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 hospitalization. Persistent or frequently recurring back pain can cause great 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 pain patients are examined, and what treatment a doctor can prescribe.
Back pain classification
From a 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 damage 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 not possible to identify organic diseases that could explain the occurrence of the pain syndrome. In addition, there are associated 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 – 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 region;
- lumbodynia – pain in the lumbar and/or lumbosacral region;
- lumbosciatica - low back pain radiating to the leg;
- sacralgia - pain in the sacral region;
- 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. 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 to a chronic form requires a different approach to patient treatment, the selection of more complex therapeutic regimens, including antidepressants.
Depending on which spinal structures are involved in the pathological process, compressive or reflex syndromes predominate in the clinical picture of the disease. Compression syndromes develop when altered spinal structures compress the roots, blood vessels, or spinal cord. Reflex syndromes arise 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
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 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 the pain corresponds to the level of the injury. So, 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 the lumbar region - problems with 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 change their body position slowly and carefully.
With the progression of pathological changes, spinal osteochondrosis can lead to the formation of an intervertebral hernia, which is characterized by transient, dull local pain that intensifies during physical activity, prolonged 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 pain and lumboischialgia - attacks of intense acute pain in the lower back and back of the thigh.
With degenerative changes in the joints connecting the articular processes of adjacent vertebrae, spondyloarthrosis develops, which manifests itself as local pain that occurs during movements and disappears with rest. As the disease progresses, patients develop morning stiffness and constant, dull back pain in the affected area, which increases with prolonged sitting.
Another degenerative disease of the spine that occurs with dull back pain is spondylosis - a chronic pathology that is 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 in spondylosis is local in nature, intensifies at the end of the day, against the background of overstrain, hypothermia, sudden movements, sometimes at night. Spondylosis is characterized by very slow progression; In the absence of other spinal diseases, clinical manifestations may not worsen for decades.
Spinal anomalies
Back pain is often observed with congenital spinal anomalies, sometimes combined with neurological symptoms. Some spinal malformations are asymptomatic for a long time and only appear 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, often accompanied by sensory and reflex disturbances and muscular hypotension.
- Sacralization.A congenital anomaly of the spine, in which the fifth lumbar vertebra fully or partially fuses with the sacrum, is a fairly common occurrence and is usually asymptomatic, but in some patients it may be accompanied by pain. With an early onset (around the age of 20), the pain occurs after excessive physical activity, falling from a foot or jumping, radiating to the lower limbs and sometimes combined with paresthesia. Characteristically, the pain decreases when lying down and intensifies when sitting on your heels, jumping or standing. The late onset of the pain syndrome is caused by secondary changes in the joints and vertebrae. The pain appears in middle age or old age and is usually located only in the lower back.
- Lumbalization.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 a reason for medical consultation in approximately 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, patients are bothered by pain in the lower back and along the spine, which is relieved by taking NSAIDs. A characteristic of the sciatic form is the irradiation of pain into the buttocks and lower extremities. In some cases, a violation of the sensitivity of the skin on the thigh and lower back is detected.
- Wedge-shaped vertebrae.Wedge-shaped vertebrae are a congenital anomaly, less commonly acquired, 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 condition, 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, dull or aching pain in the back occurs, which intensifies 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 back pain caused by unphysiological posture and muscle weakness can also be observed 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:
- Wound.When a bruise occurs, back pain is usually local and mild in nature, disappears 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, radiating 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 a jump or fall from a height. Traumatic injury is accompanied by sharp pain; With a fracture in the thoracic spine, severe pain in the middle of the back is often combined with difficulty breathing. Subsequently, the patient complains of pain in the projection of the injured vertebra, sometimes radiating to the abdomen. The pain decreases when lying down, increases with coughing, deep breathing, movement, as well as when 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 x-ray examination. However, some patients with osteoporosis may experience minor pain in the spine, more frequently in the thoracic and lumbar region, which intensifies with physical activity. Sometimes back pain is combined with 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 of this pathology is the appearance of pain at night, which intensifies in the morning and decreases in intensity after physical activity or a hot bath. During the day, pain also increases at rest and decreases during physical activity. As the disease progresses, the pain gradually spreads throughout the spine, its mobility is limited, and thoracic kyphosis forms.
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 compact substance). With vertebral osteomyelitis, pain in the spine usually has a clear localization, is intense and explosive in nature, intensifies sharply when trying to move and is combined with hyperthermia, weakness, fever and pronounced local edema.
When the infection penetrates the subdural space of the spinal cord, a spinal epidural abscess can form, which manifests as diffuse back pain and an increase in body temperature to high values. Patients present with local stiffness of the spinal muscles, pain on percussion of the spinous processes and positive symptoms of tension. With an increase in 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 innervation of the nerve roots. Gradually, back pain becomes permanent, reminiscent of the clinical picture of radiculitis, is accompanied by sensory and motor disorders, as well as a possible loss of control over the functioning of the pelvic organs.
