease of the spine that occurs with dull back pain 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 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 diseases of the spine, the clinical manifestations may not worsen for decades.
Abnormalities of the spine
Back pain is often seen with congenital anomalies of the spine, sometimes in combination with neurological symptoms. Some spinal malformations 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 the pathology is manifested by moderate local pain in the lumbosacral region, which is often accompanied by sensory and reflex disturbances and muscle hypotension.
- Sanctification.A congenital anomaly of the spine, in which the fifth lumbar vertebra is completely or partially fused with the sacrum, is a fairly common phenomenon and is often asymptomatic, but in some patients it may be accompanied by pain. In early onset (around 20 years of age), pain occurs after excessive physical activity, falling on the feet or jumping, radiating to the lower extremities and sometimes in combination with paresthesia. Typically, the pain decreases when you lie down and increases when you sit on your heels, jump, or stand. The late onset of pain syndrome is caused by secondary changes in the joints and vertebrae. The pain occurs in middle or old age and is usually localized only in the lumbar region.
- spinalization.A congenital anomaly, in which the first sacral vertebra partially or completely separates from the sacrum and "turns" into an extra (sixth) lumbar vertebra, is the reason for visits to doctors in about 2% of all cases of low back pain. Signs of pathology appear at a young age. The clinical picture depends on the form of back pain. 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 limbs. In some cases, a violation of skin sensitivity is detected in the thigh and lumbar region.
- Sphenoid vertebrae.Sphenoid vertebrae are a congenital, less commonly acquired, abnormality that can cause spinal deformity and back pain. Patients complain of increased fatigue during physical activity, discomfort and back pain. Depending on the location of the pathology, these symptoms may include headaches and shortness of breath.
Acquired deformities of the spine
With minor deformations in stages I–II of the pathology, pain is usually absent. As the process progresses, nagging or pain in the back appears, which intensifies against the background of physical activity and prolonged unpleasant body position. The pain syndrome is observed with such spinal deformities as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. Discomfort and low back pain caused by abnormal 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 severity of the pain depends on the severity of the injury:
- Damage.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 occurs most often in the lumbar region. Patients complain of moderate to severe pain in the lower back, radiating to the legs. Palpation of the spinous process is painful, the axial load sign is positive.
- Compression fracture of the spine.The injury is usually caused by jumping or falling from a height. Traumatic injury is accompanied by sharp pain; with a fracture of the thoracic spine, severe pain in the middle of the back is often combined with difficulty in breathing. Then the patient complains of pain in the projection of the damaged vertebra, which sometimes radiates to the abdomen. Pain decreases when lying down, increases with coughing, deep breaths, movements, as well as with 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 X-ray. However, some patients with osteoporosis may experience minor pain in the spine, most commonly in the thoracic and lumbar regions, which is aggravated by physical activity. Sometimes back pain is combined with pain in the sides and hip joints.
Inflammatory and infectious diseases
Dull pain and stiffness in the lower back can 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, the pain also increases during 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 solid substance). With vertebral osteomyelitis, pain in the spine is usually clearly localized, sharp, sharply intensifies when trying to move, and is combined with hyperthermia, weakness, fever, and severe local edema.
When the infection penetrates 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 present with local stiffness of the spinal muscles, pain on impingement of the spinous processes, and positive tension symptoms. With increased inflammation, a decrease in tendon reflexes is observed, paresis, paralysis and pelvic disorders appear.
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, accompanied by sensory disturbances and motor disturbances and possible loss of control of the function of the pelvic organs.
Neoplasms of the spine
Benign tumors of the spine are often asymptomatic or accompanied by mild, slowly developing symptoms. The most common spinal tumors detected in patients of any age are hemangiomas. In about 10-15% of cases, they are accompanied by local back pain, which increases after physical activity and at night. The cause of the development of pain in the hemangioma of the spine is the irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Among the malignant tumors of the spine, sarcoma of the spine is most often diagnosed. 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 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. Initially, the pain is local, dull, aching, reminiscent of the clinical picture of osteochondrosis, but quickly progresses, becomes constant and, depending on the location, may 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 (heredity, age, gender). Regulating factors include:
- professional(work associated with lifting heavy objects, static loads on the spine, monotonous physical work, including frequent forward bending and turning of the body, work accompanied by vibration processes).
