Back pain ranks first among all pain syndromes, occurring in 80–100% of the population and causing long-term disability in 4% of the world's population, being the second most common cause of pain. causes temporary disability and is the fifth most common cause of hospitalization. . Persistent or frequently recurring back pain can cause severe pain for the patient and significantly reduce quality of life.
In this article, we will tell you what diseases and conditions can cause back pain, how to examine patients with pain, and what treatments a doctor may prescribe.
Classification of back pain
From a pathophysiological point of view, nocturnal, 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 damage affects the body's sensory system. Dysfunctional pain is formed due to neurological disorders 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 appearance of the pain syndrome. There is also accompanying pain, typically back pain.
Depending on the location of the pain syndrome, there are the following types of back pain:
- Cervical pain - neck pain;
- Cervical pain - neck pain radiating to the head;
- Cervical pain - neck pain radiating to the arms;
- Chest pain - pain in the middle of the back and chest;
- Lumbago - pain in the lumbar and/or lumbosacral region;
- low back pain - lower back pain that radiates to the legs;
- Sacral pain - pain in the sacrum area;
- coccydynia - pain in the tailbone.
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, lasts for several days, and is easily relieved by nonsteroidal anti-inflammatory drugs and muscle relaxants. In about a third of patients, the pain lasts six weeks and becomes persistent. Chronic pain syndrome can lead to the appearance of patients with anxiety and depressive disorders, a feeling of fear of pain, the formation of "pain behavior" and discomfort. In this regard, the transition of pain to a chronic form requires a different approach to patient management, the selection of more complex treatment regimens including antidepressants.
Depending on which structures of the spine are involved in the pathological process, compression or reflex syndromes prevail in the clinical picture of the disease. Compression syndrome develops when altered spinal structures compress the roots, blood vessels or spinal cord. Reflex syndrome arises due to irritation of various structures of the spine. Based on localization, vertebral syndromes in the cervical, thoracic and lumbar spine are distinguished.
Causes of back pain
Back pain is a common symptom of many orthopedic and neurological diseases, 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
Spinal degeneration is one of the most common causes of back pain. The location of pain corresponds to the level of damage. So, pain in the neck, sometimes spreading to the head, indicates pathological changes in the neck region, pain in the mid-back spine indicates damage in the thoracic region, and in the lumbar region - problems in the lumbar spineback. The pain in osteoarthritis is usually moderate, dull, continuous or periodic, intensifies after physical activity and weakens with rest. Because of fear of agitation, the patient changes body position slowly and carefully.
With the progression of pathological changes, osteoarthritis of the spine can lead to the formation of intervertebral hernias, which are characterized by local transient dull pain, which intensifies with physical activity. , stays for a long time in a static position and disappears in a lying position. Gradually, the pain becomes constant, combined with severe muscle tension, some patients develop lumbago and lumbago - acute severe pain in the lumbar region and posterior thighs.
With degenerative changes in the facet joints connecting the articular processes of adjacent vertebrae, osteoarthritis develops, manifested by local pain that occurs with movement and subsides with rest. As the disease progresses, the patient experiences morning stiffness and constant dull pain in the back in the affected area, which increases with prolonged posture.
Another degenerative disease of the spine that occurs with dull pain in the back is spondylosis - a chronic disease accompanied by degenerative changes in the anterior part of the intervertebral disc, calcification of the longitudinal ligamentanteriorly and form bone spurs in the anterior part. and the lateral parts of the spine. The pain caused by spinal degeneration is local, gradually increasing at the end of the day, due to overload, 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.
Abnormalities in the spine
Back pain is often observed with congenital malformations of the spine, sometimes combined with neurological symptoms. Some spinal deformities are asymptomatic for a long time and only manifest in adolescence or even adulthood. Back pain can occur with the following diseases:
- Spina bifida.The closed form of the pathology is manifested by moderate localized pain in the lumbosacral region, often accompanied by sensory and reflex disorders and muscle hypotension.
- Hierarchy.Congenital spinal deformity, in which the fifth lumbar vertebra is completely or partially fused with the sacrum, is a fairly common phenomenon and is usually asymptomatic, but in some patients it canaccompanied by pain. With early onset (at about age 20), the pain occurs after excessive physical activity, falls or jumping, radiates to the lower extremities and is sometimes associated with paresthesias. In particular, the pain is relieved when lying down and intensifies when sitting on heels, jumping or standing. Late-onset pain syndrome is caused by secondary changes in the joints and vertebrae. The pain appears in middle-aged or elderly people and is often localized only in the lumbar region.
