Back pain occupies a leading position among all pain syndromes, it occurs in 80-100% of people and causes long-term disability in 4% of the world population, it is the second most common cause of temporary disability and the fifth most common cause of hospitalization. Persistent or recurrent 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 suffering from pain are examined and what treatment a doctor can prescribe.
Classification of back pain
From a pathophysiological point of view, the types of nociceptive, neuropathic and dysfunctional 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 due to neurodynamic disorders 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 onset of pain syndrome. Furthermore, there is associated pain, a typical example of which is back pain.
Depending on the localization of the painful syndrome, the following types of back pain are distinguished:
- cervicalgia - neck pain;
- cervicocranialgia: neck pain that extends to the head;
- cervicobrachialgia: neck pain radiating to the arm;
- Thoracalgia: pain in the center of the back and chest;
- lumbago: pain in the lumbar and/or lumbosacral region;
- lumboischialgia: lower back pain that radiates to the leg;
- sacralgia: pain in the sacral area;
- coccydynia: coccyx pain.
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 seeking medical care, back pain is acute, persists for several days, and is easily relieved by 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 "painful behavior" and irritability. 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, compressive or reflex syndromes predominate in the clinical picture of the disease. Compression syndromes develop when altered structures of the spine compress the roots, blood vessels, or spinal cord. Reflex syndromes result from irritation of various structures of the spine. Based on the location, 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 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 location of the 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 - 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 change their body position slowly and carefully.
With the progression of pathological changes, spinal osteochondrosis can lead to the formation of an intervertebral hernia, characterized by local transient dull pain that intensifies during physical activity, a long 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 severe acute pain in the lower back and back of the thigh.
With degenerative changes in the facet 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 dull, constant back pain in the affected area, which increases with prolonged posture.
Another degenerative disease of the spine that manifests itself with dull, aching pain in the back 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 parts sides of the spinal column. Pain with spondylosis is local in nature, intensifies towards the end of the day, against the background of overstrain, 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.
Spinal anomalies
Back pain is often observed with congenital anomalies of the spine, sometimes combined with neurological symptoms. Some spinal malformations remain 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, which is often accompanied by sensory and reflex disorders and muscle hypotension.
- Sacralization.A congenital spinal anomaly, in which the fifth lumbar vertebra fuses completely or partially with the sacrum, is a fairly common and often asymptomatic occurrence, but in some patients it may be accompanied by pain. With early onset (at the age of approximately 20 years), the pain occurs after excessive physical activity, falling on your feet or jumping, radiating to the lower limbs and sometimes combined with paresthesias. Typically, the pain eases when lying down and intensifies when sitting on the heels, jumping, or standing. Late onset of pain syndrome is caused by secondary changes in the joints and vertebrae. The pain appears in middle age or old age and is usually localized only in the lumbar region.
- Lumbarization.A congenital anomaly, in which the first sacral vertebra is partially or completely separated from the sacrum and "transforms" into an additional (sixth) lumbar vertebra, is a reason for medical examination in approximately 2% of all cases of backache. Signs of pathology appear at a young age. The clinical picture depends on the form of lumbarization. In the lumbar form, patients are disturbed by aching pains in the lower back and along the spine, which are relieved 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 skin sensitivity in the thigh and lumbar region is detected.
- Wedge-shaped vertebrae.Wedge-shaped vertebrae are a congenital, less commonly acquired, anomaly 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 condition, these symptoms may include headache and shortness of breath.
Acquired spinal deformities
With minor deformities in stages I-II of the pathology, pain is usually absent. As the process progresses, a nagging or aching pain in the back occurs, which intensifies against the background of physical activity and prolonged uncomfortable position of the body. Pain syndrome is observed with such deformities of the spine as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. In patients with incorrect posture, discomfort and mild back pain caused by non-physiological posture and muscle weakness may also be observed.
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:
- Injury.When a bruise occurs, back pain is usually local and moderate 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 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 symptom of axial load is positive.
