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Lumbar pain (etiology, clinical picture, diagnosis and treatment)

The most common causes of lumbar pain are spinal diseases, especially degenerative-dystrophic (osteochondrosis, spondylosis deformans), and back muscle overstrain.In addition, various abdominal and pelvic organ diseases, including tumors, can cause the same symptoms as a herniated disc that compresses the spinal cord.

It is not a coincidence that such patients not only turn to neurologists, but also to gynecologists, orthopedists, urologists, and above all, of course, to local or family doctors.

Etiology and pathogenesis of lumbar pain

According to modern ideas, the most common cause of lumbar pain is:

  • pathological changes in the spine, especially degenerative-dystrophic;
  • pathological changes in the muscles, usually myofascial syndrome;
  • pathological changes in the abdominal organs;
  • Disease of the nervous system.

Lumbar pain risk factors are:

  • heavy physical activity;
  • uncomfortable work posture;
  • injury;
  • cooling, draft;
  • alcohol abuse;
  • depression and stress;
  • Occupational diseases associated with exposure to high temperatures (in particular, in hot shops), radiation energy, temperature fluctuations, and vibrations.

Some of the causes of lumbar pain are:

  • Root ischemia (discogenic radicular syndrome, radiculopathy discogenic), which is caused by compression of the root by disc herniation;
  • Reflex muscle syndrome, a cause that can be a degenerative change in the spine.

Various disorders of lumbar spinal function can play a certain role in the occurrence of back pain, when, due to incorrect posture, intervertebral joint blocks occur and their movement is affected.At the joints located above and below the block, hypermobility of compensation develops, leading to muscle cramps.

Sign of acute compression of the spinal cord

  • numbness from perineal areas, weakness and numbness;
  • urinary retention and water removal;
  • With spinal cord compression, a decrease in pain is observed, followed by a feeling of numbness in the belt and limbs.

Lumbar pain in children and adolescents is most often caused by abnormalities in spinal development.Spinal bifida (spina bifida) occurs in 20% of adults.After examination, hyperpigmentation, birthmarks, some scars and skin hyperkeratosis in the lumbar region were lowered.Sometimes urinary incontinence, trophic disorders, and weakness in the legs are observed.

Lumbar pain can be caused by lumbarization - the transition of vertebra s1 in relation to the lumbar spine - and the sacralization - the l5 vertebrae attachment to the sacrum.This anomaly is formed due to the individual features of the development of the vertebral horizontal process.

A nosological form

Almost all patients complain of pain in the lower back.The disease is characterized mainly by low moving joint inflammation (intervertebral, costovertebral, lumbosacral joints) and spinal ligaments.Gradually, ossification develops in it, the spine loses elasticity and functional mobility, becoming like a bamboo stick, fragile, and easily injured.At the stage of the clinical manifestation of the disease, the chest movement during breathing and, as a result, the significant ability of the lungs decreases, which contributes to the development of some lung diseases.

Spinal tumor

The difference is made between benign and malignant tumors, especially from the spine and metastatic.Spinal tumors (osteochondroma, chondroma, hemangioma) are sometimes clinically without symptoms.With hemangioma, spinal fractures can occur even with small external influences (pathological fractures).

Malignant tumors, mostly metastatic, derived from prostate, uterus, breast, lungs, adrenal glands and other organs.Pain in this case occurs more frequently than with benign tumors - usually persistent, painful, intensive with slight movements, preventing patients rest and sleeping.Characterized by progressive deterioration of condition, increased general fatigue, and changes in blood.X-ray, computed tomography, and magnetic resonance imaging are very important for diagnosis.

Osteoporosis

The main cause of the disease is the decrease in the function of the endocrine gland due to the free disease or the general background of the body.Osteoporosis can develop in patients taking hormones, aminazine, anti-tuberculosis drugs, and tetracycline for a long time.Radicular disorders accompanying back pain arise from intervertebral foramine deformation, and spinal disorders (myelopathy) arise from radiculomedullary artery compression or spinal fracture, even after minor injury.