- Lumbalization.A birth defect in which the first sacral vertebra is partially or completely separated from the sacrum and "turned" into an additional (sixth) lumbar vertebra, is a reason to see a doctor within about2% of all back pain cases. Signs of the disease appear at a young age. The clinical picture depends on the lumbar form. In the lumbar form, the patient feels uncomfortable with pain in the lower back and along the spine, which is relieved by taking NSAIDs. A characteristic feature of sciatica is pain that radiates to the buttocks and lower limbs. In some cases, a violation of skin sensitivity in the thigh and lumbar areas is detected.
- Wedge-shaped vertebrae.Cuneiform vertebrae is a less common birth defect 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 pathology, these symptoms may include headaches and difficulty breathing.
Acquired spinal deformity
With mild deformities in stages I–II of the pathology, there is usually no pain. As the process progresses, persistent pain or soreness in the back occurs, which increases with prolonged physical activity and uncomfortable body positions. Pain syndrome is observed with such deformations of the spine as kyphosis and pathological lordosis, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. Discomfort and mild pain in the back due to physiological posture and muscle weakness can also be experienced in patients with poor posture.
Back injury
Injuries to the spine and surrounding soft tissue are another common cause of back pain. The severity of the pain depends on the severity of the injury:
- Injury.When a bruise appears, back pain is usually local and moderate, gradually reduces after a few days and disappears completely 1–2 weeks after the injury.
- Spondylolisthesis due to trauma.Traumatic vertebral displacement occurs most often in the lumbar region. Patients complain of moderate or severe pain in the lumbar region, radiating down the legs. Palpation of the spinous process is painful, axial load symptoms are positive.
- Compression fracture of the spine.Injuries are often caused by jumping or falling from a height. Injury is accompanied by sharp pain. When there is a fracture of the thoracic spine, severe pain in the middle of the back is often combined with difficulty breathing. Then the patient complains of pain in the protruding part of the damaged vertebra, which sometimes spreads to the abdomen. The pain decreases when lying down, increases when coughing, breathing deeply, moving as well as standing, sitting and walking.
Osteoporosis
Osteoporosis is a disease of bone tissue, accompanied by a loss of mass, decreased strength and increased bone fragility. In most cases, the disease is asymptomatic and detected during X-ray examination. However, some patients with osteoporosis may experience mild pain in the spine, most commonly in the thoracic and lumbar areas, which increases with 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 may be the first sign of ankylosing spondylitis, a chronic inflammatory disease of the spine and joints. The characteristic feature of this pathology is that the pain appears at night, intensifies in the morning and decreases in intensity after physical activity or hot baths. During the day, pain also increases with rest and decreases with physical activity. As the disease progresses, pain gradually spreads throughout the spine, mobility is limited and thoracic kyphosis forms.
Back pain can occur due to post-traumatic or postoperative osteomyelitis - osteomyelitis, which affects all components of the bone (periosteum, spongy and compact). With vertebral osteomyelitis, pain in the spine is often clearly localized, has a violent flare-up, increases sharply when trying to move and is combined with hyperthermia, weakness, fever and local edema. forward.
When infection enters the subdural space of the spinal cord, an epidural abscess can form, manifesting as diffuse back pain and elevated body temperature. The patient has a feeling of local stiffness of the spinal muscles, pain when percussing the rotational processes and active symptoms of tension. With increased inflammation, tendon reflexes decrease, paresis, paralysis, and pelvic disorders occur.
Infectious arachnoiditis of the spinal cord leads to the development of spinal arachnoiditis, which is manifested by transient pain in the innervation zone of the nerve roots. Gradually, pain in the spine becomes permanent, reminiscent of the clinical picture of radiculitis, they are accompanied by sensory disorders and motor disorders, and there may be loss of control over the activities of the spine. pelvic organs.
Spinal cancer
Benign tumors of the spine are often asymptomatic or accompanied by mild, slowly progressive symptoms. The most common spinal tumors detected in patients of all ages are hemangiomas. In about 10–15% of cases, they are accompanied by localized pain in the back, which increases after physical activity and at night. The cause of pain in spinal hemangioma is stimulation of pain receptors of the periosteum and posterior longitudinal ligament.
Among malignant tumors of the spine, spinal sarcoma is the most commonly diagnosed. In the early stages, the disease is characterized by mild or moderate intermittent pain that is worse at night. The intensity of the pain increases rapidly. Depending on the location of the tumor, the patient will experience pain in the arms, legs and internal organs.
Pain in the spine can also be a sign of metastasis of internal tumors. At first, the pain is local, dull, aching, reminiscent of the clinical picture of osteoarthritis, but quickly progresses, becomes persistent and, depending on the location, can spread to the arms or legs.
