The most common causes of low back pain are disorders of the spine, especially degenerative dystrophics (osteochondrosis, spondylosis deformans) and excessive tension in the back muscles. In addition, several diseases of the abdominal cavity and small pelvis, including tumors, can cause the same symptoms as a herniated disc, compressing the spinal root.
It is not by chance that such patients turn not only to neurologists, but also to gynecologists, orthopedists, urologists and, above all, of course, to district or family physicians.
Etiology and pathogenesis of low back pain
According to modern concepts, the most common causes of low back pain are:
- pathological changes in the spine, especially degenerative dystrophics;
- pathological changes in muscles, most often myofascial syndrome;
- pathological changes in abdominal organs;
- diseases of the nervous system.
Risk factors for low back pain are:
- intense physical activity;
- uncomfortable working posture;
- prejudice;
- refrigeration, drafts;
- alcohol abuse;
- depression and stress;
- occupational diseases associated with exposure to high temperatures (in particular, in hot shops), radiation energy, with sudden temperature fluctuations, vibration.
Among the vertebral causes of low back pain are:
- root ischemia (discogenic radicular syndrome, discogenic radiculopathy) resulting from root compression by a herniated disc;
- reflex muscle syndromes, which can be caused by degenerative dystrophic changes in the spine.
A certain role in the occurrence of back pain can be played by several functional disorders of the lumbar spine, when intervertebral joint blocks appear due to incorrect posture and their mobility is impaired. In the joints located above and below the block, compensatory hypermobility develops, leading to muscle spasm.
Signs of acute spinal canal compression
- numbness of the perineal region, weakness and numbness of the legs;
- delay in urination and bowel movements;
- with spinal cord compression, a decrease in pain is seen, alternating with a feeling of numbness in the pelvic girdle and limbs.
Low back pain in childhood and adolescence is most often caused by abnormalities in spinal development. Non-overgrowth of the arches of the vertebrae (spina bifida) occurs in 20% of adults. Physical examination reveals hyperpigmentation, birthmarks, multiple scarring, and skin hyperkeratosis in the lower back. Sometimes there is urinary incontinence, trophic disorders, leg weakness.
Low back pain can be caused by lumbarization - transition of the S1 vertebra to the lumbar spine - and sacralization - fixation 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 back pain. The disease is mainly manifested by inflammation of sedentary joints (intervertebral, costovertebral, lumbosacral joints) and spinal ligaments. Gradually, ossification develops in them, the spine loses its elasticity and functional mobility, becomes like a bamboo stick, fragile, easily injured. In the phase of pronounced clinical manifestations of the disease, the chest mobility during breathing and, consequently, the vital capacity of the lungs significantly decreases, which contributes to the development of a series of pulmonological diseases.
spine tumors
Distinguish between benign and malignant tumors, mainly originating in the spine and metastatic. Benign spinal tumors (osteochondroma, chondroma, hemangioma) are sometimes clinically asymptomatic. With hemangioma, a fracture of the spine can occur even with minor external influences (pathological fracture).
Malignant tumors, predominantly metastatic, originate from the prostate, uterus, breast, lungs, adrenal glands and other organs. Pain, in this case, is much more frequent than in benign tumors - usually persistent, painful, aggravated by the slightest movement, depriving the patient of rest and sleep. It is characterized by a progressive deterioration of the condition, an increase in general tiredness, pronounced changes in the blood. Of great importance for diagnosis are radiography, computed tomography, magnetic resonance.
osteoporosis
The main cause of the disease is the decreased function of the endocrine glands due to an independent disease or in the context of the general aging of the body. Osteoporosis can develop in patients who take hormones for a long time, chlorpromazine, anti-tuberculosis drugs, tetracycline. The radicular disorders that accompany back pain arise from deformation of the intervertebral and spinal foramen (myelopathy) - due to compression of the radiculomedullary artery or vertebral fracture, even after minor injuries.
myofascial syndrome
Myofascial syndrome is the main cause of back pain. It can occur as a result of overexertion (during heavy physical exertion), overstretching and muscle bruises, unphysiological posture during work, reactions 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), a pressure that causes pain, often radiating to neighboring areas. In addition to myofascial pain syndrome, inflammatory muscle diseases - myositis can also cause pain.
Low back pain often occurs with internal organ diseases: gastric ulcer and duodenal ulcer, pancreatitis, cholecystitis, urolithiasis, etc. They can be pronounced and mimic the image of discogenic low back pain or lumbosacral radiculitis. However, there are also clear differences, through which it is possible to differentiate the reflected pain from those resulting from peripheral nervous system diseases, which is due to the symptoms of the underlying disease.
Clinical symptoms for low back pain
Most of the time, low back pain occurs at the age of 25-44 years. Distinguish between sharp pain, which lasts, as a rule, 2-3 weeks, and sometimes up to 2 months. , And chronic - more than 2 months.