Myofascial syndrome

Myofascial syndrome is the leading cause of back pain.It can be caused by overexertion (during heavy physical activity), overextension and muscle bruises, non -physiological posture during work, reaction to emotional stress, shortening one leg and even flat feet.

Myofascial syndrome is characterized by the presence of a zone called "trigger" (trigger point), pressure that causes pain, often radiates to neighboring areas.In addition to myofascial pain syndrome, the cause of pain can also be an inflammatory muscle disease - myositis.

Lumbar pain is often caused by internal organ disease: gastric and duodenal ulcer, pancreatitis, cholecystitis, urolithiasis, and others.However, there are also obvious differences, thank you for distinguishing the pain referred to from the peripheral nervous system disease, which is caused by the symptoms of underlying disease.

Clinical symptoms of lumbar disease

Often, lumbar pain occurs between the ages of 25 and 44.There is acute pain, the last, as a rule, 2-3 weeks, and sometimes up to 2 months, and chronic pain -over 2 months.

Radiculopathy discogenic (radiculopathy) syndrome is characterized by a sudden onset, often after weight lifting, sudden movement, or hypothermia.Symptoms depend on the location of the lesion.The incidence of syndrome is based on root compression by herniated discs, which occurs due to degenerative processes facilitated by static and dynamic loads, hormone disorders, and injuries (including spinal microtraumatization).Often, the pathological process involves the area of the spinal root from the dura mater to the intervertebral foramen.In addition to disc herniation, bone growth, scarring changes in epidural tissue, and hypertrophied ligamentum flavum may be involved in root trauma.

The upper lumbar root (L1, L2, L3) is rarely affected: they contribute no more than 3% of all lumbar radical syndrome.L4 root is affected twice as often (6%), causing clinical picture features: mild pain along the inner and anterior surface of the thigh, medial surface of the foot, paresthesia (numb sensation, burning, crawling) in the area;Little weakness of the quadriceps muscle.Knee reflexes are preserved and sometimes increase.The L5 root is most often affected (46%).The pain is located in the lumbar and gluteal areas, along the outer surface of the thigh, the anterior surface of the lower leg to the foot and finger III-V.It is often accompanied by a decrease in the sensitivity of the outer surface of the anterior surface and in the strength of the third to fifth to fifth finger muscles.The patient found it difficult to stand on his heel.With the old radiculopathy, the tibial anterior muscle hypotophy develops.S1 root is also often affected (45%).In this case, the pain in the lower back radiates along the back surface of the thigh, the outer surface of the leg and the lower leg.Examinations often reveal hypalgesia of the outer surface of the foot, lowering the strength of the trisep and foot muscles.It is difficult for such patients to stand on their toes.There is a decrease or loss of Achilles reflex.

Vertebrogenic lumbar reflex syndrome

It can be acute or chronic.Acute lumbar pain (LBP) (lumbago, "lumbago") occurs within minutes or hours, often due to awkward movement.Piercing, shooting (like electric shock) pain is localized, sometimes transmitting to the iliac and back region, significantly strengthening when coughing, sneezing, and decreasing when lying down, especially if the patient finds a comfortable position.The movement of the lumbar spine is limited, the lumbar muscles are tense, causing lasegue symptoms, often bilateral.Therefore, the patient is located behind him with his feet extended.Doctors at the same time bend the affected foot in the knee and hip joints.This does not cause pain, because with this foot position, the nerves are relaxed.Then the doctor, leaving the feet bent at the hip joint, begins to straighten it to the knee, thus causing tension in the sciatic nerve, which gives intense pain.Acute lumbodynia usually lasts 5-6 days, sometimes less.The first attack ends faster than the next.Repeated attacks in Lumbago tend to develop into chronic LBPs.

