The most common causes of low back pain are spinal diseases, mainly degenerative-dystrophic (osteochondrosis, deforming spondylosis) and overexertion of the back muscles. Also, various 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 no coincidence that these patients turn not only to neurologists, but also to gynecologists, orthopedists, urologists and, above all, of course, to district or family doctors.
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, mainly degenerative-dystrophic;
- pathological changes in the muscles, most often myofascial syndrome;
- pathological changes in the abdominal organs;
- Diseases of the nervous system.
Risk factors for low back pain are:
- intense physical activity;
- uncomfortable work posture;
- injury;
- cooling, drafts;
- Alcohol abuse;
- depression and stress;
- occupational diseases associated with exposure to high temperatures (in particular, in hot stores), radiation energy, with sharp fluctuations in temperature, 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.
Various functional disorders of the lumbar spine can play a role in the appearance of back pain, when intervertebral joint blocks appear due to incorrect posture and their mobility is affected. 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 of the perineal region, weakness and numbness of the legs;
- delayed urination and bowel movements;
- with compression of the spinal cord, a decrease in pain is observed, alternating with a sensation of numbness in the pelvic girdle and extremities.
Low back pain in childhood and adolescence is usually caused by abnormalities in the development of the spine. Non-excessive growth of the arches of the vertebrae (spina bifida) occurs in 20% of adults. Examination reveals hyperpigmentation, birthmarks, multiple scars, and hyperkeratosis of the skin in the lumbar region. Sometimes there is urinary incontinence, trophic disorders, weakness in the legs.
Low back pain can be caused by lumbarization (transition of the S1 vertebra in relation to the lumbar spine) and sacralization (union of the L5 vertebra to the sacrum). These abnormalities are formed due to the individual features of the development of the transverse processes of the vertebrae.
Nosological forms
Almost all patients complain of back pain. The disease is manifested mainly by inflammation of the sedentary joints (intervertebral, costovertebral, lumbosacral joints) and ligaments of the spine. Gradually, ossification develops in them, the spine loses its elasticity and functional mobility, becomes like a bamboo stick, brittle, easily injured. At the stage of pronounced clinical manifestations of the disease, the mobility of the chest during breathing and, as a consequence, the vital capacity of the lungs significantly decreases, which contributes to the development of a number of lung diseases.
Spinal tumors
Distinguish between benign and malignant tumors, originating primarily in 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 small external influences (pathological fracture).
The predominantly metastatic malignant tumors originate in the prostate, uterus, breast, lungs, adrenal glands, and other organs. The pain in this case is much more frequent than in benign tumors, generally persistent, painful, aggravated by the slightest movement, depriving patients of rest and sleep. Characterized by a progressive deterioration of the condition, an increase in general exhaustion, pronounced changes in the blood. Of great importance for diagnosis are radiography, computed tomography, magnetic resonance imaging.
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 the general aging of the body. Osteoporosis can develop in patients who take hormones for a long time, chlorpromazine, anti-tuberculosis drugs, tetracycline. Root disorders accompanying back pain arise from deformation of the intervertebral and spinal foramen (myelopathy), due to compression of the radiculomedullary artery or a vertebral fracture, even after minor injuries.
Myofascial syndrome
Myofascial syndrome is the leading cause of back pain. It can occur as a result of overexertion (during strenuous physical exertion), overstretching and muscle bruising, 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), the pressure on which it causes pain, which often radiates to neighboring areas. In addition to myofascial pain syndrome, inflammatory diseases of the muscles, myositis can also cause pain.
Low back pain often occurs with diseases of the internal organs: gastric ulcer and duodenal ulcer, pancreatitis, cholecystitis, urolithiasis, etc. They can be pronounced and mimic lumbago or discogenic lumbosacral radiculitis. However, there are also clear differences, so it is possible to differentiate reflected pain from those derived from diseases of the peripheral nervous system, which is due to the symptoms of the underlying disease.
Clinical symptoms of low back pain
Low back pain most often occurs between the ages of 25 and 44. Distinguish between acute 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, often after heavy lifting, sudden movements, hypothermia. Symptoms depend on the location of the injury. 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 disorders, trauma (including microtraumatization of the spine). Most often, the disease process involves areas of the spinal roots from the dura to the intervertebral foramen. In addition to herniated discs, bony growths, scar changes in epidural tissue, and hypertrophied ligamentum flare may be involved in root trauma.
