The most common causes of lower back pain are diseases of the spine, mainly degenerative-dystrophic (osteochondrosis, spondylosis deformans) and overstrain of the back muscles.In addition, various diseases of the abdominal and pelvic organs, including tumors, can cause the same symptoms as a herniated disc compressing the spinal root.
It is no coincidence that such patients turn not only to neurologists, but also to gynecologists, orthopedists, urologists and above all, obviously, to local or family doctors.
Etiology and pathogenesis of low back pain
According to modern ideas, the most common causes of lower back pain are:
- pathological changes in the spine, mainly degenerative-dystrophic;
- pathological changes in muscles, most often myofascial syndrome;
- pathological changes in the abdominal organs;
- diseases of the nervous system.
Risk factors for lower back pain are:
- heavy physical activity;
- uncomfortable working posture;
- injury;
- cooling, drafts;
- alcohol abuse;
- depression and stress;
- occupational diseases associated with exposure to high temperatures (particularly in hot stores), radiant energy, sudden changes in temperature and vibration.
Among the vertebral causes of lower back pain are:
- radical ischemia (discogenic radicular syndrome, discogenic radiculopathy), resulting from compression of the root by a herniated disc;
- reflex muscle syndromes, the cause of which may be degenerative changes in the spine.
Several functional disorders of the lumbar spine can play a certain role in the onset of back pain, when, due to poor posture, blockages of the intervertebral joints occur and their mobility is impaired.In the joints located above and below the blockage, compensatory hypermobility develops, leading to muscle spasm.
Signs of acute compression of the spinal canal
- numbness in the perineal area, weakness and numbness in the legs;
- retention of urination and defecation;
- with compression of the spinal cord, a decrease in pain is observed, followed by a feeling of numbness in the pelvic girdle and limbs.
Lower back pain in childhood and adolescence is often caused by abnormalities in the development of the spine.Spina bifida (spina bifida) occurs in 20% of adults.On examination, hyperpigmentation, birthmarks, multiple scars and hyperkeratosis of the skin in the lumbar region are revealed.Sometimes urinary incontinence, trophic disorders and weakness in the legs are noted.
Lower back pain can be caused by lumbarization - the transition of the S1 vertebra relative to the lumbar spine - and sacralization - the attachment of the L5 vertebra to the sacrum.These anomalies are formed due to the individual characteristics of the development of the transverse processes of the vertebrae.
Nosological forms
Almost all patients complain of lower back pain.The disease manifests itself mainly with inflammation of low-motion joints (intervertebral, costovertebral, lumbosacral joints) and spinal ligaments.Gradually, ossification develops in them, the spine loses elasticity and functional mobility, becomes like a bamboo stick, fragile and easily injured.At the stage of pronounced clinical manifestations of the disease, the mobility of the chest during breathing and, accordingly, the vital capacity of the lungs significantly decreases, which contributes to the development of a number of lung diseases.
Spinal tumors
A distinction is made between benign and malignant tumors, originating mainly from the spine and metastatic.Benign tumors of the spine (osteochondroma, chondroma, hemangioma) are sometimes clinically asymptomatic.In hemangioma, a fracture of the spine can occur even with minor external influences (pathological fracture).
Malignant tumors, mostly metastatic, originate from the prostate, uterus, breast, lungs, adrenal glands and other organs.Pain in this case occurs much more often than with benign tumors: usually persistent, painful, intensifies with the slightest movement, depriving patients of rest and sleep.Characterized by a progressive deterioration of the condition, an increase in general exhaustion and pronounced changes in the blood.X-rays, computed tomography and magnetic resonance imaging are of great importance for diagnosis.
Osteoporosis
The main cause of the disease is a decrease in the function of the endocrine glands due to an independent disease or against the background of general aging of the body.Osteoporosis may develop in patients taking hormones, aminazine, antituberculosis drugs, and tetracyclines for a long time.Radicular disorders accompanying back pain arise due to deformation of the intervertebral holes, while spinal disorders (myelopathy) arise due to compression of the radiculomedullary artery or vertebral fracture, even after minor injuries.
Myofascial syndrome
Myofascial syndrome is the leading cause of back pain.It can occur due to overexertion (during intense physical activity), overextension and muscle bruising, non-physiological posture during work, reaction to emotional stress, shortening of a leg and even flat feet.