Unusual back pain

There are some unusual clinical symptoms for back pain caused by degenerative changes in the spine or myofascial syndrome.These signs include:

  • the appearance of pain in children and adolescents;
  • back injury shortly before the onset of back pain;
  • back pain accompanied by fever or signs of intoxication;
  • spine;
  • rectum, vagina, both feet, belt pain;
  • Lower back pain with eating, drainage, sex, urine;
  • Nonekological pathology (amenorrhea, dysmenorrhea, vaginal discharge), which appears to the background of back pain;
  • increased pain in the lower part of the horizontal position and decreased in a vertical position (razdolsky symptoms, characteristics of the tumor process in the spine);
  • increasing pain for one to two weeks;
  • limbs and the appearance of pathological reflexes.

The method of examination

  • External examination and lumbar area palpation, scoliosis identification, muscle tension, pain and trigger point;
  • Determination of various motion in the lumbar spine, the area of muscle waste;
  • Neurological status examination;Determination of tension symptoms (Lassegue, Wasserman, Neri).[Symptoms of Wasserman Symptoms: bending the legs of the knee joint in the patient in exposed position causing pain in the thighs.Study of Neri Symptoms: sharp bending of head to the chest of a patient lying on his back with straight leg causing acute pain in the lower back and along the sciatic nerve.];
  • Studies of sensitivity conditions, reflex spheres, muscle tone, vegetative disorders (swelling, color changes, temperature and skin moisture);
  • Radiography, computer or magnetic resonance imaging of the spinal cord.

MRI is very informative

  • ultrasound examination of pelvic organs;
  • gynecological examination;
  • If necessary, additional studies are conducted: cerebrospinal fluid, blood and urine, sigmoidoscopy, colonoscopy, gastroscopy, etc.
MRI image of a herniated disc MRI in the spine

Treatment

Acute back pain or severity of vertebral or myofascial syndrome

Unserved treatment.Soft motor mode.If the pain is severe on the first day, rest, and then walk on a stick to unload the spine.The bed should be difficult, and the wooden board should be placed under the mattress.For warmth, wool scarves, electric heating pads, and heated sandbags or salts are recommended.Ointment has beneficial effects: Finalgon, Tiger, Capsin, Diclofenac, and others, as well as Mustard plaster and pepper plaster.Ultraviolet irradiation in erythemal doses, leeches (taking into account possible contraindications), and irrigation of painful areas with ethyl chloride is recommended.

Electrical procedures have analgesic effects: transcutaneous electroanalgesia, sinusoidal modulation current, diadynamic current, electrophoresis with novocaine, and others.Blockade novocaine, triggering point pressure sequence.

Drug therapy includes analgesics, NSAIDs;tranquilizers and/or antidepressants;Medicines that reduce muscle tension (muscle relaxants).In the event of arterial hypotension, tizanidine should be carefully prescribed due to hypotension effect.If the swelling of the spinal root is suspected, diuretics are prescribed.

The main analgesic drugs are NSAIDs, which are often used uncontrollably by patients as pain increases or recurrents.It should be noted that long -term use of NSAID and analgesics increases the risk of complications of this type of therapy.Currently, there are many NSAID options.For patients with spinal pain, due to availability, effectiveness and lower side effects (gastrointestinal bleeding, dispepsia), "non-selective" drugs selected are 100-150 mg/day.Orally, intramuscular, rectal, local, ibuprofen and verbal ketoprofen 200 mg and topical, and among the "selective" - meloxicam orally 7.5-15 mg/day, nimesulide orally 200 mg/day.

When treating with NSAIDs, side effects may occur: nausea, vomiting, loss of appetite, pain in the epigastric region.Possible ulcerogenic effects.In some cases, ulcers and bleeding in the gastrointestinal tract may occur.In addition, headaches, dizziness, drowsiness, and allergic reactions (skin rash, etc.) are observed.Treatment is contraindicated for ulcerative processes in the gastrointestinal tract, pregnancy and breastfeeding.To prevent and reduce the symptoms of dispeptic, it is recommended to take NSAID during or after eating and drinking milk.In addition, taking NSAIDs as pain increases along with other medications that the patient takes to treat the same disease, indications, as observed in the long-term treatment of many chronic diseases, to decrease in adherence to treatment and, as a result, inadequate therapeutic effectiveness.