The upper lumbar roots (L1, L2, L3) rarely suffer: they represent no more than 3% of all lumbar root syndromes. Twice as often, the L4 root is affected (6%), causing a characteristic clinical picture: mild pain along the inner, lower and front surface of the thigh, the medial surface of the lower part of the thigh. leg, paresthesia (feeling of numbness, burning, crawling) in this area; mild quadriceps weakness. Knee reflexes persist and sometimes even increase. 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, the antero-outer surface of the lower leg to the foot and III-V toes. It is often accompanied by decreased sensation of the skin on the anterior-external surface of the leg and the force in the extensor digits III-V. It is difficult for the patient to stand on the heel. With long-term radiculopathy, hypotrophy of the tibialis anterior muscle develops and the S1 root is often affected (45%). In this case, the lower back pain radiates along the outer-posterior surface of the thigh, the outer surface of the lower leg, and the foot. Examination often reveals hypoagesia 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 tiptoe. There is a decrease or loss of the Achilles reflex.
Vertebral lumbar reflex syndrome
It can be acute and chronic. Acute low back pain (LBP) (lumbago, "lumbago") occurs within minutes to hours, often suddenly due to uncomfortable movements. A stabbing, stabbing pain (like an electric shock) is localized throughout the lower back, sometimes radiating to the iliac region and buttocks, sharply increasing when coughing, sneezing, decreasing in the supine position, especially if the patient encounters a comfortable position. Movement in the lumbar spine is limited, the lumbar muscles are tight, the Lasegue symptom is caused, often bilateral. 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 position of the leg, the diseased nerve is relaxed. Then the doctor, leaving the leg bent at the hip-hip joint, begins to flex it at the knee, causing tension on the sciatic nerve, which produces severe pain. Acute lumbodynia usually lasts 5-6 days, sometimes less. The first attack ends faster than the following ones. Recurrent attacks of low back pain tend to develop into chronic PB.
Atypical back pain
A series of clinical symptoms are distinguished that are 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 the onset of low back pain;
- back pain accompanied by fever or signs of intoxication;
- spine;
- rectum, vagina, both legs, pain in the waist;
- the connection of low back pain with food, defecation, intercourse, urination;
- necological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which appeared against the background of back pain;
- increased pain in the lumbar area in a horizontal position and decrease in a vertical position (Razdolsky's symptom, characteristic of the tumor process in the spine);
- constantly increasing pain for a week or two;
- limbs and the appearance of pathological reflexes.
Survey methods
- external examination and palpation of the lumbar region, detection of scoliosis, muscle tension, pain and trigger points;
- determination of the range of motion in the lumbar spine, areas of muscle wasting;
- investigation of neurological status; determination of symptoms of tension (Lassegh, Wasserman, Neri). [Wasserman Symptom Study: Knee flexion in prone patient causes hip pain. Study of the Neri symptom: a sharp tilt of the head towards the chest of a patient lying on his back with the 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 disorders (swelling, color changes, temperature and humidity of the skin);
- X-ray, magnetic resonance imaging or computerized 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 motor mode. With severe pain in the first days, bed rest and then walking with crutches to relieve the spine. The bed should be firm, a wooden board should be placed under the mattress. A wool shawl, an electric heating pad, hot sandbags or salt is recommended for heating. Ointments have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc. , as well as mustard plasters, pepper plaster. Ultraviolet irradiation in erythemal doses, leeches (taking into account possible contraindications), irrigation of the painful area with ethyl chloride is recommended.
The anesthetic effect is provided by electrical procedures: percutaneous electroanalgesia, sinusoidal modulated currents, diadynamic currents, electrophoresis with novocaine, etc. The use of reflexology (acupuncture, laser, moxibustion) is effective; novocaine blocking, trigger point pressure massage.
