The most common causes of low back pain are spinal diseases, mainly degenerative dystrophic diseases (osteochondrosis, spondylosis deformans) and excessive tension of the back muscles.Additionally, 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, of course, to local or family doctors.
Etiology and pathogenesis of low back pain
According to modern ideas, the most common causes of low 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;
- nervous system diseases.
The risk factors for low back pain are:
- intense physical activity;
- uncomfortable working posture;
- wound;
- cooling, drafts;
- alcohol abuse;
- depression and stress;
- occupational diseases associated with exposure to high temperatures (in particular, in hot workshops), radiation energy, sudden temperature fluctuations and vibration.
Among the vertebral causes of low back pain are:
- root ischemia (discogenic radicular syndrome, discogenic radiculopathy), resulting from root compression due to a herniated disc;
- reflex muscle syndromes, the cause of which may be degenerative changes in the spine.
Various functional disorders of the lumbar spine can play a certain role in the occurrence of back pain, when, due to incorrect 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 spinal canal compression
- numbness of the perineal region, weakness and numbness in the legs;
- retention of urination and defecation;
- with compression of the spinal cord, there is a decrease in pain, followed by a sensation of numbness in the pelvic girdle and limbs.
Low back pain in childhood and adolescence is most often caused by anomalies 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.Urinary incontinence, trophic disorders, and leg weakness are sometimes observed.
Low back pain can be caused by lumbarization – transition of the S1 vertebra in relation to the lumbar spine – and sacralization – attachment of the L5 vertebra to the sacrum.These anomalies are formed due to the individual features of the development of the transverse processes of the vertebrae.
Nosological forms
Almost all patients complain of pain in the lower back.The disease is mainly manifested by 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 is easily injured.In the phase of pronounced clinical manifestations of the disease, the mobility of the chest during breathing and, consequently, the vital capacity of the lungs significantly decrease, 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.With hemangioma, a spinal fracture can occur even with minor external influences (pathological fracture).
Malignant tumors, mainly 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, intensifying with the slightest movement, depriving patients of rest and sleep.Characterized by a progressive deterioration of the condition, increased general exhaustion and pronounced changes in the blood.Radiographs, 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 can develop in patients who take hormones, aminazine, anti-tuberculosis drugs, and tetracycline for a long time.Radicular disorders accompanying back pain arise due to deformation of the intervertebral foramina, and spinal disorders (myelopathy) arise due to compression of the radiculomedullary artery or vertebral fracture, even after mild injuries.
Myofascial syndrome
Myofascial syndrome is the main cause of back pain.It can occur due to excessive effort (during intense physical activity), excessive extension and muscle bruising, unphysiological 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), whose pressure causes pain, often radiating to neighboring areas.In addition to myofascial pain syndrome, the cause of pain can also be inflammatory muscle diseases - myositis.
Lower back pain often occurs due to diseases of internal organs: gastric and duodenal ulcers, pancreatitis, cholecystitis, urolithiasis, etc.They can be pronounced and mimic low back pain or discogenic lumbosacral radiculitis.However, there are also clear differences, thanks to which it is possible to differentiate the referred pain from that resulting from diseases of the peripheral nervous system, which is due to the symptoms of the underlying disease.
Clinical symptoms of low back pain
Most often, low 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, usually after heavy lifting, sudden movements, or hypothermia.Symptoms depend on the location of the lesion.The occurrence of the syndrome is based on compression of the root by a 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 growths, scarring changes in the epidural tissue, and hypertrophied 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 radicular syndromes.The L4 root is affected twice as often (6%), causing a characteristic clinical picture: mild pain in the lower and anterior inner surface of the thigh, medial surface of the leg, paresthesia (sensation 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 affected (46%).The pain is localized in the lumbar and gluteal regions, along the outer surface of the thigh, antero-outer surface of the leg to the foot and III-V fingers.Muitas vezes é acompanhada por uma diminuição na sensibilidade da pele da superfície externa anterior da perna e na força dos músculos extensores do terceiro ao quinto dedos.The patient has difficulty standing.In long-standing radiculopathy, hypotrophy of the tibialis anterior muscle develops.The S1 root is also frequently 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 usually reveals hypoalgesia of the outer posterior surface of the leg, decreased strength of the triceps muscle and toe flexors.It is difficult for these patients to stay on their toes.There is a decrease or loss of the Achilles reflex.
Vertebrogenic lumbar reflex syndrome
It can be acute or chronic.Acute lower back pain (lumbalgia) (lumbago, “lumbago”) occurs within minutes or hours, often suddenly due to strange movements.Sharp, piercing 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 become tense, causing Lasegue's symptom, often bilateral.Thus, 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, since with this position of the leg the diseased nerve is relaxed.Then, the doctor, leaving the leg bent at the hip-femoral joint, begins to straighten it at the knee, causing tension in the sciatic nerve, which causes severe pain.Acute lumbodynia usually lasts 5 to 6 days, sometimes less.The first attack ends faster than subsequent ones.Repeated attacks of low back pain tend to develop into chronic low back pain.
