Back pain is the leading cause of all pain syndromes, affecting 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 for 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 the pathophysiological point of view, nociceptive, neuropathic and dysfunctional types of pain are distinguished. Nociceptive pain occurs through direct tissue damage and activation of peripheral pain receptors. Neuropathic pain develops when there is an injury that 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 impossible 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 - neck pain;
- Cervicocranialgia - pain in the neck that extends to the head;
- Cervicobrachialgia - pain in the neck that radiates to the arm;
- Thoracalgia - pain in the back and chest;
- Lumbodynia - pain in the lumbar and/or lumbosacral region;
- Lumboischialgia - lower back pain that radiates to the leg;
- Sacralgia - pain in the area of the palate;
- Coccydynia - pain in the tailbone.
According to the course of the pain syndrome, acute (lasting less than 4 weeks), subacute (from 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 permanent. The chronicity of the pain syndrome can cause anxiety and depressive disorders in the patient, the feeling of anticipation of pain, the formation of "pain behavior" and irritation. 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, compression or reflex syndromes predominate in the clinical picture of the disease. Compression syndromes develop when the altered structures of the spinal column compress the roots, blood vessels, or spinal cord. Reflex syndromes arise as a result of 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 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 problems in the thoracic region, and in the lumbar region - problems with the lumbosacral spine. Pain in osteochondrosis is usually moderate, dull, constant or periodic, intensifies after physical exertion and weakens during rest. For fear of provoking an attack, patients change their body slowly and carefully.
With the progression of pathological changes, osteochondrosis of the spine can cause the formation of an intervertebral hernia, which is characterized by a local transient dull pain, which increases during physical activity, during a long 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 lower back and back of the thigh.
With degenerative changes in the joints of the connecting phase of the articular processes of the adjacent vertebrae, spondyloarthrosis develops, which is manifested as local pain that occurs during movement and disappears during rest. As the disease progresses, patients develop morning stiffness and constant dull pain in the affected area of the back, which increases with prolonged posture.
Another degenerative disease of the spine, manifested by painful back pain, is spondylosis - a chronic pathology accompanied by degenerative changes in the anterior parts of the intervertebral discs, calcification of the anterior longitudinal ligaments, and the formation of osteophytes in the anterior part. and the 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 diseases of the spine, clinical manifestations may not worsen for decades.
Anomalies of the spinal column
Back pain is often observed with congenital anomalies of the spine, sometimes along with neurological symptoms. Some spine malformations are asymptomatic for a long time and appear 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 spinal anomaly, in which the fifth lumbar vertebra completely or partially fuses with the sacrum, is a fairly common phenomenon and is often asymptomatic, but in some patients it may be accompanied by pain. At an early onset (around 20 years of age), the pain appears after excessive physical exertion, falling or jumping, spreads to the lower limbs, and sometimes is accompanied by paresthesia. Typically, the pain eases when lying down and worsens when sitting on heels, jumping or standing. The late onset of pain syndrome is caused by secondary changes in the joints and spine. The pain occurs in middle or old age and is usually localized only in the lower back.
- Lumbarization.A 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 for visiting a 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 lumbarizationPatients with sciatica suffer from aching pain along the lower back and spine, which is relieved by taking non-steroidal anti-inflammatory drugs. A characteristic symptom of sciatica is radiating pain to the buttocks and lower limbs. In some cases, skin sensitivity disorders in the thigh and lower back have been reported.
- wedge-shaped vertebrae.Wedge-shaped vertebrae are a congenital, less common acquired anomaly that can cause spinal column deformity and back pain. Patients complain of increased fatigue, discomfort and pain in the back during physical activity. Depending on the location of the pathology, these symptoms may include headache and shortness of breath.
Acquired spinal deformities
In stages I-II of the pathology, with minor deformations, pain is usually absent. As the process progresses, aching or aching pain appears in the back, which intensifies due to physical exertion and prolonged uncomfortable position of the body. Pain syndrome is characterized by such deformations of the spinal column as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, Scheuermann-Maus disease. Discomfort and low back pain caused by abnormal posture and muscle weakness can 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:
- trauma.When a bruise occurs, the back pain is usually local and moderate in nature, disappears after a few days and completely disappears 1-2 weeks after the injury.
- Traumatic spondylolisthesis.Traumatic displacement of the spine most often occurs in the lumbar region. Patients complain of moderate to severe pain in the lower back that radiates to the legs. Palpation of the spinous process is painful, axial load symptom is positive.