- psychosocial(muscular discomfort caused by being under conditions of acute and/or chronic stress)
- individual physical and physical characteristics(scoliosis, kyphosis and other spinal deformities, weak muscle corset, monotonous stereotyped movements).
- Poor diet 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 duration of exposure. In the context of such predisposing factors, hypothermia, uncomfortable movement or an acute stressful situation are enough to create a pain syndrome.
Examination of patients with low back pain
The main tasks of a neurologist when examining a patient with acute or chronic low back pain is to determine an accurate local diagnosis and etiology of the pain syndrome. At the initial appointment, the doctor talks with the patient, finding out all the circumstances surrounding the onset of pain.
Download History
Although patients describe pain differently, a careful history may suggest pathophysiological mechanisms underlying the pain syndrome.
Thus, 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 characteristic of pain syndromes associated with damage to the joints of the spine, ligaments and muscles. Burning, 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 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 back pain without extremity radiation in patients under 50 years of age (in the absence of a history of malignant neoplasm, clinical signs of systemic disease and neurological deficit) with a probability of up to 99% caused by musculoskeletal disorders, for example, myofascial pain syndrome or painin the joints - ligament 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. Thus, the presence of fever, local pain and an increase in local temperature in the paraspinal region may indicate an infectious lesion of the spine, weight loss without a cause, a history of malignant tumors, persistence of pain at rest - malignant neoplasm of the spinal column, accompanying uveitis andarthralgia – spondyloarthritis.
Patient examination
Physical examination for back pain in most cases makes it possible to determine the source and pathogenesis of the pain syndrome, suggest or accurately determine the nature of the underlying pathological process.
During a neurological examination, the doctor pays attention to the posture, posture and gait of the patient, checks for contractures, deformations and asymmetries of the limbs, assesses the condition of the spine, clarifies the presence and nature of motor disorders, sensory andtrophic disorders and changes in tendon reflexes. Based on the research data and examination results, the neurologist prescribes additional tests for the patient.
Laboratory and organic diagnosis
Laboratory and instrumental research methods help to make a differential diagnosis, to confirm or reject the suspected diagnosis.
When examining patients with low back pain, X-ray with functional tests, CT and MRI are informative. For acute low back pain, patients are advised to have general and biochemical blood tests and urine tests.
In some cases, neuroimaging methods such as CT and MRI come to the fore. Radioisotope scintigraphy is used to diagnose local inflammatory or metastatic processes. The 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 clarifying the nature of the radiculopathy.
Treatment of back pain
The main goals of treating patients with low back pain are pain relief, prevention of chronic disease, provision of conditions for a full course of rehabilitation measures and prevention of recurrence of exacerbations.
The basis of the conservative treatment of the pain syndrome consists of non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotropic vitamins and some other non-pharmacological methods, which mainly affect the passive component of pain, such as massage, therapeutic exercises, manual therapy.
During the acute period, excessive physical activity is excluded, but instead of long-term bed rest, an early return to the usual level of activity occurs in these patients in order to avoid the formation of chronic pain syndrome. Strict immobilization is recommended for the first three days. For acute lower back pain, 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 a vertebral fracture or the presence of lumbar spondylolisthesis.
As the pain syndrome subsides, patients are prescribed physiotherapeutic procedures: ultrasound, magnetic therapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is performed according to the indications.
In case of spinal instability, spinal compression, intervertebral hernia or neoplasms, the patient may recommend surgical treatment. The type and extent of surgery are selected individually by the attending physician or by a medical board. After the operation, antibacterial and analgesics, neurotropic vitamins and other drugs are used, and rehabilitation measures are carried out, including physiotherapy techniques, massage and physical therapy.