Spinal Neoplasms
Benign spinal tumors are often asymptomatic or accompanied by mild, slowly progressing symptoms. The most common spinal tumors detected in patients of any age are hemangiomas. In approximately 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 spinal hemangioma is irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Among malignant tumors of the spine, spinal sarcoma is the most frequently diagnosed. In the initial phase, the disease is characterized by mild or moderate intermittent pain, worsening 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.
Back pain can also be a sign of metastasis of neoplasms in internal organs. At first, the pain is local, dull, aching, reminiscent of the clinical picture of osteochondrosis, but it progresses quickly, becomes constant and, depending on the location, can radiate to the arms or legs.
Risk factors for developing back pain
The factors that can trigger the appearance of back pain can be divided into correctable and non-correctable (heredity, age, sex). Adjustable factors include:
- professional(work associated with lifting heavy objects, static loads on the spine, monotonous physical work, including frequent bending forward and turning the body, work accompanied by vibration processes);
- psychosocial(muscular discomfort caused by acute and/or chronic stress conditions);
- individual physical and somatic characteristics(scoliosis, kyphosis and other deformities of the spine, weak muscular corset, monotonous stereotypical movements);
- Poor nutrition and gastrointestinal diseases(poor absorption 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 the duration of exposure. Against the background of such predisposing factors, hypothermia, awkward movements or an acute stressful situation are sufficient for the formation of a pain syndrome.
Examination of patients with back pain
The main tasks of a neurologist when examining a patient with acute or chronic low back pain are to establish an accurate topical diagnosis and etiology of the pain syndrome. In the initial consultation, the doctor talks to the patient, discovering all the circumstances surrounding the occurrence of pain.
Making history
Although patients describe pain differently, a careful history may suggest pathophysiological mechanisms underlying the pain syndrome.
Thus, the development of acute pain with a clear localization, which is well relieved by the use of analgesics and is not accompanied by a violation of surface sensitivity, is characteristic of nociceptive pain syndromes associated with injuries to the joints of the spine, ligaments and muscles. Burning, stabbing 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, discoloration of the skin, excessive sweating, is often spasmodic in nature and radiates to the opposite half of the body.
It is noteworthy that low back pain without irradiation to the limb in patients under 50 years of age (in the absence of a history of malignant neoplasia, clinical signs of systemic disease and neurological deficit) with a probability of up to 99% is caused by musculoskeletal disorders. skeletal disorders, for example, myofascial pain syndrome or joint pain.
However, even during the patient's first examination, 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 paravertebral region may indicate an infectious lesion of the spine, causeless weight loss, a history of malignant tumors, persistence of pain at rest - a malignant neoplasm of the spinal column, uveitis and concomitant arthralgia - spondyloarthritis.
Patient examination
A physical examination for back pain in most cases makes it possible to establish the origin 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 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 tendon reflexes. Based on the research data and test results, the neurologist prescribes additional examinations for the patient.
Laboratory and instrumental diagnostics
Laboratory and instrumental research methods help to carry out differential diagnoses, confirm or refute the suspected diagnosis.
When examining patients with back pain, radiographic spondylography with functional tests, computed tomography and magnetic resonance imaging are informative. For acute back pain, patients are advised to undergo general and biochemical blood and urine tests.
In some cases, neuroimaging methods, such as computed tomography and magnetic resonance imaging, gain prominence. 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 to clarify the nature of radiculopathy, electroneuromyography is performed.
Back pain treatment
The main goals of treating patients with back pain are to alleviate pain, prevent the disease from becoming chronic, provide conditions for a full cycle of rehabilitation measures and prevent relapse of exacerbations.
The basis of conservative treatment of pain syndrome consists of non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotropic vitamins and some other non-drug methods, mainly affecting the nociceptive component of pain, including massage, therapeutic exercises, manual therapy.
During the acute period, excessive physical activity is excluded, but instead of prolonged bed rest, these patients show an early return to the usual level of activity in order 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 neck pain, a cervical collar is used. However, prolonged fixation of the cervical or lumbar spine is not recommended except in selected cases, such as vertebral fracture or the presence of lumbar spondylolisthesis.
As the pain syndrome regresses, patients are prescribed physiotherapeutic procedures: ultrasound, magnetic therapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is carried out as indicated.
In case of vertebral instability, spinal compression, intervertebral hernia or neoplasms, the patient may be indicated for surgical treatment. The type and extent of surgical intervention are selected individually by the attending physician or medical board. After the operation, antibacterial and analgesic agents, neurotropic vitamins and other medications are used, and rehabilitation measures are carried out, including physiotherapy, massage and physiotherapy techniques.