The most common causes of lumbar pain are diseases of the spine, primarily degenerative-dystrophic (osteochondrosis, deforming spondylosis) and excessive strain on 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, 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 lumbar pain
According to modern concepts, the most common causes of lumbar pain are:
- pathological changes in the spine, primarily 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 lumbar pain are:
- heavy physical activity;
- uncomfortable working posture;
- injury;
- cooling, draft;
- alcohol abuse;
- depression and stress;
- occupational diseases associated with exposure to high temperatures (especially in hot shops), radiation energy, with sharp temperature fluctuations, vibrations.
Among the vertebral causes of lumbar pain are:
- root ischemia (discogenic radicular syndrome, discogenic radiculopathy), caused by 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 certain role in the development of back pain, when due to improper posture, blocks of the intervertebral joints appear and their mobility is impaired. Compensatory hypermobility develops in the joints located above and below the block, leading to muscle spasms.
Signs of acute spinal canal compression
- numbness of the perineal area, weakness and numbness of the legs;
- delay in urination and bowel movements;
- spinal cord compression reduces pain, alternating with a feeling of numbness in the pelvic girdle and limbs.
Lumbar pain in childhood and adolescence is most often caused by anomalies in the development of the spine. Undiscovered vertebral arches (spina bifida) occur 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.
Lumbar pain can occur by lumbarization - the transition of the S1 vertebra to the lumbar spine - and sacralization - by attaching the L5 vertebra to the sacrum. These anomalies occur due to individual characteristics of the development of transverse processes of the vertebrae.
Nosological forms
Almost all patients complain of back pain, and the disease is primarily manifested by inflammation of inactive joints (intervertebral, rib-spine, lumbosacral joints) and ligaments of the spine. Gradually, ossification develops in them, the spine loses elasticity and functional mobility, it becomes like a bamboo stick, fragile, easily injured. In the phase of pronounced clinical manifestations of the disease, the mobility of the chest during breathing and, as a consequence, the vital capacity of the lungs are significantly reduced, which contributes to the development of numerous pulmonary diseases.
Spinal tumors
Distinguish benign and malignant tumors, primarily originating from the spine and metastatic Benign tumors of the spine (osteochondroma, chondroma, hemangioma) are sometimes clinically asymptomatic. In hemangiomas, a fracture of the spine can occur even with small external influences (pathological fracture).
Malignant tumors, predominantly metastatic, originate from the prostate, uterus, breast, lung, adrenal gland, and other organs. Pain is much more common in this case than in benign tumors - usually permanent, painful, intensified with the slightest movement, depriving patients of rest and sleep. It is 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 in the background of general aging of the body. Osteoporosis can develop in patients who take hormones for a long time, chlorpromazine, anti-tuberculosis drugs, tetracycline. Radicular disorders that accompany back pain are caused by deformation of the intervertebral foramen and spine (myelopathy) - due to compression of the radiculomedullary artery or a 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), excessive stretching and bruising of muscles, unphysiological posture during work, reactions to emotional stress, shortening of one 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 the appearance of myofascial pain syndrome, inflammatory muscle diseases - myositis can also cause pain.
Lumbar pain often occurs in diseases of internal organs: gastric and duodenal ulcers, pancreatitis, cholecystitis, urolithiasis, etc. They can be pronounced and mimic the image of lumbago or discogenic lumbosacral radiculitis. However, there are also clear differences, due to which it is possible to distinguish reflected pain from pain arising from diseases of the peripheral nervous system, which are a consequence of the symptoms of the underlying disease.
Clinical symptoms for lumbar pain
Low back pain most commonly occurs between the ages of 25 and 44 years. Distinguish acute pain, which usually lasts 2-3 weeks and sometimes up to 2 months. And chronic - more than 2 months.
