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Lower back pain (etiology, clinical picture, diagnosis and treatment)

The most common causes of lower back pain are spinal diseases, mainly degenerative-dystrophic (osteochondrosis, deforming spondylosis) and overload of the back muscles. In addition, various diseases of the abdominal cavity and small pelvis, including tumors, can cause the same symptoms as a herniated disc by 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 district or family doctors.

Etiology and pathogenesis of lower back pain

According to modern concepts, the most common causes of lower 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.

The 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 (in particular, in hot shops), radiant energy, with strong changes in temperature, vibrations.

Among the vertebral causes of lower back pain are:

  • root ischemia (discogenic root syndrome, discogenic radiculopathy), resulting from compression of the root by a herniated disc;
  • reflex muscle syndromes, which can be caused by degenerative-dystrophic changes in the spine.

A certain role in the onset of back pain can be played by various functional disorders of the lumbar spine, when blockages of the intervertebral joints appear due to incorrect posture and their mobility is impaired. In the joints located above and below the block, compensatory hypermobility develops, which leads to muscle spasm.

Signs of acute compression of the spinal canal

  • numbness of the perineal region, weakness and numbness of the legs;
  • delay in urination and bowel movements;
  • with compression of the spinal cord, a decrease in pain is observed, alternating with a feeling of numbness in the pelvic girdle and limbs.

Lower back pain in childhood and adolescence is most often caused by abnormalities in the development of the spine. Non-overgrowth of the arches of the vertebrae (spina bifida) occurs in 20% of adults. Examination reveals hyperpigmentation, birthmarks, multiple scarring, and hyperkeratosis of the skin in the lumbar region. Sometimes there is urinary incontinence, trophic disorders, weakness in the legs.

Lower back pain can be caused by lumbarization - transition of the S1 vertebra in relation to the lumbar spine - and sacralization - the 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 back pain. The disease is mainly manifested by inflammation of sedentary joints (intervertebral, costo-vertebral, 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, fragile, easily injured. At the stage of pronounced clinical manifestations of the disease, the mobility of the chest during breathing and, as a result, 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, mainly originating from the spine and metastatic Benign spinal tumors (osteochondroma, chondroma, hemangioma) are sometimes clinically asymptomatic. With hemangioma, a spinal fracture can occur even with small external influences (pathological fracture).

Malignant tumors, predominantly metastatic, originate in the prostate gland, 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 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 the 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 general aging of the body. Osteoporosis can develop in patients who take hormones for a long time, chlorpromazine, antituberculous drugs, tetracycline. Root disorders accompanying back pain result 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 leading cause of back pain. It can occur due to overexertion (during intense physical exertion), overstretching and muscle bruises, non-physiological 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, often radiated to neighboring areas. In addition to myofascial pain syndrome, inflammatory muscle diseases - myositis can also cause pain.

Lower 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 the image of low back pain or discogenic lumbosacral radiculitis. However, there are also clear differences, thanks to which it is possible to differentiate reflected pain from that resulting from diseases of the peripheral nervous system, which is due to the symptoms of the underlying disease.

Clinical symptoms for lower back pain

Most often, low back pain occurs at the age of 25-44. Distinguish between acute pain, which lasts, as a rule, 2-3 weeks and sometimes up to 2 months. And chronic - more than 2 months.

Radicular compression syndromes (discogenous radiculopathy) are characterized by a sudden onset, often after heavy lifting, sudden movements, hypothermia. Symptoms depend on the location of the lesion. At the heart of the syndrome is the compression of the root 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 pathological process involves areas of the spinal roots from the dura mater to the intervertebral foramen. In addition to herniated disc, bone growths, scarring changes in the epidural tissue, and hypertrophy of the yellow ligament may be involved in root trauma.

Upper lumbar roots (L1, L2, L3) rarely suffer: they account for 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-inferior and anterior surface of the thigh, the medial surface of the lower leg, paraesthesia (feeling of numbness, burning, creeping) in this area; slight weakness in the quadriceps. Knee reflexes persist and sometimes even increase. The L5 root is 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 toes III-V. It is often accompanied by a decrease in the sensitivity of the skin of the anterior - outer surface of the leg and strength in the extensor of the fingers III - V. It is difficult for the patient to stand on the heel. With long-term radiculopathy, anterior tibial muscle hypotrophy develops, and the S1 root is often affected (45%). In this case, the 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, a decrease in the strength of his triceps muscle and toe flexors. It is difficult for such patients to stand upright. 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) (low back pain, "low back pain") occurs within minutes or hours, often suddenly due to awkward movements. A piercing, stabbing pain (like an electric shock) is localized throughout the lower back, sometimes radiates to the iliac region and buttocks, sharply increases with coughing, sneezing, decreases in the supine position, especially if the patient find a comfortable position. Movement in the lumbar spine is limited, lumbar muscles are tense, Lasegue's symptom is caused, often bilateral. Therefore, the patient lies on his back with his legs stretched out. 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 in the hip-hip joint, begins to stretch it in the knee, thereby causing tension on the sciatic nerve, which gives intense pain. Acute lombosis 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 number of atypical clinical symptoms are distinguished for back pain caused by degenerative-dystrophic changes of the spine or myofascial syndrome. These signs include:

  • the appearance of pain in childhood and adolescence;
  • back injury just before the onset of lower back pain;
  • back pain accompanied by fever or signs of intoxication;
  • vertebral column;
  • rectum, vagina, both legs, pain in the girdle;
  • the connection of lower back pain with eating, defecation, sexual intercourse, urination;
  • necological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which appeared against the background of back pain;
  • increased pain in the lower back in a horizontal position and decrease in a vertical position (Razdolsky symptom, characteristic of the tumor process in the spine);
  • steadily increasing pain for one to two weeks;
  • limbs and the appearance of pathological reflexes.

Methods of investigation

  • 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 atrophy;
  • research of the neurological status; determination of tension symptoms (Lassegh, Wasserman, Neri). [Wasserman symptom study: knee flexion in a patient in the prone position causes hip pain. Neri's symptom study: a strong flexion of the head on the chest of a patient lying on his back with straight legs 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, changes in color, temperature and humidity of the skin);
  • x-ray, MRI or computerized resonance 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.
MRI of the herniated disc of the spine

Treatment

Acute low back pain or exacerbation of vertebral or myofascial syndromes

Undifferentiated treatment. Gentle engine mode. With severe pain in the first few days, bed rest and then walking on crutches to relieve the spine. The bed should be solid, a wooden board should be placed under the mattress. For warming we recommend a wool shawl, an electric heating pad, heated sandbags or salt. Ointments have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc. , As well as mustard patches, pepper patches. Ultraviolet irradiation recommended at doses erythema, leeches (taking into account any contraindications), irrigation of the painful area with ethyl chloride.

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 therapy, moxibustion) is effective; novocaine block, 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 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 from this type of therapy. Currently, there is a large selection of NSAIDs. For patients suffering from spinal pain, diclofenac 100-150 mg / day is preferable to "non-selective" drugs in terms of availability, efficacy and less likelihood of side effects (gastrointestinal bleeding, dyspepsia). inside, intramuscularly, rectally, topically, ibuprofen and ketoprofen within 200 mg and topically, and by "selective" - meloxicam within 7. 5-15 mg / day, nimesulide inside of 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 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 to drink milk. In addition, taking NSAIDs with increased pain in combination with other drugs that the patient takes for the treatment of concomitant diseases leads, as observed with long-term treatment of many chronic diseases, to a decrease in adherence to treatment. and, consequently, insufficient efficacy of the therapy.

Therefore, modern methods of conservative treatment include the mandatory use of drugs that have a chondroprotective, chondrostimulating 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 drug Teraflex-Advance 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 the destruction of cartilage 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 of arachidonic acid metabolism, which leads to a decrease in prostaglandin synthesis. The presence of NSAIDs in the Teraflex-Advance preparation helps to increase the range of motion of the joints and to 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.

After relieving the pain, it is rational to switch to taking 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 from pain syndrome and a decrease in neurological symptoms. The drug is well tolerated by patients, allergic manifestations were not noted. 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, B vitamins with neurotropic effects are widely used for lesions of the peripheral nervous system, including those associated with osteochondrosis of the spine. Traditionally, the method of alternating administration of vitamins B1, B6 and B12, 1-2 ml, is used. intramuscular with daily alternation. The course of treatment is 2-4 weeks. The disadvantages of this method include the use of small doses of drugs that 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 case of 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 herniated disc we recommend:

  • wear a rigid "weight lifter belt" type corset;
  • elimination of sudden movements and inclinations, limitation of physical activity;
  • physiotherapy exercises to create a muscle corset and restore muscle mobility;
  • massage;
  • novocaine blockade;
  • reflexology;
  • physiotherapy: ultrasound, laser therapy, thermotherapy;
  • intramuscular vitamin therapy (B1, B6, B12), multivitamins with mineral supplements;
  • carbamazepine is prescribed for paroxysmal pain.

Non-pharmacological treatments

Despite the availability of effective means of conservative treatment, the existence of dozens of techniques, some patients need surgical treatment.

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 decrease, despite the 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, firstly, due to the formation of irreversible changes in the roots, and secondly , because in most cases in the course of the treatment and rehabilitation interventions, the process regresses within about 6 months. The same regression periods are observed with delayed operations.

Relative indications include the ineffectiveness of conservative treatment, recurrent sciatica. The duration of conservative therapy should not exceed 3 months. and last at least 6 weeks. It is assumed that the surgical approach in acute radicular syndrome and 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 neurological deficit.

From physiotherapeutic procedures, electrophoresis with the proteolytic enzyme caripazim is currently widely used.

Physical therapy and massage are known to be integral parts of the complex treatment of spinal injury patients. Therapeutic gymnastics pursues the objectives of general strengthening of the body, increasing efficiency, improving coordination of movements, increasing physical fitness. At the same time, special exercises are aimed at restoring certain motor functions.