Risk factors for developing back pain
Factors that can cause back pain can be divided into modifiable and non-modifiable (genetics, age, gender). Adjustment factors include:
- professional(labor associated with lifting heavy objects, static loads on the spine, monotonous manual labor, including frequent bending forward and turning, work accompanied by vibration processes);
- Psychosocial(muscle failure due to acute and/or chronic stress);
- individual physical and body characteristics(scoliosis, kyphosis and other spinal deformities, weak muscle coat, monotonous stereotypic movements);
- Poor nutrition and gastrointestinal diseases(malabsorption of B vitamins, consumption of foods with large amounts of purine, excess body weight);
- bad habits(smoking, alcoholism).
These risk factors are common but can be eliminated or limited by the duration of exposure. Against the background of such predisposing factors, hypothermia, awkward movements or acute stress conditions are enough to form a pain syndrome.
Examination of patients with back pain
The main task of the neurologist when examining a patient with acute or chronic back pain is to establish the correct local diagnosis and cause of the pain syndrome. At the first appointment, the doctor talks with the patient, finds out all the circumstances surrounding the pain.
Get history
Although patients describe pain differently, a careful history can suggest pathophysiological mechanisms underlying the pain syndrome.
Therefore, the development of acute pain with clear localization, relieved by taking analgesics and not accompanied by a violation of surface sensitivity, is characteristic of the associated nocturnal pain syndrometo damage to spinal joints, ligaments and muscles. Burning pain, pain spreading to the limbs and accompanied by sensory disturbances may be due to nerve 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 and spreads to the opposite half of the muscle. can.
It should be noted that low back pain without irradiation to the extremities in patients under 50 years of age (without a history of malignant neoplasms, clinical signs of systemic disease and neurological deficits) with a probability of up to 99% isdue to musculoskeletal disorders, such as myofascial pain syndrome or arthralgia.
However, even during the patient's first examination, doctors also pay attention to signs that back pain may be a symptom of a more serious condition. Therefore, the presence of fever, local pain and local increased temperature in the paravertebral region may indicate an infectious lesion in the spine, unexplained weight loss, a history of malignant tumors, persistent pain at rest - a malignant tumor of the spine. spine, concurrent uveitis and joint pain - ankylosing spondylitis.
Patient examination
Physical examination of back pain in most cases can determine the origin 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 patient's posture, gait and gait, checks for contractures, deformities and asymmetry of the limbs, evaluates the condition of the spine, and clarifies the presence ofPresence and nature of motor, sensory and nutritional disorders. disorders and changes in tendon reflexes. Based on survey data and examination results, the neurologist prescribes additional tests for the patient.
Diagnostic laboratories and instruments
Laboratory and instrumental research methods help to carry out differential diagnosis, confirm or refute the suspected diagnosis.
When examining patients with back pain, spinal X-rays with functional tests, computed tomography, and magnetic resonance imaging are informative. For acute back pain, patients should undergo general blood and biochemical tests as well as urine tests.
In some cases, neuroimaging methods such as computed tomography and magnetic resonance imaging are applied. Radioisotope scintigraphy is used to diagnose local inflammatory or metastatic processes. Diagnosis of osteoporosis is based on densitometry. To determine the degree of damage to the structures of the spinal cord and peripheral nervous system, including clarifying the nature of radiculopathy, electromyography is performed.
Back pain treatment
The main goal of treating patients with back pain is to relieve pain, prevent the disease from becoming chronic, facilitate the full implementation of rehabilitation measures and prevent recurrence of exacerbations.
The basis of conservative treatment of pain syndrome includes non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotropic vitamins and a number of other non-pharmacological methods, mainly affecting the nociceptive componentpain, including massage, therapeutic exercises, manual therapy.
During the acute phase, excessive physical activity is excluded, but instead of long-term bed rest, these patients soon return to their usual level of activity to prevent the formation of pain syndrome. chronic. Strict immobilization is recommended for the first three days. For acute pain in the lower back, a fixation belt is used, for pain in the neck, a collar is used. However, long-term immobilization of the cervical or lumbar spine is not recommended, except in selected cases, such as vertebral fractures or lumbar spondylolisthesis.
When the pain syndrome subsides, the patient is prescribed physiotherapeutic procedures: ultrasound, magnetic therapy, electrical stimulation, acupressure, exercise and massage are recommended, while therapy is performed. Manual methods as indicated.
In cases of vertebral instability, spinal compression, intervertebral herniation or tumors, the patient may be offered surgical treatment. The type and extent of surgical intervention is selected individually by the attending physician or medical board. After surgery, antibacterial and analgesic drugs, neurotropic vitamins and other drugs are used, and rehabilitation measures are carried out, including physiotherapy, massage and physical therapy techniques. therapy.