Compression radicular syndromes (discogenic radiculopathy) are characterized by a sudden onset, often after heavy lifting, sudden movements, hypothermia. Symptoms depend on the location of the lesion. At the center of the syndrome is root compression by a herniated disc, which occurs as a result of dystrophic processes, which alleviate static and dynamic loads, hormonal disorders, and trauma (including microtraumatization of the spine). The most common pathological process involves areas of the spinal root from the dura mater to the intervertebral foramen. In addition to disc herniation, bone growths, cicatricial changes in epidural tissue, and hypertrophied ligamentum flavum may be involved in root trauma.
The upper lumbar roots (L1, L2, L3) rarely suffer: they make up no more than 3% of all lumbar radicular syndromes. Twice more often the root of L4 is affected (6%), which causes a characteristic clinical picture: mild pain along the inner-lower and anterior surface of the thigh, medial surface of the lower leg, paresthesia (feeling numb, burning, crawling) in this area; mild quadriceps weakness. Knee reflexes last and sometimes increase. The L5 root is most commonly affected (46%). The pain is localized in the lumbar and gluteal area, along the outer surface of the thigh, the antero-outer surface of the lower leg to the feet, and the III-V toes. It is often accompanied by a decrease in the sensitivity of the skin of the front - outer surface of the foot and the strength in the extensor III - V toes. It is difficult for the patient to stand on his heel. Prolonged radiculopathy develops hypotrophy of the anterior part of the tibialis muscle, and the S1 root is often 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 the foot. Examination often reveals hypoalgesia of the posterior-outer surface of the leg, a decrease in the strength of the triceps muscle and the flexors of the toes. It is difficult for such patients to stand on their toes. There is a reduction or loss of the Achilles reflex.
Vertebral lumbar reflex syndrome
It can be acute or chronic. Acute low back pain (LBP) (lumbago, "lumbago") occurs within minutes or hours, often suddenly due to uncomfortable movements. The stabbing, shooting (like electric shock) pain is localized throughout the lower back, sometimes radiating to the iliac region and buttocks, increasing sharply with coughing, sneezing, decreasing in the supine position, especially if the patient finds a comfortable position. Movements in the lumbar spine are limited, the lumbar muscles are tense, and the Lasegue symptom is caused, often on both sides. Thus, the patient lies on his back with his legs outstretched. The doctor simultaneously bends 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 bend it at the knee, thus causing tension on the sciatic nerve, which causes intense pain. Acute lumbodinia usually lasts 5-6 days, sometimes less. The first attack ends faster than the next. Recurrent attacks of lumbago usually develop into chronic PB.
Atypical back pain
There are a number of clinical symptoms that are atypical for back pain caused by degenerative-dystrophic changes in the spine or myofascial syndrome. These signs include:
- occurrence 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;
- spine;
- rectum, vagina, both legs, waist pain;
- association of lower back pain with eating, defecation, intercourse, urination;
- non-pathological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which appeared in the background of back pain;
- increased pain in the lower back in a horizontal position and a decrease in the vertical position (Razdolsky symptom, characteristic of the tumor process in the spine);
- continuously increasing 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;
- determining the range of motion in the lumbar spine, the area of muscle wear;
- neurological status research; determination of tension symptoms (Lassegh, Wasserman, Neri). [Study of Wasserman's symptom: Knee flexion in a supine patient causes hip pain. Study of Neri's symptom: a sharp bending of the head in the chest of a patient lying on the back of 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);
- radiography, computed tomography or magnetic resonance imaging of the spine.
MRI is particularly 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 worsening of vertebral or myofascial syndromes
Undifferentiated treatment. Gentle motor mode. With severe pain in the first days, resting in bed, and then walking on crutches to relieve the spine. The bed should be solid, a wooden plank should be placed under the mattress. A woolen scarf, an electric heating pad, bags of heated sand or salt are recommended for warming up. Fats have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc. , As well as mustard plasters, pepper plaster. Recommended ultraviolet radiation in erythematous 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, sinusoidal modulated currents, diadynamic currents, electrophoresis with novocaine, etc. The use of reflexology (acupuncture, laser therapy, moxibustion) is effective; novocaine blockade, trigger pressure massage.