- Compression fracture of the spine.The injury is usually caused by a jump or fall from a height. The traumatic injury is accompanied by acute pain; in case of a fracture of the thoracic spine, severe pain in the center of the back is often combined with difficulty breathing. Subsequently, the patient complains of pain in the projection of the damaged vertebra, sometimes radiating to the abdomen. The pain decreases when lying down, increases with coughing, deep breathing, movements, 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 radiographic examination. However, some osteoporosis patients may experience mild pain in the spine, most often in the thoracic and lumbar region, which worsens with physical activity. Sometimes back pain is combined with pain in the ribs and hip joints.
Inflammatory and infectious diseases
A dull ache and 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 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 at 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, 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 in nature, sharply intensifies 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 may form, which is manifested by widespread back pain and increased body temperature to high values. Patients experience local stiffness of the spinal muscles, pain on percussion of 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 innervation of the nerve roots. Gradually, pain in the spine becomes permanent, resembles the clinical picture of radiculitis, is accompanied by sensory and motor disorders and a possible loss of control over the functioning of the pelvic organs.
Spinal neoplasms
Benign tumors of the spine are often asymptomatic or accompanied by mild, slowly progressive symptoms. The most common spinal tumors found in patients of any age are hemangiomas. In approximately 10-15% of cases they are accompanied by localized 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 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 experience pain in the arms, legs and internal organs.
Pain in the spine can also be a sign of metastases of neoplasms of internal organs. Initially, the pain is local, dull, aching, resembles the clinical picture of osteochondrosis, but rapidly progresses, becomes constant and, depending on the location, can radiate to the arms or legs.
Risk factors for the development of back pain
The factors that can trigger the appearance of 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 rotations of the body, work accompanied by vibration processes);
- psychosocial(muscle stress 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 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 enough for a pain syndrome to form.
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 first appointment, the doctor talks to the patient, finding out all the circumstances surrounding the appearance of pain.
Taking the story
Although patients describe pain differently, a careful history can suggest the pathophysiological mechanisms underlying the pain syndrome.
Therefore, the development of acute pain with a clear localization, which is well relieved by taking analgesics and is not accompanied by a violation of superficial sensitivity, is characteristic of nociceptive pain syndromes associated with damage to the joints of the spine, ligaments and of the muscles. A 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 should be noted that low back pain without irradiation of the limb 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% is caused by musculoskeletal disorders, for example example myofascial pain syndrome or joint pain. -ligament dysfunction.
However, already during the patient's first visit, the doctor pays attention to the signs that indicate that back pain may be a symptom of a more serious pathology. Therefore, the presence of fever, local pain and local temperature increase 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 spine column, concomitant uveitis and arthralgia - spondyloarthritis.
Patient examination
A physical examination for back pain in most cases allows you to establish the source and pathogenesis of the pain syndrome, to suggest or accurately determine the nature of the underlying pathological process.
During a neurological examination, the doctor pays attention to the patient's posture, posture and gait, checks for possible contractures, deformities and asymmetries of the limbs, evaluates the state of the spine, clarifies the presence and nature of motor, sensory and trophic 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 make differential diagnoses, confirm or refute the 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 have general and biochemical blood tests 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 or metastatic inflammatory 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, also to clarify the nature of radiculopathy, electroneuromyography is performed.
Treatment of back pain
The main goals of treating patients with back pain are to relieve pain, prevent the disease from becoming chronic, provide conditions for a full course of rehabilitation measures, and prevent relapse 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-pharmacological methods, which mainly affect the nociceptive component of pain, 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 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, long-term 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, foot reflexology, physical therapy and massage are recommended, and manual therapy is performed according to indications.
In case of vertebral instability, spinal compression, intervertebral hernia or neoplasms, the patient may be advised to undergo surgical treatment. The type and extent of surgical intervention are selected individually by the attending physician or a medical council. After the operation, antibacterial and analgesic agents, neurotropic vitamins and other drugs are used, and rehabilitation measures are performed, including physiotherapeutic techniques, massage and physical therapy.