The most urgent tasks should be completed before time.degeneration – dystrophy (osteochondrosis, ankylosing spondylitis deformation) and prevention of the spine.In addition, various diseases of the abdominal and pelvic organs, including tumors, can cause the same symptoms as a herniated disc that compresses 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 local or family doctors.
Etiology and pathogenesis of lower 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:
- intense physical activity;
- uncomfortable working posture;
- injury;
- cooling, drafts;
- alcohol abuse;
- depression and stress;
- occupational diseases associated with exposure to high temperatures (especially in hot stores), radiation energy, sudden temperature changes and vibration.
Among the spinal causes of lower back pain are:
- radicular 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.
Various functional disorders of the lumbar spine can play a certain role in the occurrence of back pain, when, due to poor posture, blockages in the intervertebral joints occur and their mobility is impaired.In the joints above and below the block, compensatory hypermobility develops, leading to muscle spasms.
Signs of acute spinal canal compression
- numbness of the perineal region, weakness and numbness of 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 most 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 of the legs are noted.
Lower back pain can be caused by lumbarization – the 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 characteristics of the development of the transverse processes of the vertebrae.
Nosological forms
Almost all patients complain of lower back pain.The disease mainly manifests itself by inflammation of poorly mobile joints (intervertebral, costovertebral, lumbosacral joints) and ligaments of the spine.Gradually, ossification develops there, the spine loses its 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, as a result, the vital capacity of the lungs significantly decreases, which contributes to the development of a number of lung diseases.
Spinal tumors
There are benign and malignant tumors, mainly originating 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, mostly metastatic, arise 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 gradual 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 can develop in patients who take hormones, aminazine, anti-tuberculosis drugs and tetracycline for a long time.Radicular disorders accompanying back pain occur due to deformation of the intervertebral foramina, and spinal disorders (myelopathy) occur 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.This can occur due to overexertion (during intense physical activity), excessive extension and bruising of muscles, unphysiological posture during work, a reaction to emotional stress, shortening of one leg and even flat feet.
Myofascial syndrome is characterized by the presence of so-called “trigger” areas, on which pressure causes pain, often radiating to neighboring areas.In addition to myofascial pain syndrome, the cause of pain can also be an inflammatory muscle disease - myositis.
Lower back pain is often caused by diseases of the internal organs: gastric and duodenal ulcers, pancreatitis, cholecystitis, urolithiasis, etc.They can be pronounced and imitate the image of lumbago or discogenic lumbosacral radiculitis.However, there are also obvious differences, thanks to which it is possible to differentiate referred pain from that resulting from diseases of the peripheral nervous system, due to 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 usually last 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 carrying heavy loads, 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 results from degenerative processes facilitated by static and dynamic loads, hormonal disorders and injuries (including microtrauma 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, scar changes in epidural tissue, and hypertrophy of the ligamentum flavum may be involved in radicular trauma.
The upper lumbar roots (L1, L2, L3) are rarely affected: they do not represent more than 3% of all lumbar root syndromes.The L4 root is affected twice as often (6%), causing a characteristic clinical picture: slight pain along the inner-lower and anterior surface of the thigh, the medial surface of the leg, paresthesias (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 most often affected (46%).The pain is localized in the lumbar and gluteal regions, along the external aspect of the thigh, from the antero-external aspect of the lower leg to the foot and fingers III-V.It is often accompanied by a reduction in the sensitivity of the skin of the anterior outer surface of the leg and in the strength of the extensor muscles of the third to fifth fingers.The patient has difficulty standing on his heels.In cases of long-standing radiculopathy, hypotrophy of the tibialis anterior muscle develops.The S1 root is also often affected (45%).In this case, the pain in the lower back radiates along the rear outer surface of the thigh, the outer surface of the lower leg and the foot.Examination often reveals hypalgesia 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.
Lumbar vertebrogenic reflex syndrome
It can be acute or chronic.Acute lower back pain (LBP) (lumbago, “lumbago”) occurs within minutes or hours, often suddenly due to awkward movements.Piercing, shooting 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.Movements of the lumbar spine are limited, the lumbar muscles are tense, causing a Lasègue symptom, often bilateral.So, 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 leg position the diseased nerve is relaxed.Then the doctor, leaving the leg bent at the hip-femoral joint, begins to straighten it at the knee, thereby causing tension on the sciatic nerve, which causes severe pain.Acute lumbodynia usually lasts 5 to 6 days, sometimes less.The first attack ends more quickly than the following ones.Repeated attacks of lumbago tend to develop into chronic low back pain.
