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 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 pathophysiological point of view, nociceptive, neuropathic and dysfunctional types of pain are distinguished. Nociceptive pain is caused by direct tissue damage and activation of peripheral pain receptors. Neuropathic pain develops when there is damage affecting the somatosensory system. Dysfunctional pain is caused by neurodynamic disturbances in the central nervous system. As a rule, when examining a patient with dysfunctional pain, it is not possible to identify organic diseases that could 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 - pain in the neck;
- cervicocranialgia - pain in the neck that spreads to the head;
- cervicobrachialgia - pain in the neck 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 that radiates to the leg;
- sacralgia - pain in the sacral area;
- coccidinia - 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 attention, the 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 becomes persistent. The chronicity of the pain syndrome can lead to the appearance of anxiety and depressive disorders in the patient, the feeling of anticipation of pain, the formation of "pain behavior", irritability. In this regard, the transition of pain into a chronic form requires a different approach to the treatment of patients, the selection of more complex therapeutic regimens, including antidepressants.
Depending on which spinal structures are involved in the pathological process, compression or reflex syndromes predominate in the clinical picture of the disease. Compression syndromes occur when altered spinal structures compress the roots, blood vessels, or spinal cord. Reflex syndromes occur as a result of irritation of various spinal structures. Vertebrogenic syndromes of the cervical, thoracic and lumbosacral spine are distinguished based on localization.
Causes of back pain
Back pain is a common symptom of many orthopedic and neurological pathologies, some diseases of internal organs, metabolic disorders, tumor processes. Let's take a closer look at the most common causes of back pain.
Degenerative diseases of the spinal column
Osteochondrosis of the spine is one of the most common causes of back pain. The localization of the pain corresponds to the level of the lesion. Thus, pain in the neck, sometimes radiating to the head, indicates pathological changes in the neck, pain in the spine in the middle of the back indicates damage to the thoracic part, and in the lumbar part - to problems in the lumbosacral 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, which is characterized by local transient dull pain that intensifies during physical activity, long-term stay in a static position and disappears when lying down. Gradually, the pain becomes constant, combined with strong muscle tension, some patients develop lumbago and lumboischialgia - attacks of acute intense pain in the lumbar region and the back of the thighs.
In the case of 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 at rest. As the disease progresses, patients experience morning stiffness and constant dull pain in the back in the affected area, which intensifies 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 front parts of the intervertebral discs, calcification of the anterior longitudinal ligament and the formation of osteophytes in the front part of the spine. and lateral parts of the spine. Pain in spondylosis is local in nature, intensifies at 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 in combination with neurological symptoms. Some malformations of the spinal column 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, which is often accompanied by sensory and reflex disorders, and muscle hypotension.
- Sacralization.Congenital spine anomaly, in which the fifth lumbar vertebra completely or partially fuses with the sacrum, is quite common and is often asymptomatic, but may be accompanied by pain in some patients. In the early onset (at the age of about 20 years), the pain occurs after excessive physical activity, falling on one's feet or jumping, radiating to the lower extremities, and sometimes in combination with paresthesia. Characteristically, the pain eases when you lie down, and intensifies 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.
- 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 a visit to the doctor in approximately 2% of all cases of back pain. Signs of pathology appear at a young age. Clinical picturedepends on the form of lumbarization. In the lumbar form, patients are tormented by pain in the lower back and along the spine, which are alleviated by taking NSAIDs. A characteristic feature of the sciatic form is the radiation of pain to the buttocks and lower extremities. In some cases, a violation of the sensitivity of the skin in the thigh andlumbar region.
- Cuneiform vertebrae.Scoliosis is a congenital, less often acquired, anomaly that can cause spinal column deformation 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 spinal deformities
With minor deformities in stages I-II of pathology, pain is usually absent. As the process progresses, a nagging or aching pain in the back appears, which intensifies against the background of physical activity and long-term uncomfortable body position. Pain syndrome is observed in such spinal deformities as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. Discomfort and minor back pain caused by non-physiological posture and muscle weakness can also be seen in patients with poor posture.
Back injuries
Traumatic injuries to the spine and surrounding soft tissue are another common cause of back pain. The intensity of the pain depends on the severity of the injury:
- An injury.When a bruise occurs, back pain is usually local and moderate in nature, disappearing after a few days and completely disappearing 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 intense pain in the lower back that spreads to the legs. Palpation of the spinous process is painful, the symptom of axial load is positive.
- Compression fracture of the spine.The injury is usually caused by jumping or falling from a height. A traumatic injury is accompanied by sharp pain, and 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 projection of the damaged vertebra, which sometimes radiates to the abdomen. The pain decreases in the lying position, intensifies when coughing, deep breathing, movements, as well as when standing, sitting and walking.