Myofascial syndrome is characterized by the presence of so-called "trigger" zones (trigger points), the pressure of which causes pain, often radiating to nearby areas.In addition to myofascial pain syndrome, the cause of pain can also be an inflammatory muscle disease - myositis.
Lower back pain often occurs due to diseases of internal organs: gastric and duodenal ulcers, pancreatitis, cholecystitis, urolithiasis, etc.They may be pronounced and mimic the pattern of low back pain or discogenic lumbosacral radiculitis.However, there are also obvious differences, thanks to which it is possible to differentiate reported pain from that resulting from diseases of the peripheral nervous system, which is due to the symptoms of the underlying disease.
Clinical symptoms of lower back pain
Most often, lower back pain occurs between the ages of 25 and 44.There are acute pains, which last, as a rule, 2-3 weeks, and sometimes up to 2 months, and chronic pains – more than 2 months.
Radicular compression syndromes (discogenic radiculopathy) are characterized by sudden onset, often after heavy lifting, sudden movements, or hypothermia.Symptoms depend on the location of the lesion.The onset of the syndrome is based on compression of the root by the herniated disc, which occurs as a result of degenerative processes facilitated by static and dynamic loads, hormonal disorders and injuries (including microtraumatization of the spine).Most often, the pathological process involves areas of the spinal roots from the dura mater to the intervertebral foramen.In addition to disc herniation, bony overgrowths, cicatricial changes in the epidural tissue, and hypertrophy of the ligamentum flavum may be involved in root trauma.
The upper lumbar roots (L1, L2, L3) are rarely affected: they represent no more than 3% of all lumbar root syndromes.The L4 root is affected twice as often (6%), causing a characteristic clinical picture: mild pain along the lower and anterior inner surface of the thigh, the medial surface of the leg, paresthesia (feeling of numbness, burning, crawling) in this area;slight weakness of the quadriceps muscle.Knee reflexes are preserved and sometimes even increased.The L5 root is the most often affected (46%).The pain is localized in the lumbar and gluteal regions, along the external surface of the thigh, the antero-external surface of the lower leg up to the foot and III-V toes.It is often accompanied by a decrease in the sensitivity of the skin of the external anterior surface of the leg and the strength of the extensor muscles of the third and fifth toes.The patient has difficulty standing on his heels.With long-standing radiculopathy, hypotrophy of the tibialis anterior muscle develops.The S1 root is also often affected (45%).In this case, pain in the lower back radiates along the outer posterior surface of the thigh, the outer surface of the lower leg and foot.Examination often reveals hypoalgesia of the posterior outer surface of the leg, decreased strength of the triceps muscle and toe flexors.It is difficult for these patients to stand on their tiptoes.There is a decrease or loss of the Achilles reflex.
Vertebrogenic lumbar reflex syndrome
It can be acute or chronic.Acute low back pain (LBP) (low back pain, “low back pain”) occurs within minutes to hours, often suddenly due to awkward movements.Penetrating, stabbing pain (like an electric shock) is localized throughout the lower back, sometimes radiating to the iliac region and buttocks, sharply intensifies when coughing, sneezing, and decreases when lying down, especially if the patient finds a comfortable position.Movement in the lumbar spine is limited, the lumbar muscles are tense, causing Lasegue's symptom, often bilateral.Therefore, the patient lies on his back with his legs extended.The doctor simultaneously bends the affected leg at the knee and hip joints.This does not cause pain, because with this position of the leg the affected nerve is relaxed.Then the doctor, leaving the leg bent at the hip-femur joint, begins to straighten it at the knee, thereby causing tension on the sciatic nerve, which causes intense pain.Acute low back pain usually lasts 5-6 days, sometimes less.The first attack ends faster than subsequent attacks.Repeated attacks of low back pain tend to develop into chronic LBP.
Atypical low back pain
There are numerous atypical clinical symptoms of back pain caused by degenerative changes in the spine or myofascial syndrome.These signs include:
- the appearance of pain in childhood and adolescence;
- back injury shortly before the onset of lower back pain;
- back pain accompanied by fever or signs of intoxication;
- spine;
- pain in the rectum, vagina, both legs, girdle;
- connection of back pain with eating, defecation, sexual intercourse, urination;
- non-ecological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which appeared against the background of lower back pain;
- increased pain in the lower back in a horizontal position and decreased in a vertical position (Razdolsky's symptom, characteristic of a tumor process in the spine);
- steadily increasing pain over a week or two;
- limbs and the appearance of pathological reflexes.