Drug therapy includes analgesics, NSAIDs; sedatives 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 spinal root swelling is suspected, diuretics are prescribed.
The main analgesics are NSAIDs, which patients often use uncontrollably when the pain intensifies or recurs. It should be noted that long-term use of NSAIDs and analgesics increases the risk of complications of this type of therapy. There is currently a large selection of NSAIDs. For patients suffering from spinal pain, in terms of availability, efficacy and less likelihood of side effects (gastrointestinal bleeding, dyspepsia), diclofenac is 100-150 mg / day more preferable than "non-selective" drugs. ketoprofen within 200 mg and topically, and from the "selective" - meloxicam inside 7, 5-15 mg / day, nimesulide within 200 mg / day.
In the treatment of NSAIDs, side effects can occur: nausea, vomiting, loss of appetite, pain in the epigastric region. Possible ulcerogenic actions. In some cases, ulceration and bleeding in the gastrointestinal tract may occur. In addition, headaches, dizziness, drowsiness, allergic reactions (skin rash, etc. ) have been reported. Treatment is contraindicated in ulcerative processes in the gastrointestinal tract, pregnancy and lactation. To prevent and reduce dyspeptic symptoms, it is recommended to take nonsteroidal anti-inflammatory drugs during or after meals and drink milk. In addition, taking NSAIDs with increased pain along with other medications that the patient takes to treat comorbidities leads, as noted in the long-term treatment of many chronic diseases, to reduced adherence to treatment and, consequently, insufficient efficacy of 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. Teraflex-Advance, an alternative to NSAIDs for mild to moderate pain syndrome, fully meets these requirements. Each capsule of Teraflex-Advance 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, and encouraging tissue regeneration. Ibuprofen has analgesic, anti-inflammatory and antipyretic effects. The mechanism of action is due to the selective blocking 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 Teraflex-Advance helps to increase the range of motion in the joints and 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 its analgesic effect. 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 pain relief and reduction of neurological symptoms. Patients tolerate the drug well, 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 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, 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. intramuscularly with daily change. The course of treatment is 2-4 weeks. 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 the case of myofascial syndrome after local treatment (novocaine blockade, ethyl chloride irrigation, anesthetic ointments), a hot compress is applied to the muscles several times a minute.
Chronic low back pain of vertebrogenic or myogenic origin
In case of disc herniation, it is recommended:
- wearing a rigid corset type "weight lifting strap";
- elimination of sudden movements and inclinations, restriction of physical activity;
- physiotherapy exercises in order to create a muscular corset and restore muscle mobility;
- massage;
- novocaine blockade;
- reflexology;
- physiotherapy: ultrasound, laser therapy, heat therapy;
- intramuscular vitamin therapy (B1, B6, B12), multivitamins with mineral supplements;
- carbamazepine is prescribed for paroxysmal pain.
Drug-free treatments
Despite the availability of effective means for conservative treatment, the existence of dozens of techniques, some patients need 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 sequestered disc herniation, pronounced radicular pain syndrome, which does not decrease, despite ongoing treatment. The development of radiculomyelochemistry also requires urgent surgical intervention, however, after the first 12-24 hours the indications for surgery in such cases become relative, first, due to the creation of irreversible changes in the roots, and second, because in most cases during treatment and rehabilitation measureswithdraws within approximately 6 months. The same regression periods are observed for delayed operations.
Relative indications include 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 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. Relative indications are cases of extremely pronounced pain syndrome, when the component of pain changes with increasing neurological deficit.
Of the 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 patients with spinal lesions. Therapeutic gymnastics strives for the goals of general strengthening of the body, increasing efficiency, improving coordination of movements, increasing fitness. At the same time, special exercises aim to restore certain motor functions.