Back pain is the leading cause of all pain syndromes, affecting 80-100% of people and causing long-term disability for 4% of the world's population, 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 impair quality of life.
In this article, we will tell you what diseases and conditions can cause back pain, how to examine patients with back pain, and what treatment your doctor may prescribe.
Classification of back pain
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 in case of damage affecting the somatosensory system. Dysfunctional pain is caused by neurodynamic disorders of the central nervous system. When examining patients with dysfunctional pain, it is usually not possible to identify organic diseases that could explain the occurrence of the pain syndrome. It is also associated with pain, a typical example of which is back pain.
Depending on the location of the pain syndrome, the following types of back pain can be distinguished:
- cervicalgia - neck pain;
- cervicocranalgia - pain in the neck that spreads to the head;
- cervicobrachialgia - neck pain radiating to the arm;
- Thoracalgia - pain in the middle of 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 sacral area;
- coccydynia - pain in the coccyx.
According to the course of the pain syndrome, acute (less than 4 weeks), subacute (4-12 weeks) and chronic (more than 12 weeks) forms are distinguished. In most patients who seek medical help, 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 persists for six weeks and becomes permanent. The chronicity of the pain syndrome can lead to the appearance of anxiety and depression disorders, the feeling of waiting for pain, the development of "pain behavior", and irritability. In this regard, the transition of pain into a chronic form requires a different approach to patient treatment, 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 dominate the clinical picture of the disease. Compression syndromes develop when the altered structure of the spinal column compresses the roots, blood vessels, or spinal cord. Reflex syndromes develop as a result of irritation of various structures of the spine. 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, certain diseases of the 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 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 region, pain in the spine in the middle of the back indicates damage to the thoracic region, and problems in the lumbosacral spine in the lumbar region. The pain occurring in osteochondrosis is usually moderate, dull, constant or intermittent, intensifies after physical activity, and weakens during rest. For fear of provoking an attack, patients change their position slowly and carefully.
As the pathological changes progress, osteochondrosis of the spine can lead to the development of an intervertebral hernia, which is characterized by local temporary dull pain, which intensifies during physical activity, lasts in a static position for a long time, and disappears in a lying position. Gradually, the pain becomes constant, combined with severe muscle tension; some patients develop lumbago and lumboischialgia - attacks of acute intense pain in the lumbar region and the back of the thigh.
Degenerative changes in the facet joints connecting the articular processes of adjacent vertebrae lead to spondyloarthrosis, which manifests itself as local pain that occurs during movement and disappears with rest. As the disease progresses, patients develop morning stiffness and constant dull pain in the back in the affected area, which is aggravated by prolonged posture.
Another degenerative disease of the spine, which is accompanied by a 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 anterior osteophytes. and the lateral parts of the spine. The pain of spondylosis is local, it increases towards 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, the clinical manifestations do not worsen for decades.
Anomalies of the spine
Back pain is often observed with congenital abnormalities of the spine, sometimes combined with neurological symptoms. Some malformations of the spinal column remain 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 manifests itself in moderate local pain in the lumbosacral region, which is often accompanied by sensory and reflex disorders, as well as muscle hypotension.
- Sacralization.Congenital spinal cord disorder in which the fifth lumbar vertebra is completely or partially fused to the sacrum is quite common and often asymptomatic, but may be accompanied by pain in some patients. The pain initially occurs (around age 20) after excessive physical activity, falling or jumping, radiates to the lower limbs and is sometimes combined with paresthesia. Typically, the pain eases when lying down and gets worse when sitting on a heel, jumping or standing. The late appearance of the 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.
- Lubalization.A congenital abnormality, 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 visiting doctors in approximately 2% of 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 aching pain in the lower back and along the spine, which is relieved by taking NSAIDs. The sitting form is characterized by pain radiating to the buttocks and lower limbs. In some cases, skin sensitivityviolations are detected in the thigh and lumbar region.
- 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 back pain during physical activity. Depending on the location of the pathology, these symptoms may include headache and shortness of breath.
Acquired spinal deformities
In the case of minor deformations, pathology I–II. stage, pain is usually absent. As the process progresses, a nagging or aching pain appears in the back, which intensifies against the background of physical activity and prolonged uncomfortable posture. Pain syndrome can be observed in such deformations of the spinal column 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 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:
- Injury.In the case of a contusion, the back pain is usually local and moderate, goes away after a few days, and disappears completely 1-2 weeks after the injury.
- Traumatic spondylolisthesis.Displacement of traumatic vertebrae occurs most often in the lumbar region. Patients complain of moderate to intense pain in the lower back that radiates 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, with a fracture of the thoracic spine, the severe pain in the middle of the back is often accompanied by difficulty in breathing. After that, the patient complains of pain in the projection of the damaged vertebra, which sometimes radiates to the abdomen. The pain decreases when lying down and increases with coughing, deep breathing, movements, 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 can be detected during an X-ray examination. However, some patients with osteoporosis may experience minor pain in the spine, most often in the chest and lumbar region, 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 feeling of stiffness in the lower back can be the first signs of ankylosing spondylitis, a chronic inflammatory disease of the spine and joints. This pathology is characterized by the appearance of pain at night, intensification in the morning and a decrease in intensity after physical activity or a hot shower. During the day, the pain increases even at rest and decreases during physical activity. As the disease progresses, the pain gradually spreads in the spine, mobility is limited, and thoracic kyphosis develops.