Atypical lower back pain
There are a number of atypical clinical symptoms 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 lower back pain;
- back pain accompanied by fever or signs of intoxication;
- spine;
- rectum, vagina, both legs, girdle pain;
- link between lower back pain and 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);
- pain that increases steadily over one to two weeks;
- limbs and 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 the range of motion of the lumbar spine and areas of muscle wasting;
- examination of neurological status;determination of tension symptoms (Lassegue, Wasserman, Neri).Study of Wasserman's symptom: flexion of the leg at the knee joint in a patient in a lying position causes pain in the thigh.Study of Neri's symptom: a sharp flexion 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, autonomic disorders (swelling, color changes, temperature and humidity of the skin);
- x-ray, computer or magnetic resonance imaging 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 spinal or myofascial syndromes
Undifferentiated treatment.Gentle motor mode.In case of intense pain in the first few days, rest in bed, 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, a wool shawl, an electric heating pad, and heated sand or salt bags are recommended.Ointments have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc., as well as mustard and pepper plasters.Ultraviolet irradiation in erythematous 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, novocaine electrophoresis, etc.The use of reflexology (acupuncture, laser therapy, cauterization) is effective;novocaine blockages, trigger point pressure massage.
Pharmacotherapy 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 analgesic drugs 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 painkillers increases the risk of complications from this type of therapy.There is currently a wide choice of NSAIDs.For patients with pain in the spine, due to their availability, effectiveness and lower likelihood 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” – meloxicam orally 7.5-15 mg/day, nimesulide orally 200 mg/day.
During treatment with NSAIDs, side effects may occur: nausea, vomiting, loss of appetite, pain in the epigastric region.Possible ulcerogenic effect.In some cases, ulcerations and bleeding in the gastrointestinal tract may occur.Additionally, headache, dizziness, drowsiness and allergic reactions (rash, etc.) are noted.Treatment is contraindicated in case of 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.In addition, taking NSAIDs when pain increases 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 compliance with treatment and, as a result, insufficient effectiveness of therapy.
Therefore, modern methods of conservative treatment include the obligatory use of drugs that have chondroprotective and chondrostimulating effects and have a better therapeutic effect than NSAIDs.The drug Teraflex-Advance fully meets these requirements, which is 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 is due to the selective blockade of cyclooxygenase (COX types 1 and 2), the main enzyme of arachidonic acid metabolism, 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 in the joints and spine.It should be noted that, according to R.J. According to Tallarida et al., the presence of glucosamine and ibuprofen in Theraflex-Advance ensures synergy regarding the analgesic effect of the latter.In addition, the analgesic effect of the glucosamine/ibuprofen combination is ensured by a dose of ibuprofen 2.4 times lower.
After relieving the pain, it is rational to switch to 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 and no allergic manifestations were noted.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 gradually decreases.
In clinical practice, for lesions of the peripheral nervous system, especially those associated with spinal osteochondrosis, B vitamins, which have a neurotropic effect, are widely used.Traditionally, the method of administering vitamins B1, B6 and B12 alternately, 1 to 2 ml each, is used.intramuscularly with daily alternation.The duration of treatment is 2 to 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, ethyl chloride irrigation, anesthetic ointments), a warm compress is applied to the muscles for several minutes.
Chronic lower back pain of vertebrogenic or myogenic origin
In the event of a herniated disc, it is recommended:
- wear a rigid corset like a “weightlifter’s belt”;
- avoid sudden movements and bending, limit physical activity;
- physiotherapy to create a muscle corset and restore muscle mobility;
- massage;
- novocaine blockages;
- reflexology;
- physiotherapy: ultrasound, laser therapy, heat therapy;
- 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 and 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, 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 surgery in such cases become relative, on the one hand, due to the formation of irreversible changes in the roots, and on the other hand, because in most cases, during treatment and rehabilitation measures, the process regresses in about 6 months.The same periods of regression are observed with delayed operations.
Relative indications include failure of conservative treatment and recurrent sciatica.Conservative treatment should not last more than 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 in the first 3 months.after the onset of pain to prevent chronic pathological changes in the root.A relative indication is in 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 condition.In this case, special exercises are aimed at restoring certain motor functions.