Osteoporosis
Osteoporosis is a pathology of bone tissue that 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 by X-ray examination. However, some patients with osteoporosis may experience minor pain in the spine, most often in the thoracic and lumbar regions, which are 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 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 reduction of its intensity after physical activity or a warm shower. During the day, the pain also increases at rest and decreases during physical activity. As the disease progresses, the pain gradually spreads along 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, cancellous and compact matter). In vertebral osteomyelitis, the pain in the spine usually has a clear localization, is intense shooting, suddenly intensifies when trying to move and is combined with hyperthermia, weakness, fever and marked local edema.
When the infection penetrates into the subdural space of the spinal cord, a spinal epidural abscess can occur, which manifests itself as diffuse back pain and an increase in body temperature to high values. Patients feel local rigidity of the spinal muscles, pain when percussing 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 area of nerve root innervation. Gradually, pain in the spine becomes permanent, reminiscent of the clinical picture of radiculitis, accompanied by sensory and motor disorders, and a possible loss of control over the work of the pelvic organs.
Neoplasms of the spine
Benign tumors of the spinal column 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 10-15% of cases, they are accompanied by local aching pain in the back, which intensifies after physical activity and at night. The cause of pain development in spinal hemangioma is irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Spinal sarcoma is the most commonly diagnosed malignant tumor of the spinal column. 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 their arms, legs and internal organs.
Pain in the spine can also be a sign of metastases of internal organ neoplasms. In the beginning, the pain is local, dull, painful, reminiscent of the clinical picture of osteochondrosis, but it progresses quickly, becomes constant and, depending on the localization, can radiate to the hands or feet.
Risk factors for developing back pain
Factors that can cause back pain can be divided into correctable and non-correctable (heredity, age, gender). Adjustable 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 distress caused by acute and/or chronic stress);
- individual physical and somatic characteristics(scoliosis, kyphosis and other deformities of the spine, weak muscle corset, monotonous stereotyped movements);
- Poor nutrition and gastrointestinal diseases(malabsorption of vitamin B, consumption of food 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. Against the background of such predisposing factors, hypothermia, uncomfortable movement or an acute stressful situation are sufficient for the onset of 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 the etiology of the pain syndrome. At the initial examination, the doctor talks to the patient, reveals all the circumstances related to the onset of pain.
History taking
Although patients describe pain differently, a careful history can suggest pathophysiological mechanisms underlying pain syndromes.
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 spinal joints, ligaments and muscles. Burning, shooting pain that spreads to the extremities and is accompanied by sensory disturbances can be caused by compressive radiculopathy.
Pain associated with damage to internal organs often has no 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 pain in the lower back without radiation to the extremity in patients younger than 50 years old (in the absence of a history of malignant neoplasm, clinical signs of systemic disease and neurological deficit) with a probability of up to 99% is caused by musculoskeletal disorders, for example, myofascial syndromeaches or pain in the joints. - ligament dysfunction.
However, already during the first examination of the patient, the doctor pays attention to the signs that indicate that back pain may be a symptom of a more serious pathology. Thus, the presence of fever, local pain and local temperature increase in the paravertebral region may indicate an infectious lesion of the spine, unexplained weight loss, history of malignant tumors, persistence of pain at rest - malignant neoplasm of the spine. column, simultaneous uveitis and arthralgia - spondyloarthritis.
Patient review
A physical examination of back pain in most cases makes it possible to establish the source and pathogenesis of the pain syndrome, to suggest or accurately 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, checks for contractures, deformities and asymmetries of the limbs, assesses the condition of the spinal column, clarifies the presence and nature of motor, sensory and trophic disorders. disorders and changes in tendon reflexes. Based on the data from the survey and the results of the examination, the neurologist prescribes additional tests for the patient.
Laboratory and instrumental diagnostics
Laboratory and instrumental research methods help in carrying out differential diagnosis, confirming or refuting a suspected diagnosis.
When examining patients with back pain, X-ray spondylography with functional tests, computed tomography and magnetic resonance are informative. With acute back pain, patients are advised to have general and biochemical tests of blood and urine.
In some cases, neuroimaging methods such as computed tomography and magnetic resonance 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 level of damage to the structures of the spinal cord and peripheral nervous system, including clarifying the nature of the radiculopathy, electroneuromyography is performed.
Treatment of back pain
The main goals of treating patients with back pain are pain relief, prevention of chronic disease, provision of conditions for a complete course of rehabilitation measures and prevention of 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-medicinal 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 such patients, instead of long-term rest in bed, 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 lower back pain, and a cervical collar is used for neck pain. 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 regresses, patients are prescribed physiotherapeutic procedures: ultrasound, magnetotherapy, electrostimulation, reflexology, exercise and massage, and manual therapy is performed according to indications.
In case of spinal instability, spinal column compression, intervertebral hernia or neoplasm, the patient may be recommended surgical treatment. The type and extent of surgical intervention is chosen individually by the doctor or the medical council. After surgery, antibacterial and analgesic agents, neurotropic vitamins and other drugs are used, and rehabilitation measures are carried out, including physiotherapeutic techniques, massage and physical therapy.