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 cause of hospitalization. Constant or frequently recurring back pain can cause severe suffering to patients and significantly reduce the 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 the doctor can prescribe.
Classification of back pain
From a pathophysiological point of view, 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 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 appearance of the pain syndrome. In addition, there is associated pain, a typical example of which is back pain.
Depending on the localization of the pain syndrome, there are the following types of back pain:
- cervicalgia - pain in the neck;
- cervicocranialgia - pain in the neck spreading to the head;
- cervicobrachialgia - pain in the neck radiating to the arm;
- Thoracalgia - pain in the middle of the back and chest area;
- Lumbodynia - pain in the lumbar and/or lumbosacral region;
- Lumboschialgia - pain in the lower back, radiating to the leg;
- sacralgia - pain in the sacral area;
- coccydynia - pain in the coccyx.
According to the course of the pain syndrome, acute (lasting less than 4 weeks), subacute (4-12 weeks) and chronic (more than 12 weeks) forms are distinguished. In most patients who seek medical attention, the back pain is acute, lasts several days, and is easily relieved by 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 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 into a chronic form requires a different approach to the treatment of the patient, the choice 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 altered spinal structures compress the roots, blood vessels, or spinal cord. Reflex syndromes occur as a result of irritation of various structures of the spine. Based on the localization, the 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 localization of pain corresponds to the level of the lesion. Thus, 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 intermittent, intensifies after physical exertion 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 a local transient dull pain that intensifies during physical activity, 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 lumboschialgia - attacks of acute intense pain in the lumbar region and the 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 movement and subsides at rest. As the disease progresses, patients develop morning stiffness and constant dull pain in the back in the affected area, which worsens with prolonged posture.
Another degenerative disease of the spine, which occurs with dull pain in the back, is spondylosis - a chronic pathology accompanied by degenerative changes in the front parts of the intervertebral discs, calcification of the anterior longitudinal ligament and the formation of osteophytes in the front part of the back. and the lateral parts of the spine. Pain in spondylosis is local in nature, intensifies 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 diseases of the spine, clinical manifestations may not worsen for decades.
Abnormalities of the spine
Back pain is often observed in congenital anomalies of the spine, sometimes combined with neurological symptoms. Some malformations of the spine are asymptomatic for a long time and manifest only in adolescence or even in 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 hypotonia.
- Sacralization.A congenital anomaly of the spine, in which the fifth lumbar vertebra completely or partially fuses with the sacrum, is quite common and is often asymptomatic, but in some patients it can be accompanied by pain. At an early onset (around 20 years of age), the pain appears after excessive physical activity, falling on the foot or jumping, radiating to the lower limbs and sometimes combined with paresthesia. It is characteristic that the pain weakens in a lying position and intensifies when sitting on heels, jumping or standing up. The late onset of the pain syndrome is due to secondary changes in the joints and vertebrae. The pain occurs in middle 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 "turns" into an additional (sixth) lumbar vertebra is the reason for a visit to the doctor in approximately 2% of all cases of back pain. Signs of pathology areappear at an early age. The clinical picture depends on the form of lumbarization. In the lumbar form, patients are worried about pain 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 buttockand lower limbs. In some cases, a disturbance of the sensitivity of the skin in the thigh and lumbar region is detected.
- Sphenoid vertebrae.Scoliosis is a congenital, less common acquired abnormality 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 pathology, these symptoms may include headache and shortness of breath.
Acquired spinal curvatures
In mild deformations of stages I-II of the pathology, pain is usually absent. As the process progresses, nagging or pain in the back appears, which intensifies against the background of physical activity and a prolonged uncomfortable position of the body. Pain syndrome is observed in such spinal deformities as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. Discomfort and mild 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 strength of the pain depends on the severity of the injury:
- Injury.When a bruise occurs, back pain is usually local and moderate in nature, subsides after a few days and completely disappears 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 to intense pain in the lower back, radiating to the legs. Palpation of the spinous process is painful, the axial load symptom 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 chest, 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 damaged vertebra, sometimes radiating to the abdomen. The pain decreases when lying down, increases when coughing, deep breathing, movements, as well as when standing up, 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 often in the thoracic and lumbar regions, 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 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, increasing in the morning and decreasing in 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 throughout the 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). In vertebral osteomyelitis, the pain in the spine usually has a clear localization, has an intense bursting character, sharply intensifies when trying to move and is combined with hyperthermia, weakness, fever and pronounced local edema.