Drug therapy includes pain relievers, 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 pain relievers are NSAIDs, which are often used uncontrollably by patients when pain intensifies or reappears. It should be noted that long-term use of NSAIDs and pain relievers increases the risk of complications from this type of therapy. Currently, there is a large selection of NSAIDs. For patients suffering from pain in the spine, in terms of availability, efficacy and less likelihood of side effects (gastrointestinal bleeding, dyspepsia), diclofenac 100-150 mg / day is preferable to "non-selective" drugs. 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. Also, headaches, dizziness, drowsiness, allergic reactions (skin rash, etc. ) are noted. Treatment is contraindicated in ulcerative processes in the gastrointestinal tract, pregnancy and lactation. To prevent and reduce dyspeptic symptoms, it is recommended to take NSAIDs during or after meals and drink milk. In addition, the intake of NSAIDs with increased pain together with other drugs that the patient takes to treat concomitant diseases, leads, as seen with the long-term treatment of many chronic diseases, to a decrease in adherence to treatment and, as consequently, to a decrease in adherence to treatment. insufficient efficacy of therapy.
Therefore, modern methods of conservative treatment include the mandatory use of drugs that have a chondroprotective, chondro-stimulating effect and have a 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 the Teraflex-Advance medicine contains 250 mg of glucosamine sulfate, 200 mg of chondroitin sulfate, and 100 mg of ibuprofen. Chondroitin sulfate and glucosamine are involved in the biosynthesis of connective tissue, helping to prevent cartilage destruction, 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 of arachidonic acid metabolism, which leads to a decrease in the synthesis of prostaglandins. The presence of NSAIDs in the Teraflex-Advance preparation helps to increase the range of motion in the joints and to reduce the 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 Teraflex-Advance provides synergism with respect to the analgesic effect of the latter. In addition, the analgesic effect of the combination of glucosamine / ibuprofen is provided by 2. 4 times the dose of ibuprofen.
After pain relief, it is logical to switch to 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.
In the vast majority of patients, when taking Teraflex, there is a positive trend in the form of relief of pain syndrome and reduction of neurological symptoms. The drug is well tolerated by patients, no allergic manifestations have been observed. The use of Teraflex in degenerative-dystrophic 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 is progressively reduced.
In clinical practice, for lesions of the peripheral nervous system, including those associated with osteochondrosis of the spine, B vitamins with neurotropic effects are widely used. Traditionally, the method of alternate administration of vitamins B1, B6 and B12, 1-2 ml is used. intramuscularly with daily alternation. The course of treatment is 2 to 4 weeks. The disadvantages of this method include the use of small doses of drugs that reduce the effectiveness of the treatment and the need for frequent injections.
For discogenic radiculopathy, traction therapy is used - traction (even underwater) in a neurological hospital. In case of myofascial syndrome after local treatment (novocaine block, ethyl chloride irrigation, anesthetic ointments), a warm compress is applied to the muscles for several minutes.
Chronic low back pain of vertebral or myogenic origin
In case of herniated disc, it is recommended:
- wear a rigid corset of the "weightlifter belt" type;
- elimination of sudden movements and inclinations, limitation of physical activity;
- physical therapy exercises to create a muscle corset and restore muscle mobility;
- massage;
- novocaine blockade;
- reflexology;
- physical therapy: 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 need surgical treatment.
The indications for surgical treatment are divided into relative and absolute. An absolute indication for surgical treatment is the development of caudal syndrome, the presence of a sequestered herniated disc, pronounced radicular pain syndrome, which does not diminish, despite ongoing treatment. The development of radiculomyeloischemia also requires urgent surgical intervention, however, after the first 12-24 hours, the indications for surgery in such cases become relative, first of all, due to the formation of irreversible changes in the roots. , and secondly, because in most cases In the course of treatment and rehabilitation measures, the process regresses by about 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 at least 6 weeks. It is assumed that the surgical approach in the case of acute root syndrome and the ineffectiveness 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 is cases of extremely pronounced pain syndrome, when the pain component changes with an increase in the neurological deficit.
Starting from physiotherapeutic procedures, electrophoresis with the proteolytic enzyme caripazim is currently widely used.
Physiotherapy and massage are known to be integral parts 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, increasing fitness. At the same time, special exercises are aimed at restoring certain motor functions.