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). In vertebral osteomyelitis, pain in the spine usually has a clear localization, is of an intense explosive 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 can develop, which is manifested by diffuse back pain and an increase in body temperature to high values. Patients experience local stiffness of the spinal muscles, pain when impinging on the spinal extensions, and positive symptoms of tension. In case of 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 manifests itself in temporary pain in the innervation area of the nerve roots. Spinal pain gradually becomes permanent, reminiscent of the clinical picture of radiculitis, accompanied by sensory and motor disturbances and a possible loss of control over the functioning of the pelvic organs.
Spinal neoplasms
Benign tumors of the spinal column are often asymptomatic or have mild, slowly progressing symptoms. The most common spinal tumors seen in patients of any age are hemangiomas. In approximately 10-15% of cases, it is accompanied by local painful back pain, which increases after physical activity and at night. The cause of pain in spinal hemangioma is irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Among the malignant tumors of the spinal column, spinal sarcoma is most often diagnosed. In the initial stage, the disease is characterized by mild or moderate periodic pain, which worsens at night. The intensity of the pain increases rapidly. Depending on the location of the tumor, patients feel pain in the arms, legs and internal organs.
Pain in the spine can also be a sign of metastases from tumors of the internal organs. At first, the pain is local, dull, aching, reminiscent of the clinical picture of osteochondrosis, but it progresses rapidly, becomes permanent and, depending on the location, may also radiate to the arms or legs.
Risk factors for the development of back pain
The factors that trigger the appearance of back pain can be divided into correctable and non-correctable (heredity, age, gender) categories. The adjustable factors are:
- professional(work involving lifting heavy objects, static loading of the spine, monotonous physical work, including frequent bending forward and turning the body, work involving vibrational processes);
- psychosocial(muscle disorder caused by acute and/or chronic stress);
- individual physical and somatic characteristics(spinal curvature, kyphosis and other spinal deformities, weak musculature, monotonous stereotyped movements);
- Poor nutrition and gastrointestinal diseases(impaired absorption of B vitamins, consumption of foods containing large amounts of purine bases, overweight);
- bad habits(smoking, alcohol consumption).
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 movement or an acute stressful situation are sufficient for the development of pain syndrome.
Examination of patients with back pain
When examining patients with acute or chronic back pain, the neurologist's main tasks are to establish an accurate local diagnosis and etiology of the pain syndrome. During the first meeting, the doctor talks to the patient and reveals all the circumstances of the occurrence of the pain.
History collection
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 taking painkillers and does not involve a violation of surface sensitivity, is characteristic of nociceptive pain syndromes associated with damage to the spine, ligaments and joints of muscles. The burning, shooting pain radiating into the limbs may be accompanied by sensory disturbances and may be caused by compression radiculopathy.
Pain associated with damage to internal organs often has an unclear localization, can be accompanied by nausea, skin discoloration, excessive sweating, is often spasmodic, and radiates to the opposite side of the body.
It should be noted that lower back pain without irradiation of the limb in patients under 50 years of age (in the absence of malignant tumor, clinical symptoms of systemic disease and neurological deficit) is up to 99% likely to be caused by musculoskeletal diseases, such as myofascial pain syndrome or joint pain - ligament dysfunction.
However, even at the first examination of the patient, the doctor pays attention to the signs that indicate that the 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, unexplained weight loss, the occurrence of malignant tumors in the medical history, the persistence of pain at rest - a malignant tumor of the spine. column, simultaneous uveitis and arthralgia - spondyloarthritis.
Patient examination
In most cases, the physical examination of back pain makes it possible to establish the source and pathogenesis of the pain syndrome, to suggest or precisely determine the nature of the underlying pathological process.
During the neurological examination, the doctor monitors the patient's posture, posture, and gait, checks the contractures, deformities, and asymmetries of the limbs, assesses the condition of the spine, and clarifies the existence and nature of motor, sensory, and trophic disorders. abnormalities and changes in tendon reflexes. Based on the survey data and test results, the neurologist prescribes additional tests for the patient.
Laboratory and instrumental diagnostics
Laboratory and instrumental research methods help to carry out differential diagnosis, to confirm or refute the presumed diagnosis.
X-ray spondylography with functional tests, computed tomography and magnetic resonance imaging are informative when examining patients with back pain. In case of acute back pain, patients should undergo 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 inflammatory or metastatic processes. The diagnosis of osteoporosis is based on a densitometer. 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 goal of treating patients with back pain is to relieve pain, prevent the disease from becoming chronic, ensure the conditions for the full course of rehabilitation measures, and prevent the 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-pharmacological methods, which primarily affect the nociceptive component of pain, including massage, therapeutic exercises, manual therapy.
In the acute period, excessive physical activity is excluded, but instead of long-term bed rest, such patients show an early return to the usual activity level to prevent the development of chronic pain syndrome. Strict immobilization is recommended for the first three days. In the case of acute pain in the lower back, a fastening belt is used, and in the case of neck pain, a neck collar is used. However, long-term fixation of the cervical or lumbar spine is not recommended, except in certain cases, such as the presence of a vertebral fracture or lumbar spondylolisthesis.
With the regression of the pain syndrome, patients are prescribed physiotherapy procedures: ultrasound, magnetic therapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is recommended.
In the case of vertebral instability, compression of the spinal column, intervertebral hernia, or cancer, the patient may recommend surgical treatment. The type and extent of the surgical intervention is selected individually by the attending physician or the medical board. After the operation, antibacterial and pain-relieving agents, neurotropic vitamins and other drugs are used, rehabilitation measures are carried out, including physiotherapy techniques, massage and physical therapy.