Root compression syndromes (discogenic radiculopathy) are characterized by a sudden onset, usually after heavy lifting, sudden movements, and hypothermia. Symptoms depend on the location of the lesion. At the heart of the syndrome is root compression by a herniated disc, which occurs as a result of dystrophic processes, which are facilitated by static and dynamic loads, hormonal disturbances, trauma (including microtraumatization of the spine). Most of the time, the pathological process involves areas from the spinal roots of the dura mater to the intervertebral foramen. In addition to the herniated disc, bone growths, scarring changes in the epidural tissue and hypertrophied ligamentum flavum may be involved in root trauma.
The upper lumbar roots (L1, L2, L3) rarely suffer: they account for no more than 3% of all lumbar radicular syndromes. Twice as often, the L4 root is affected (6%), causing a characteristic clinical picture: mild pain along the inner and front surface of the thigh, the medial surface of the leg, paresthesia (sense of numbness, burning, crawling creeps) in this area; mild quadriceps weakness. Knee reflexes persist and sometimes even increase. The L5 root is most often affected (46%). Pain is localized in the lumbar and gluteal regions, along the outer surface of the thigh, on the antero-external surface of the leg to the foot and toes III-V. It is often accompanied by a decrease in skin sensitivity on the anterior surface of the outer leg and force on the extensor of the fingers III - V. It is difficult for the patient to stand on the heel. With long-term radiculopathy, tibialis anterior muscle atrophy develops and the S1 root is frequently affected (45%). In this case, the pain in the lower back radiates along the posterior posterior surface of the thigh, the outer surface of the leg, and the foot. Physical examination often reveals hypoalgesia of the posterior external surface of the leg, a decrease in the strength of the triceps muscle and toe flexors. It is difficult for these patients to stand on tiptoe. There is a decrease or loss of the Achilles reflex.
Lumbar Spinal Reflex Syndrome
It can be acute and chronic. Acute low back pain (LBP) (lumbago, "lumbago") occurs within minutes or hours, often suddenly due to awkward movements. A sharp, stabbing pain (such as an electric shock) is localized throughout the lower back, sometimes radiates to the iliac region and buttocks, increases markedly with coughing, sneezing, decreases in the supine position, especially if the patient finds a position. comfortable. Movement of the lumbar spine is limited, the lumbar muscles are tense, the Lasegue symptom is caused, often bilaterally. Thus, the patient lies on his back with his legs extended. The doctor simultaneously flexes the affected leg at the knee and hip joints. This does not cause pain, because in this leg position, the diseased nerve is relaxed. Then the doctor, leaving the leg bent at the hip joint, begins to unfold it at the knee, causing tension in the sciatic nerve, which gives severe pain. Acute lumbodynia usually lasts for 5 to 6 days, sometimes less. The first attack ends faster than the subsequent ones. Recurrent lumbago attacks tend to evolve into chronic PB.
atypical back pain
Several clinical symptoms are characterized as atypical for back pain caused by degenerative dystrophic changes in the spine or myofascial syndrome. These signs include:
- the appearance of pain in childhood and adolescence;
- back injury shortly before onset of low back pain;
- back pain accompanied by fever or signs of intoxication;
- spine;
- rectum, vagina, both legs, waist pain;
- the connection of low back pain with eating, defecating, sexual intercourse, urinating;
- necological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which appeared in the context of back pain;
- increase in low back pain in the horizontal position and decrease in the vertical position (Razdolsky's symptom, characteristic of the spinal tumor process);
- steady increase in pain for one to two weeks;
- limbs and the appearance of pathological reflexes.
research methods
- external examination and palpation of the lumbar region, detection of scoliosis, muscle tension, pain and trigger points;
- determination of range of motion of the lumbar spine, areas of muscle loss;
- neurological status research; determination of tension symptoms (Lassegh, Wasserman, Neri). [Wasserman's Symptom Study: Knee flexion in a prone patient causes hip pain. Study of Neri's Symptom: A steep tilt of the head to the chest of a patient lying on his back with his legs straight, causes acute pain in the lower back and along the sciatic nerve. ];
- study of the state of sensitivity, reflex sphere, muscle tone, autonomic disturbances (swelling, changes in skin color, temperature and moisture);
- radiography, computerized image or magnetic resonance imaging of the spine.
MRI is especially informative.
- ultrasound examination of the pelvic organs;
- gynecological examination;
- if necessary, additional studies are performed: 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. With severe pain in the first few days, bed rest and then walking on crutches to relieve the spine. The bed must be firm, a wooden board must be placed under the mattress. For heating, a fleece shawl, an electric heating pad, heated sand bags or salt are recommended. Ointments have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc. , as well as mustard plasters, pepper plasters. Recommended ultraviolet irradiation in erythemal doses, leeches (taking into account possible contraindications), irrigation of the painful area with ethyl chloride.
The anesthetic effect is provided by electrical procedures: percutaneous electroanalgesia, modulated sinusoidal currents, diadynamic currents, electrophoresis with novocaine, etc. The use of reflexology (acupuncture, laser therapy, moxibustion) is effective; novocaine blockage, trigger point pressure massage.