Examination methods
- external examination and palpation of the lumbar region, identification of scoliosis, muscle tension, pain and trigger points;
- determination of range of motion in the lumbar spine, areas of muscle atrophy;
- neurological status examination;determination of tensive symptoms (Lassegue, Wasserman, Neri).Study of Wasserman's symptom: bending the leg at the knee joint in a patient in the prone position causes pain in the thigh.Study of Neri's symptom: a sharp bending of the head towards the chest of a patient lying on his back with straight legs causes sharp pain in the lower back and along the sciatic nerve.];
- study of the state of sensitivity, reflex sphere, muscle tone, vegetative disorders (swelling, changes in color, temperature and humidity of the skin);
- x-ray, computer or MRI of the spine.
MRI is particularly informative
- ultrasound examination of the pelvic organs;
- gynecological examination;
- If necessary, additional studies are carried out: cerebrospinal fluid, blood and urine, sigmoidoscopy, colonoscopy, gastroscopy, etc.
Treatment
Acute low back pain or exacerbation of vertebral or myofascial syndromes
Undifferentiated treatment.Gentle motor mode.In case of severe pain in the first few days, rest in bed and then walk with crutches to unload the spine.The bed should be hard and a wooden board should be placed under the mattress.To keep warm, we recommend a wool shawl, an electric heating pad and heated bags of sand or salt.Ointments have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc., as well as mustard plasters and pepper plasters.Ultraviolet irradiation at erythematic doses, leeches (taking into account possible contraindications) and irrigation of the painful area with ethyl chloride are recommended.
Electrical procedures have an analgesic effect: transcutaneous electroanalgesia, sinusoidal modulated currents, diadynamic currents, electrophoresis with novocaine, etc.The use of reflexology (acupuncture, laser therapy, cauterization) is effective;novocaine blocks, pressure massage of trigger points.
Drug therapy includes analgesics, NSAIDs;tranquilizers and/or antidepressants;drugs that reduce muscle tension (muscle relaxants).In case of arterial hypotension, tizanidine must be prescribed with great caution due to its hypotensive effect.If swelling of the spinal roots is suspected, diuretics are prescribed.
The main analgesic drugs are NSAIDs, which are often used uncontrollably by patients when pain intensifies or recurs.It should be noted that long-term use of NSAIDs and analgesics increases the risk of complications of this type of therapy.There is currently a large selection of NSAIDs.For patients suffering from spinal pain, due to availability, effectiveness and lower probability of side effects (gastrointestinal bleeding, dyspepsia), the preferred "non-selective" drugs are diclofenac 100-150 mg/day.orally, intramuscularly, rectally, locally, ibuprofen and ketoprofen orally 200 mg and topically, and among the "selective" ones - meloxicam orally 7.5-15 mg/day, nimesulide orally 200 mg/day.
Side effects may occur during treatment with NSAIDs: nausea, vomiting, loss of appetite, pain in the epigastric region.Possible ulcerogenic effect.In some cases, ulceration and bleeding in the gastrointestinal tract may occur.In addition, headaches, dizziness, drowsiness and allergic reactions (skin rashes, etc.) are noted.Treatment is contraindicated for ulcerative processes in the gastrointestinal tract, during pregnancy and breastfeeding.To prevent and reduce dyspeptic symptoms it is recommended to take NSAIDs during or after meals and drink milk.Furthermore, taking NSAIDs when pain increases together with other drugs that the patient takes to treat concomitant diseases, leads, as observed in the long-term treatment of many chronic diseases, to a decrease in adherence to treatment and, consequently, to insufficient effectiveness of therapy.
