The most common causes of lumbar pain are diseases of the spine, primarily degenerative-dystrophic (osteochondrosis, deforming spondylosis), and overstrain of the back muscles. In addition, various diseases of the abdominal and pelvic organs, 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 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, drafts;
- alcohol abuse;
- depression and stress;
- occupational diseases associated with exposure to high temperatures (in particular, in hot shops), radiation energy, with sharp temperature fluctuations, vibration.
Among the vertebral causes of lumbar pain are:
- ischemia of the root (discogenic radicular 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 occurrence of back pain can be played by various functional disorders of the lumbar spine, when blocks of intervertebral joints appear due to an 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 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.
Lumbar 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 scars and hyperkeratosis of the skin in the lumbar region. Sometimes there is urinary incontinence, trophic disorders, weakness in the legs.
Lumbar 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 characteristics of the development of the transverse processes of the vertebrae.
Nosological forms
Almost all patients complain of back pain. The disease is manifested primarily by inflammation of the sedentary joints (intervertebral, costo-vertebral, 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. 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 decrease significantly, which contributes to the development of a number of pulmonological diseases.
Spine tumors
Distinguish between benign and malignant tumors, primarily 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 from 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 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, anti-tuberculosis drugs, tetracycline. Radicular disorders accompanying back pain arise from deformation of the intervertebral foramen, and spinal (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, non-physiological 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), pressure on which causes pain, often radiating to neighboring areas. In addition to myofascial pain syndrome, inflammatory muscle diseases - myositis can also cause pain.
Lumbar pain often occurs with diseases of internal organs: gastric ulcer and duodenal ulcer, pancreatitis, cholecystitis, urolithiasis, etc. They can be pronounced and mimic the picture of lumbago or discogenic lumbosacral radiculitis. However, there are also clear differences, due to which it is possible to differentiate reflected pain from those arising from diseases of the peripheral nervous system, which is due to the symptoms of the underlying disease.
Clinical symptoms for lumbar pain
Most often, low back pain occurs at the age of 25–44 years. Distinguish between acute pain, lasting, as a rule, 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 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 disc herniation, bone growths, cicatricial changes in epidural tissue, and hypertrophied ligamentum flavum can be involved in traumatizing the root.
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-lower and front surface of the thigh, the medial surface of the lower leg, paresthesia (feeling of numbness, burning, crawling creeps) in this area; slight weakness of 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 outer surface of the thigh, the antero-outer surface of the lower leg up to the foot and III-V fingers. It is often accompanied by a decrease in the sensitivity of the skin of the anterior – external surface of the leg and strength in the extensor of the III – V fingers. 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, 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 hypalgesia of the posterior-external surface of the leg, a decrease in the strength of its triceps muscle and flexors of the toes. It is difficult for such patients to stand on their toes. 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 or hours, often suddenly due to awkward movements. A piercing, shooting (like an electric shock) pain 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 finds a comfortable posture. Movement in the lumbar spine is limited, the lumbar muscles are tense, the Lasegue symptom is caused, often bilateral. Thus, the patient lies on his back with 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 in the hip-hip joint, begins to unbend it in the knee, thereby causing tension on the sciatic nerve, which gives intense pain. Acute lumbodynia usually lasts 5-6 days, sometimes less. The first attack ends faster than the subsequent ones. Recurrent attacks of lumbago tend to develop into chronic PB.
Atypical back pain
A number 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 lower back pain;
- back pain accompanied by fever, or signs of intoxication;
- spine;
- rectum, vagina, both legs, girdle pain;
- the connection of lower back pain with eating, defecation, intercourse, urination;
- necological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which appeared against the background of back pain;
- increased pain in the lower back in the horizontal position and decrease in the vertical position (Razdolsky's symptom, characteristic of the tumor process in the spine);
- steadily increasing pain for one to two weeks;
- limbs and the appearance of pathological reflexes.