Atypical low back pain
There are several clinical symptoms that are atypical for 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 low back pain;
- back pain accompanied by fever or signs of intoxication;
- column;
- rectum, vagina, both legs, pain in waist;
- connection of low back pain with eating, defecation, sexual intercourse, urination;
- non-ecological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which arose against the background of lower back pain;
- an increase in pain in the lower back in a horizontal position and a decrease in a vertical position (Razdolsky's symptom, characteristic of a tumor process in the spine);
- steady increase in pain over one to two weeks;
- 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 of the lumbar spine, areas of muscle loss;
- neurological status examination;determination of tension 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: the sharp inclination of the head towards the chest of a patient lying on his back with his legs straight 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 magnetic resonance imaging of the spine.
MRI is especially 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.Smooth engine 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 must be hard and a wooden board must be placed under the mattress.To stay warm, a woolen shawl, an electric heating pad, and heated bags of sand or salt are recommended.Ointments have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc., as well as mustard plasters and pepper plasters.Ultraviolet irradiation in erythemal 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 blockages, trigger point pressure massage.
Drug therapy includes analgesics, NSAIDs;tranquilizers and/or antidepressants;medicines that reduce muscle tension (muscle relaxants).In case of arterial hypotension, tizanidine should be prescribed with great caution due to its hypotensive effect.If swelling of the spinal roots is suspected, diuretics are prescribed.
The main analgesics are NSAIDs, which are often used uncontrollably by patients when the pain intensifies or recurs.It should be noted that prolonged use of NSAIDs and analgesics increases the risk of complications from this type of therapy.Currently, there is a large selection of NSAIDs.For patients suffering from back pain, due to availability, efficacy and less likelihood of side effects (gastrointestinal bleeding, dyspepsia), the preferred “non-selective” medications are diclofenac 100–150 mg/day.orally, intramuscularly, rectally, locally, ibuprofen and ketoprofen orally 200 mg and topically, and among the “selective” – 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.Additionally, headaches, dizziness, drowsiness and allergic reactions (rash, etc.) are observed.Treatment is contraindicated in ulcerative processes of the gastrointestinal tract, 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 medications that the patient takes to treat concomitant diseases, leads, as is observed in the long-term treatment of many chronic diseases, to decreased 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 Teraflex-Advance drug fully meets these requirements, being an alternative to NSAIDs for mild to moderate pain.One capsule of 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 due to the selective blockade of cyclooxygenase (COX types 1 and 2), the main enzyme in arachidonic acid metabolism, which leads to a decrease in the synthesis of prostaglandins.The presence of NSAIDs in the composition of the medicine Theraflex-Advance helps to increase the range of motion in the joints and reduce morning stiffness in the joints and spine.It is worth noting that, according to R.J. Tallarida et al., the presence of glucosamine and ibuprofen in Theraflex-Advance provides synergism in terms of the latter's analgesic effect.Furthermore, the analgesic effect of the glucosamine/ibuprofen combination is provided by a 2.4 times lower dose of ibuprofen.
After pain relief, it is rational to start taking the medication 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 twice a day.over the next three weeks.
The vast majority of patients taking Theraflex experience positive dynamics in the form of pain relief and reduced neurological symptoms.The drug was well tolerated by patients, no allergic manifestations were observed.The use of Teraflex for 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 is 2 to 4 weeks.Disadvantages of this method include the use of small doses of medication, 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.In myofascial syndrome, after local treatment (novocaine blockade, irrigation with ethyl chloride, anesthetic ointments), a hot compress is applied to the muscles for several minutes.
Chronic low back pain of vertebrogenic or myogenic origin
In case of a herniated disc, it is recommended:
- wearing a rigid corset as a “weightlifter’s belt”;
- avoiding sudden movements and bending, limiting physical activity;
- physiotherapy to create a muscle corset and restore muscle mobility;
- massage;
- novocaine blockades;
- reflexology;
- physiotherapy: ultrasound, laser therapy, thermotherapy;
- intramuscular vitamin therapy (B1, B6, B12), multivitamins with mineral supplements;
- for paroxysmal pain, carbamazepine is prescribed.
Non-drug treatments
Despite the availability of effective means of conservative treatment, the existence of dozens of techniques, some patients require surgical treatment.
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, and intense radicular pain syndrome that does not decrease despite treatment.The development of radiculomyeloischemia also requires emergency surgical intervention, however, after the first 12 to 24 hours, surgical indications 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 in approximately 6 months.The same regression periods are observed with delayed operations.
Relative indications include failure of conservative treatment and recurrent sciatica.Conservative therapy should not exceed 3 months in duration.and last at least 6 weeks.It is assumed that the surgical approach in cases of acute radicular syndrome and failure of conservative treatment is justified in the first 3 months.after the onset of pain to prevent chronic pathological changes in the root.A relative indication is cases of extremely intense 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 integral parts of the complex treatment of patients with spinal injuries.Therapeutic gymnastics aims to general strengthen the body, increasing efficiency, improving coordination of movements and increasing physical fitness.In this case, special exercises are aimed at restoring certain motor functions.