Therefore, modern methods of conservative treatment include the mandatory use of drugs that have chondroprotective, chondrostimulating effects and have a better therapeutic effect than NSAIDs.The drug Teraflex-Advance fully meets these requirements, representing an alternative to NSAIDs for mild to moderate pain.One capsule of the drug Teraflex-Advance contains 250 mg of glucosamine sulfate, 200 mg of chondroitin sulfate and 100 mg of ibuprofen.Chondroitin sulfate and glucosamine participate in the biosynthesis of connective tissue, helping to prevent cartilage destruction processes and stimulating tissue regeneration.Ibuprofen has analgesic, anti-inflammatory and antipyretic effects.The mechanism of action occurs thanks to the selective blockade of cyclooxygenase (COX types 1 and 2), the main enzyme in the metabolism of arachidonic acid, which leads to a decrease in the synthesis of prostaglandins.The presence of NSAIDs in the composition of the drug Theraflex-Advance helps to increase the range of motion of the joints and reduce morning stiffness of the joints and spine.It should be noted that, according to R.J.Tallarida et al., the presence of glucosamine and ibuprofen in Theraflex-Advance provides a synergism regarding the analgesic effect of the latter.Furthermore, the analgesic effect of the glucosamine/ibuprofen combination is provided by a 2.4 times lower dose of ibuprofen.
After relieving the pain, it is rational to switch to taking the drug Teraflex, which contains the active ingredients chondroitin and glucosamine.Teraflex is taken 1 capsule 3 times a day.during the first three weeks and 1 capsule 2 times a day.in the next three weeks.
The vast majority of patients taking Theraflex experience positive dynamics in the form of pain relief and reduction of neurological symptoms.The drug was well tolerated by patients, no allergic manifestations were noted.The use of Teraflex in degenerative diseases of the spine is rational, especially in young patients, both in combination with NSAIDs and as monotherapy.In combination with NSAIDs, the analgesic effect occurs 2 times faster and the need for therapeutic doses of NSAIDs progressively decreases.
In clinical practice, for lesions of the peripheral nervous system, including those associated with spinal osteochondrosis, B vitamins, which have a neurotropic effect, are widely used.Traditionally, the method of alternating administration of vitamins B1, B6 and B12, 1-2 ml each, is used.intramuscularly with daily alternation.The course of treatment lasts 2-4 weeks.The disadvantages of this method include the use of small doses of drugs, which reduce the effectiveness of treatment, and the need for frequent injections.
For discogenic radiculopathy, traction therapy is used: traction (including underwater) in a neurological hospital.For myofascial syndrome, after local treatment (novocaine blockade, irrigation with ethyl chloride, anesthetic ointments), a warm compress is applied to the muscles for several minutes.
Chronic low back pain of vertebrogenic or myogenic origin
In case of disc herniation we recommend:
- wear a stiff corset such as a “weightlifter's belt”;
- avoid sudden movements and bending, limiting physical activity;
- physical therapy to create a muscle corset and restore muscle mobility;
- massage;
- novocaine blocks;
- reflexology;
- physiotherapy: ultrasound, laser therapy, heat therapy;
- intramuscular vitamin therapy (B1, B6, B12), multivitamins with mineral supplements;
- for paroxysmal pain carbamazepine is prescribed.
Non-pharmacological treatments
Despite the availability of effective means of conservative treatment, the existence of dozens of techniques, some patients require surgical treatment.
The indications for surgical treatment are divided into relative and absolute.The absolute indication for surgical treatment is the development of caudal syndrome, the presence of a sequestered intervertebral disc herniation, severe radicular pain syndrome that does not decrease despite treatment.The development of radiculomyeloischemia also requires emergency surgical intervention, however, after the first 12-24 hours, the indications for surgical intervention in these cases become relative, firstly, due to the formation of irreversible changes in the roots and, secondly, because in most cases, during treatment and rehabilitation measures, the process regresses within about 6 months.The same periods of regression are observed with delayed operations.
Related indications include failure of conservative treatment and recurrent sciatica.The duration of conservative therapy should not exceed 3 months.and last at least 6 weeks.It is assumed that a surgical approach in cases of acute radicular syndrome and failure of conservative treatment is justified within the first 3 months.after the onset of pain to prevent chronic pathological changes in the root.A relative indication are cases of extremely severe pain syndrome, when the painful component is replaced by an increase in neurological deficit.
Among physiotherapeutic procedures, electrophoresis with the proteolytic enzyme caripazim is currently widely used.
It is known that therapeutic physical training and massage are an integral part of the complex treatment of patients with spinal injuries.Therapeutic gymnastics pursues the goals of general strengthening of the body, increasing efficiency, improving coordination of movements and increasing physical fitness.In this case, special exercises are aimed at restoring some motor functions.