Drug therapy includes analgesics, NSAIDs; tranquilizers and/or antidepressants; drugs 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 uncontrolled by patients when pain intensifies or reappears. 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, in terms of availability, efficacy and less likely side effects (gastrointestinal bleeding, dyspepsia), diclofenac 100-150 mg/day is preferable to the "non-selective" medications. inside, intramuscularly, rectally, topically, ibuprofen and ketoprofen within 200 mg and topically, and from "selective" - meloxicam within 7, 5-15 mg / day, nimesulide within 200 mg / day.
In the treatment of NSAIDs, side effects may occur: nausea, vomiting, loss of appetite, pain in the epigastric region. Possible ulcerogenic action. In some cases, there may be ulceration and bleeding in the gastrointestinal tract. In addition, headaches, dizziness, drowsiness, allergic reactions (rash, etc. ) are observed. Treatment is contraindicated in ulcerative processes in the gastrointestinal tract, pregnancy and breastfeeding. To prevent and reduce dyspeptic symptoms, it is recommended to take NSAIDs with or after meals and drink milk. In addition, taking NSAIDs with increased pain in conjunction with other medications that the patient takes to treat concomitant diseases leads, as seen with the long-term treatment of many chronic diseases, to a decrease in treatment adherence and, as a consequence, insufficient efficacy of therapy.
Therefore, modern methods of conservative treatment include the mandatory use of drugs that have a chondroprotective, chondrostimulant and better therapeutic effect than NSAIDs. These requirements are fully met by the drug Teraflex-Advance, which is an alternative to NSAIDs for mild to moderate pain syndrome. One capsule of Teraflex-Advance medicine contains 250 mg glucosamine sulphate, 200 mg chondroitin sulphate and 100 mg ibuprofen. Chondroitin sulfate and glucosamine are involved in connective tissue biosynthesis, helping to prevent cartilage destruction by stimulating tissue regeneration. Ibuprofen has analgesic, anti-inflammatory and antipyretic effects. The mechanism of action is due to the selective blockade of cyclooxygenase (COX type 1 and type 2) - the main enzyme in arachidonic acid metabolism, which leads to decreased prostaglandin synthesis. The presence of NSAIDs in the Teraflex-Advance preparation helps to increase joint range of motion and reduce morning stiffness in the joints and spine. It should be noted that, according to R. J. Tallarida et al. , The presence of glucosamine and ibuprofen in Teraflex-Advance provides synergism with respect to the analgesic effect of the latter. In addition, the analgesic effect of the glucosamine / ibuprofen combination is provided by 2, 4 times the dose of ibuprofen.
Once the pain has been relieved, it is rational to switch to Teraflex treatment, 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 / day. in the next three weeks.
In the overwhelming majority of patients taking Teraflex, there is a positive trend in the form of relief from the pain syndrome and decrease in neurological symptoms. The drug is well tolerated by patients, no allergic manifestations were observed. The use of Teraflex in degenerative dystrophic diseases of the spine is rational, especially in young patients, both in combination with NSAIDs and in monotherapy. In combination with NSAIDs, the analgesic effect occurs twice as fast and the need for therapeutic doses of NSAIDs is progressively reduced.
In clinical practice, for peripheral nervous system injuries, including those associated with osteochondrosis of the spine, B vitamins with neurotropic effects are widely used. Traditionally, the alternate administration method of vitamins B1, B6 and B12, 1-2 ml 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 that reduces the effectiveness of the treatment and the need for frequent injections.
For discogenic radiculopathy, traction therapy is used: traction (including underwater) in a neurological hospital. In case of myofascial syndrome after local treatment (novocaine blockade, ethyl chloride irrigation, 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 a herniated disc, it is recommended:
- wear a stiff "weight lifting belt" type corset;
- elimination of sudden movements and inclinations, limitation of physical activity;
- physical therapy exercises to create a muscular corset and restore muscle mobility;
- massage;
- novocaine blockade;
- reflexology;
- physiotherapy: ultrasound, laser therapy, thermal therapy;
- therapy with intramuscular vitamins (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. An absolute indication for surgical treatment is the development of caudal syndrome, presence of a sequestered disc herniation, pronounced radicular pain syndrome, which does not decrease despite ongoing treatment. The development of radiculomyelochemia also requires urgent surgical intervention, however, after the first 12-24 hours, the 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 the course of treatment and rehabilitation measures, the process regresses in approximately 6 months. The same regression periods are observed with lagged operations.
Relative indications include ineffective conservative treatment, recurrent sciatica. Conservative therapy in duration should not exceed 3 months. and last for at least 6 weeks. It is assumed that the surgical approach in case of acute radicular syndrome and ineffectiveness 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 pronounced painful syndrome, when the painful component changes with increasing neurological deficit.
From physical therapy procedures, electrophoresis with the proteolytic enzyme caripazim is currently widely used.
It is known that physiotherapy and massage are integral parts of the complex treatment of patients with spinal injuries. Therapeutic gymnastics aims at the goals of general strengthening of the body, increasing efficiency, improving movement coordination, increasing physical conditioning. At the same time, special exercises aim to restore certain motor functions.