Back pain: Classification, causes and risk factors, patient examination and treatment

Back pain dominates all pain syndromes, occurring in 80-100% of people and causing long-term disability in 4% of the world's population, being the second most common cause of temporary disability and the fifth leading cause of hospitalizationCommon causes. Persistent or frequently recurring back pain can cause severe suffering and significantly reduce quality of life.In this article, we'll tell you which diseases and conditions can cause back pain, how to examine someone with pain, and what treatments your doctor can prescribe.

Classification of back pain

From a pathophysiological perspective, pain can be divided into nociceptive pain, neuropathic pain, and dysfunctional pain. Nociceptive pain occurs through direct tissue damage and peripheral pain receptor activation. Neuropathic pain occurs when the somatosensory system is damaged. Dysfunctional pain results from neurodynamic disturbances in the central nervous system. Often, when examining patients with functional pain, it is not possible to identify an organic disease that could explain the development of the pain syndrome. Additionally, there are associated pains, a classic example being back pain.Depending on the location of the pain syndrome, back pain can be divided into the following types:

• Neck pain - pain in the neck;
• Cervicocranial pain - pain in the neck that spreads to the head;
• Cervicobrachial pain - pain in the neck that radiates to the arms;
• Chest pain - pain in the back and middle of the chest;
• Low back pain - pain in the lower back and/or lumbosacral region;
• Lumbar pain - pain in the lower back that radiates into the legs;
• Sacrodynia - pain in the sacrum area;
• Coccydynia – Pain in the tailbone.

Depending on the course of the pain syndrome, it can be divided into acute (lasting less than 4 weeks), subacute (4 to 12 weeks), and chronic (more than 12 weeks) forms. In most patients who seek medical help, back pain is acute, lasts for several days, and is easily relieved by nonsteroidal anti-inflammatory drugs and muscle relaxants. About one-third of patients have pain that persists for six weeks and becomes constant. Chronic pain syndromes can lead to anxiety and depressive disorders, anticipation of pain, "pain behavior" and irritability. In this regard, the transformation of pain into chronic forms requires a different approach to patient management, with the choice of more complex treatment options, including antidepressants.Depending on the spinal structures involved in the pathological process, compression or reflex syndromes predominate in the clinical manifestations of the disease. Compression syndrome occurs when structural changes in the spine compress the roots, blood vessels, or spinal cord. Reflex syndrome occurs due to irritation of various structures in the spine. Depending on localization, vertebral syndromes of the cervical, thoracic, and lumbosacral spine can be distinguished.

causes of back pain

Back pain is a common symptom of many orthopedic and neuropathological conditions, some visceral organ diseases, metabolic disorders, and neoplastic processes. Let’s take a closer look at the most common causes of back pain.

spinal degenerative disease

Spinal osteochondrosis is one of the most common causes of back pain. The location of pain corresponds to the extent of the disease. Thus, pain in the neck, sometimes radiating to the head, indicates pathology in the cervical region, pain in the mid-back spine indicates damage to the thoracic region, and pain in the lower back indicates problems in the lumbosacral spine. The pain of osteochondrosis is usually moderate, dull, constant, or periodic, worsening after physical activity and subduing at rest. The patient slowly and carefully changes body position for fear of triggering an attack.As the disease progresses, spinal osteochondrosis can lead to intervertebral hernia formation, which is characterized by local, transient dull pain that is aggravated by physical activity, remains in a static position for a long time, and disappears when lying down. Gradually, the pain becomes constant and is accompanied by severe muscle tension; some patients develop low back pain and lumbar pain - acute, severe pain in the waist and back of the thigh.Spondyloarthropathy occurs as degenerative changes occur in the facet joints that connect the facet joints of adjacent vertebrae, manifesting as localized pain with movement that subsides with rest. As the disease progresses, patients develop morning stiffness and a persistent dull pain in the back in the affected area that worsens with prolonged posture.Another degenerative spinal disease associated with dull back pain is spondylosis, a chronic pathology associated with degenerative changes in the anterior part of the disc, calcification of the anterior longitudinal ligament, and anterior osteophyte formation. and the lateral portion of the spine. Pain in spondylosis is local in nature and intensifies at the end of the day, against the background of overload, hypothermia, sudden movements, and sometimes at night. Spondylosis is characterized by very slow progression; in the absence of other spinal disorders, clinical manifestations may not worsen for decades.

spinal abnormalities

Back pain is often associated with congenital abnormalities of the spine and is sometimes associated with neurological symptoms. Some spinal deformities are asymptomatic for a long time and only become apparent in adolescence or even adulthood. The following conditions may cause back pain:

• Spina bifida.Closed pathology manifests as local moderate pain in the lumbosacral region, often accompanied by sensory and reflex disorders and muscle hypotension.
• Sanctify.Congenital spinal anomaly, in which the fifth lumbar vertebrae is completely or partially fused to the sacrum, is a fairly common condition that is usually asymptomatic but may be associated with pain in some patients. In the early stage of the disease (around 20 years old), pain occurs after excessive physical activity, falling or jumping, radiating to the lower limbs, and sometimes accompanied by abnormal sensation. Generally, the pain decreases when you lie down and worsens when you sit on your heels, jump, or stand. Delayed pain syndrome is caused by secondary changes in the joints and vertebrae. The pain occurs in middle age or old age and is usually limited to the lumbar area.
• Lumbarization.Congenital anomalies, in which the first sacral vertebra partially or completely separates from the sacrum and "turns into" an additional (sixth) lumbar vertebra, is the cause of presentation in approximately 2% of all back pain cases. Signs of pathology appear at a young age. Clinical manifestations depend on the form of lumbarization. In lumbar spondylosis, patients suffer from lower back and spinal pain, which can be relieved by taking NSAIDs. A characteristic feature of sciatic nerve form is pain that radiates to the buttocks and lower limbs. In some cases, violations of skin sensitivity in the thigh and waist area are detected.
• The vertebrae are wedge-shaped.Wedging vertebrae is a congenital and less common acquired abnormality that can cause spinal deformity and back pain. Patients complain of increased fatigue, back discomfort, and pain during physical activity. Depending on the location of the pathology, these symptoms may include headache and shortness of breath.

acquired spinal deformity

Pain is usually not present in minor deformities of pathological stages I-II. As the process progresses, lingering pain develops in the back, which worsens against the background of physical activity and prolonged uncomfortable body positions. Pain syndromes can be seen in spinal deformities such as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, and Scheuermann-Mau disease. Back discomfort and minor pain caused by unphysiological postures and muscle weakness may also be observed in patients with poor posture.

back injury

Trauma to the spine and surrounding soft tissues is another common cause of back pain. The severity of pain depends on the severity of the injury:

• Injuried.When bruising occurs, back pain is usually localized, moderate, subsides in a few days, and is completely gone 1-2 weeks after the injury.
• Traumatic spondylolisthesis.Traumatic vertebral displacement most commonly occurs in the lumbar region. The patient complains of moderate or severe pain in the waist that radiates to the legs. Spinal synapse diagnosis is painful, and axial load symptoms are positive.
• Spinal compression fractures.Injuries are often caused by jumping or falling from a height. Trauma will be accompanied by severe pain; when the thoracic spine is fractured, there will be severe pain in the middle of the back, often accompanied by difficulty breathing. Subsequently, the patient complains of pain in the protruding area of the damaged vertebra, sometimes radiating to the abdomen. The pain decreases when lying down and worsens when coughing, taking deep breaths, exercising, and standing, sitting, and walking.

osteoporosis

Osteoporosis is a pathology of bone tissue associated with loss of mass, strength, and increased bone fragility. In most cases, the disease is asymptomatic and is discovered during an X-ray. However, some people with osteoporosis may experience mild pain in the spine, most commonly in the thoracic and lumbar areas, which worsens with physical activity. Sometimes back pain is accompanied by rib and hip pain.

Inflammation and infectious diseases

Dull pain and stiffness in the lower back may be the first symptoms of ankylosing spondylitis, a chronic inflammatory disease of the spine and joints. A characteristic feature of this pathology is the onset of pain at night, which is worse in the morning and decreases in intensity after physical activity or hot showers. During the day, the pain may also increase during rest and decrease during physical activity. As the disease progresses, the pain gradually spreads to the entire spine, limiting its movement and forming thoracic kyphosis.Back pain may be caused by post-traumatic or postoperative osteomyelitis (inflammation of the bone marrow, affecting all components of the bone (periosteal, spongy, and compact)). With vertebral osteomyelitis, spinal pain is usually well localized, intensely explosive, acutely aggravated by attempts to move, and is accompanied by high fever, weakness, fever, and significant local edema.When infection penetrates into the subdural space of the spinal cord, a spinal epidural abscess develops and manifests as diffuse back pain and increased body temperature. Patients will experience positive symptoms of local stiffness of spinal muscles, percussion pain on spinous processes, and tension. As inflammation increases, tendon reflexes weaken, and paresis, paralysis, and pelvic disease occur.Infectious inflammation of the spinal arachnoid membrane leads to the development of spinal arachnoiditis, which manifests as transient pain in the area innervated by the nerve roots. Gradually, spinal pain becomes permanent and is reminiscent of the clinical manifestations of radiculitis, they are accompanied by sensory and motor impairments and possible loss of control over the functions of the pelvic organs.

spinal tumors

Benign tumors of the spine are usually asymptomatic or have mild, slowly progressive symptoms. The most common spinal tumors in patients of any age are hemangiomas. About 10-15% of cases are accompanied by localized soreness in the back, which worsens after physical activity and at night. The cause of pain from spinal hemangioma is stimulation of pain receptors in the periosteum and posterior longitudinal ligament.Among spinal malignancies, spinal sarcomas are most commonly diagnosed. The disease initially manifests as mild or moderate intermittent pain that worsens at night. The intensity of the pain increases rapidly. Depending on the location of the tumor, patients may experience pain in their arms, legs, and internal organs.Spinal pain may also be a sign of tumor metastasis to internal organs. Initially, the pain is localized, dull, aching, reminiscent of the clinical manifestations of osteochondrosis, but it quickly progresses, becomes constant, and, depending on location, can radiate to the arms or legs.