- Vertebral compression fracture.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. Subsequently, the patient complains of pain in the projection of the damaged spine, which sometimes radiates to the abdomen. 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, 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 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
A dull ache and tightness in the lower back can be the first signs of ankylosing spondylitis, a chronic inflammatory disease of the spine and joints. A characteristic sign of this pathology is the appearance of pain at night, intensification in the morning and a decrease in its intensity after physical exertion 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 to the entire 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 that affects all elements of the bone (periosteum, spongy and compact substance). Spinal pain during osteomyelitis of the spine usually has a clear localization, is of an intense bursting nature, sharply intensifies when trying to move, and is combined with hyperthermia, weakness, fever and pronounced local swelling.
When the infection reaches the subdural space of the spinal cord, a spinal epidural abscess can form, which is manifested by diffuse back pain and a rise in body temperature to high values. Patients present with local stiffness of the back muscles, pain on percussion of the spinal processes, and positive tension symptoms. With increased inflammation, tendon reflexes decrease, 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, which is reminiscent of the clinical picture of sciatica, accompanied by sensory disturbances and motor disturbances and possible loss of control over the functioning of the pelvic organs.
Neoplasms of the spine
Benign tumors of the spinal column are often asymptomatic or present with mild, slowly progressive symptoms. The most common tumor of the spine, which is detected in patients of any age, is hemangioma. In about 10-15% of cases, they are accompanied by local aching pain in the back, which increases after physical exertion 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 the most frequently 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 experience pain in the arms, legs, and internal organs.
Spine pain 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 progresses, becomes permanent and, depending on the location, can spread to the hands and feet.
Risk factors for developing back pain
Factors that can cause 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 and turning of 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, monotonous stereotyped movements);
- Poor nutrition and gastrointestinal diseases(malabsorption of B vitamins, consumption of food with a large amount of purine base, excess body weight);
- bad habits(smoking, alcohol abuse).
These risk factors are quite common, but they can be eliminated or limited by the duration of exposure. Against the background of such predisposing factors, hypothermia, awkward movement or an acute stressful situation are enough to form 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 is to determine the exact current diagnosis and etiology of the pain syndrome. During the initial appointment, the doctor talks to the patient, determines all the circumstances of the pain.
history taking
Although patients describe pain differently, a careful history can reveal the pathophysiological mechanisms underlying the pain syndrome.
Thus, the development of acute pain with a clear localization, which is well resolved by taking analgesics and is not accompanied by a violation of surface sensitivity, is characteristic of pain syndromes associated with damage to the spine, ligaments and muscle joints. Burning, shooting pain that radiates to the extremities 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, skin color change, excessive sweating, is often spasmodic and radiates to the opposite half of the body.
It should be noted that low back pain without extremity irradiation in patients under 50 years of age (in the absence of a history of malignant neoplasm, clinical signs of systemic disease and neurological deficit) is up to 99% likely to be caused by musculoskeletal disorders, for example, myofascial pain syndrome or joint pain. - Ligament dysfunction.
However, even during the first examination of the patient, the doctor pays attention to the signs that indicate that back pain can be a symptom of a more serious pathology. Thus, an increase in fever, local pain and local temperature in the paravertebral area may indicate an infectious lesion of the spine, unexplained weight loss, a history of malignant tumors, persistence of pain at rest - a malignant tumor of the spine. column, accompanying uveitis and arthralgia - spondyloarthritis.
Examination of the patient
Physical examination of 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 the neurological examination, the doctor pays attention to the patient's posture, posture and gait, checks limb contracture, deformation and asymmetry, assesses the condition of the spinal column, specifies the presence and nature of motor disorders, sensory and trophic. Disorders and changes in tendon reflexes. Based on the survey data and examination results, the neurologist prescribes additional examinations 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.
X-ray spondylography with functional tests, computed tomography and magnetic resonance imaging are informative in the examination of patients with back pain. Patients with acute back pain are advised to undergo general and biochemical blood 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. 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 the nature of radiculopathy, electroneuromyography is performed.
Treatment of back pain
The main goal of treatment of patients with back pain is to relieve pain, prevent the disease from becoming chronic, provide 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 other non-narcotic methods that mainly affect the pain-relieving component, including massage, therapeutic exercises, manual therapy.
During the acute period, excessive physical activity is excluded, but instead of prolonged bed rest, such patients are prescribed an early return to usual activity to prevent the development of chronic pain syndrome. During the first three days, strict immobilization is recommended. 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.
Along with the regression of the pain syndrome, patients are prescribed physiotherapeutic procedures: ultrasound, magnetotherapy, electrostimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is performed according to the indications.
In case of instability of the spine, compression of the spinal column, intervertebral hernia or neoplasms, the patient may be advised to undergo surgical treatment. The type and extent of surgical intervention is chosen individually by the attending physician or the medical board. After the operation, antibacterial and painkillers, neurotropic vitamins and other drugs are used, rehabilitation measures are carried out, including physiotherapy techniques, massage and physiotherapy.