Therefore, modern methods of conservative treatment include the use of mandatory drugs that have chondroprotective, chondrostimulating effects and have better therapeutic effects than NSAIDs.Teraflex-Advance drugs fully meet these requirements, which is an alternative to NSAIDs for mild and moderate pain.One capsule of teraflex drugs contains 250 mg glucosamine sulfate, 200 mg chondroitin sulfate and 100 mg ibuprofen.Chondroitin sulfate and glucosamine participate in connective tissue biosynthesis, helping prevent cartilage destruction and stimulates tissue regeneration.Ibuprofen has analgesic, anti-inflammatory, and antipyretic effects.The mechanism of action is caused by the selective blocking of cyclooxygenase (COX 1 and 2), a major enzyme in arachidonic acid metabolism, leading to a decrease in prostaglandin synthesis.The presence of NSAIDs in the composition of Theraflex-Advance drugs helps increase various movement in the joints and reduce morning and spinal cord stiffness.Keep in mind that, according to R.J.Tallarida et al., The presence of glucosamine and ibuprofen in Theraflex-Advance gives synergies on the last analgesic effect.In addition, the combined analgesic effect of glucosamine/ibuprofen is provided by 2.4 times lower ibuprofen doses.

After relieving pain, it is rational to switch to taking Teraflex medicine, which contains active ingredients of chondroitin and glucosamine.Teraflex is taken 1 capsule 3 times a day.In the first three weeks and 1 capsule 2 times a day.In the next three weeks.

Most patients taking Theraflex experience positive dynamics in the form of pain relief and reduction of neurological symptoms.This drug is well received by the patient, no manifestations of allergies are observed.The use of teraflex for spinal degenerative disease is rational, especially in young patients, both combined with NSAIDs and as monotherapy.In combination with NSAIDs, analgesic effects occur 2 times faster, and the need for NSAID therapeutic doses is decreasing.

In clinical practice, for lesions of the peripheral nervous system, including those related to spinal osteochondrosis, vitamin B, which has neurotropic effects, is widely used.Traditionally, methods for administering vitamins B1, B6 and B12, 1-2 ml each, used.intramuscularly with daily replacement.The course of treatment is 2-4 weeks.Lack of this method includes the use of small doses of the drug, which reduces the effectiveness of the treatment and the need for frequent injection.

For Discogenic radiculopathy, attractiveness therapy is used: attractiveness (including underwater) in a neurological hospital.For myofascial syndrome, after local treatment (novocaine blockade, irrigation with ethyl chloride, anesthetic ointment), hot compress is used for muscles for several minutes.

Chronic lumbar pain from the original -usul vertebrogenic or myogenic

In the event of a disc herniation, it is recommended:

  • wearing hardcore corsets such as "heavy lifting belts";
  • avoiding movements suddenly and bending, limiting physical activity;
  • physical therapy to create muscle corset and restore muscle mobility;
  • Massage;
  • Blockade novocaine;
  • 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 treatment

Although there are effective treatment 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 an isolated herniated intervertebral disc, 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 signs of surgery in the cases are relative, first, due to the formation of irreversible changes in the root, and second, in most cases, during treatment and recovery of steps, the process is damaged in about 6 months.The same regression period is observed with delayed operations.

Relative indicators include failure of conservative treatment and recurrent sciatica.Conservative therapy should not exceed 3 months in the period.And last at least 6 weeks.It is considered that the surgical approach in the case of acute radical syndrome and conservative treatment failure is allowed during the first 3 months.After the onset of pain to prevent chronic pathological changes in the root.Relative indications are the case of severe pain syndrome, when the component of the pain is replaced by an increase in neurological deficits.

Among the physiotherapy procedures, electrophoresis with caripazim proteolytic enzymes are now widely used.

It is known that therapeutic physical training and massage are an important part of the complex treatment of patients with spinal lesions.Therapeutic gymnastics pursue the goals of general strengthening of the body, improves efficiency, improves movement coordination, and enhances fitness.In this case, special training is intended to restore certain motor functions.