When the infection penetrates into the subdural space of the spinal cord, a spinal epidural abscess can form, which is manifested by diffuse pain in the back and an increase in body temperature to high values. Patients experience local stiffness of the spinal muscles, pain on percussion of the spinous processes, and positive tension symptoms. 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 constant, reminiscent of the clinical picture of radiculitis, accompanied by sensory and motor disorders and 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 local back pain that increases after physical activity and at night. The reason for the development of pain in hemangioma of the spine is irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Among the malignant tumors of the spine, spinal sarcoma is most often diagnosed. In the initial stage, the disease is characterized by mild or moderate periodic pain, worsening 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. At first, the pain is local, dull, painful, reminiscent of the clinical picture of osteochondrosis, but it quickly progresses, becomes constant and, depending on the localization, can radiate to the hands or feet.
Risk factors for developing back pain
Factors that can cause the appearance of back pain can be divided into correctable and non-correctable (heredity, age, gender). Correctable factors include:
- professional(work related to 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 distress caused by staying in conditions of acute and/or chronic stress);
- individual physical and somatic characteristics(scoliosis, kyphosis and other spinal distortions, weak muscle corset, monotonous stereotyped movements);
- Malnutrition and gastrointestinal disease(malabsorption of vitamins of group B, 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, uncomfortable movement or an acute stressful situation are enough to form a pain syndrome.
Review of patients with back pain
The main tasks of the neurologist when examining a patient with acute or chronic back pain are to establish an accurate local diagnosis and etiology of the pain syndrome. At the initial appointment, the doctor talks with the patient, establishing all the circumstances surrounding the onset of pain.
History taking
Although patients describe pain differently, a careful history can suggest pathophysiological mechanisms underlying the pain syndrome.
Thus, the development of acute pain with a clear localization, which is well relieved by taking analgesics and is not accompanied by a violation of surface sensitivity, is characteristic of nociceptive pain syndromes associated with damage to the joints of the spine, ligaments and muscles. 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, change in skin color, excessive sweating, often has a spasmodic character and radiates to the opposite half of the body.
It should be noted that low back pain without radiation to 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 myofascial pain syndrome or joint pain - ligament dysfunction.
However, even at the first examination of the patient, 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 area can mean infectious damage to the spine, unexplained weight loss, a history of malignant tumors, persistence of pain at rest - a malignant neoplasm of the spine column, accompanyinguveitis and arthralgia - spondyloarthrosis.
Patient examination
Physical examination for back pain in most cases allows to establish the source and pathogenesis of the pain syndrome, to assume or accurately determine the nature of the main pathological process.
During a neurological examination, the doctor pays attention to the posture, posture and gait of the patient, checks for contractures, deformations and asymmetries of the limbs, assesses the condition of the spine, clarifies the presence and nature of motor disorders, sensory and trophic. disorders and changes in tendon reflexes. Based on the data of the study and the results of the examination, the neurologist prescribes additional tests for the patient.
Laboratory and instrumental diagnostics
Laboratory and instrumental research methods help to make a differential diagnosis, to confirm or refute the suspected diagnosis.
When examining patients with back pain, X-ray spondylography with functional tests, computed tomography and nuclear magnetic resonance are informative. With 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 nuclear magnetic resonance come to the fore. Radioisotope scintigraphy is used for diagnosis of 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 treatment for patients with back pain are pain relief, prevention of the chronicity of the disease, provision of conditions for a full course of rehabilitation measures and prevention of recurrence of exacerbation.
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 that 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 to prevent the formation of a chronic pain syndrome. Strict immobilization is recommended for the first three days. For acute pain in the lower back, a fixing 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 a vertebral fracture or the presence of lumbar spondylolisthesis.
As the pain syndrome regresses, patients are prescribed physiotherapy procedures: ultrasound, magnetic therapy, electrostimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is performed as indicated.
In case of vertebral instability, compression of the spine, intervertebral hernia or neoplasms, the patient may be recommended surgical treatment. The type and volume of surgical intervention is chosen individually by the attending physician or medical board. After the operation, antibacterial and analgesic agents, neurotropic vitamins and other drugs are used, and rehabilitation measures are carried out, including physiotherapy techniques, massage and physiotherapy.