Survey methods
- external examination and palpation of the lumbar region, identification of scoliosis, muscle tension, pain and trigger points;
- determination of the range of motion in the lumbar spine, areas of muscle wasting;
- research of neurological status; determination of symptoms of tension (Lassegh, Wasserman, Neri). [Study of Wasserman's symptom: flexion of the knee in a patient in the prone position causes pain in the hip. Study of Neri's symptom: a sharp bending of the head to 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 moisture of the skin);
- radiography, computed or magnetic resonance imaging of the spine.
MRI is especially informative.
- ultrasound examination of the pelvic organs;
- gynecological examination;
- if necessary, additional examinations are carried out: cerebrospinal fluid, blood and urine, sigmoidoscopy, colonoscopy, gastroscopy, etc.
Treatment
Acute low back pain or exacerbation of vertebral or myofascial syndromes
Undifferentiated treatment. Gentle motor mode. In case of severe pain in the first days, bed rest, and then walking on crutches to relieve the spine. The bed should be firm, a wooden board should be placed under the mattressFor warming, a woolen shawl, an electric heating pad, bags of heated sand or salt are recommended. Ointments have a beneficial effect: finalgon, tiger, capsin, diclofenac, etc. , as well as mustard plasters, pepper plaster. Recommended ultraviolet irradiation in erythemal doses, leeches (taking into account possible contraindications), irrigation of the painful area with ethyl chloride.
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, pressure massage of trigger points.
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 because of 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 of this type of therapy. Currently, there is a large selection of NSAIDs. For patients suffering from pain in the spine, in terms of availability, effectiveness and less likelihood of side effects (gastrointestinal bleeding, dyspepsia), diclofenac 100–150 mg / day is preferable from the "non-selective" drugs. inside, intramuscularly, rectally, topically, ibuprofen and ketoprofen inside 200 mg and topically, and from the "selective" - meloxicam inside 7. 5-15 mg / day, nimesulide inside 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 (skin rash, etc. ) are noted. 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 during or after meals and drink milk. In addition, taking NSAIDs with increased pain in conjunction with other drugs that the patient takes to treat concomitant diseases, leads, as is observed with long-term treatment of many chronic diseases, to a decrease in adherence to treatment and, as a consequence, insufficient effectiveness 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 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, stimulating tissue regeneration. Ibuprofen has analgesic, anti-inflammatory, antipyretic effects. The mechanism of action is due to the selective blocking of cyclooxygenase (COX type 1 and type 2) - the main enzyme of the metabolism of arachidonic acid, 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 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 glucosamine / ibuprofen combination is provided by 2. 4 times the dose of ibuprofen.
After relieving 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 / day. in the next three weeks.
In the overwhelming majority of patients, when taking Teraflex, there is a positive trend in the form of relief of pain syndrome and a decrease in neurological symptoms. The drug is well tolerated by patients, no allergic manifestations have been 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, 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 alternating administration of vitamins B1, B6 and B12, 1-2 ml, is used. intramuscularly 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, pain relieving ointments), a hot compress is applied to the muscles for several minutes.
Chronic low back pain of vertebrogenic or myogenic origin
In case of disc herniation, it is recommended:
- wearing a rigid corset of the "weightlifter belt" type;
- elimination of sudden movements and inclinations, limitation of physical activity;
- physiotherapy exercises in order to create a muscle 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;
- 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 need surgical treatment.
Indications for surgical treatment are divided into relative and absolute. An absolute indication for surgical treatment is the development of the 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 inIn the course of treatment and rehabilitation measures, the process regresses within approximately 6 months. The same periods of regression are observed with delayed operations.
Relative indications include the ineffectiveness of 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 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 there is a change in the pain component by an increase in neurological deficit.
From physiotherapeutic procedures, electrophoresis with the proteolytic enzyme caripazim is currently widely used.
It is known that physical therapy and massage are integral parts of the complex treatment of patients with spinal lesions. 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.