Risk factors for developing back pain

Factors that contribute to back pain can be divided into correctable and non-correctable factors (genetics, age, gender). Adjustable factors include:

• professional(Work associated with lifting heavy objects, static loads on the spine, monotonous physical work including frequent forward bending and turning of the body, work accompanied by vibration processes);
• psychosocial(Muscle pain due to exposure to acute and/or chronic stress conditions);
• Personal physical and physical characteristics(Scoliosis, kyphosis and other spinal deformities, weak muscle strength, monotonous and stereotyped movements);
• Malnutrition and gastrointestinal disease(B vitamin malabsorption, eating foods containing a large amount of purine bases, being overweight);
• bad habits(Smoking, drinking).

These risk factors are fairly common but can be eliminated or limited by the length of exposure. In the context of these predisposing factors, hypothermia, clumsiness, or acute stress situations are sufficient to develop a pain syndrome.

Examination of patients with back pain

The main task of the neurologist when examining patients with acute or chronic back pain is to establish an accurate local diagnosis and etiology of the pain syndrome. During the initial appointment, the doctor talks with the patient to understand all the circumstances surrounding the occurrence of pain.

Medical history collection

Although patients' descriptions of pain vary, a careful history can suggest the pathophysiology of the pain syndrome.Therefore, the development of acute pain with a clear localization is characteristic of nociceptive pain syndromes associated with injuries to the spine, ligaments and muscles and joints, which is well relieved by the administration of analgesics and is not accompanied by surface sensitivityViolate. Burning, stinging pain that radiates to the extremities and is accompanied by sensory disturbance may be caused by compressive radiculopathy. Pain associated with internal organ damage is often not well localized and may be accompanied by nausea, skin discoloration, excessive sweating, is often spasmodic, and radiates to the other half of the body.It is worth noting that patients under 50 years of age (in the absence of a history of malignancy, clinical symptoms of systemic disease, and neurological deficits) have a 99% chance of developing low back pain caused by muscle damage without irradiation of the limb. Caused by bone disorders such as myofascial pain syndrome or joint pain. -Ligament dysfunction.However, even during the first examination of the patient, doctors will pay attention to signs that indicate that back pain may be a symptom of a more serious pathology. Therefore, the presence of fever, localized pain, and localized temperature increase in the paravertebral region may indicate the presence of infectious lesions in the spine, unexplained weight loss, history of malignancy, persistent pain at rest - column of spinal malignancies, with uveitis and jointPain - arthritis of the spine.

patient examination

In most cases, a physical examination of back pain can identify the source and pathogenesis of the pain syndrome to suggest or accurately determine the nature of the underlying pathological process.During the neurological examination, the doctor will focus on the patient's posture, posture, and gait, examine the limbs for contractures, deformities, and asymmetries, evaluate the condition of the spine, and determine the presence and nature of motor, sensory, and nutritional disorders. Disease and changes in tendon reflexes. Based on the survey data and examination results, the neurologist prescribes additional tests for the patient.

Laboratory and Instrumental Diagnostics

Laboratory and instrumental investigation methods aid in differential diagnosis and confirm or refute a suspected diagnosis.X-ray spinal x-rays and functional tests, computed tomography and magnetic resonance imaging can provide a wealth of information when examining patients with back pain. For acute back pain, patients are advised to undergo general and biochemical blood tests and urine tests.In some cases, neuroimaging methods such as computed tomography and magnetic resonance imaging come to the fore. Radioisotope scintigraphy is used to diagnose local inflammatory or metastatic processes. The diagnosis of osteoporosis is based on densitometry. To determine the extent of damage to the spinal cord and peripheral nervous system structures, including clarifying the nature of the radiculopathy, neuroelectromyography is performed.

Treat back pain

The main goals of treating patients with back pain are to relieve pain, prevent the condition from becoming chronic, provide conditions for full rehabilitation measures, and prevent aggravation and recurrence of the condition.The basis of conservative treatment of pain syndromes includes nonsteroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotrophic vitamins and other non-pharmacological methods, which mainly affect the nociceptive component of pain, including massage, therapeutic exercises, and manual therapy. .In the acute phase, excessive physical activity should be excluded, but long-term bed rest should be avoided. Instead, such patients should be allowed to return to their usual activity levels as soon as possible to prevent the formation of chronic pain syndrome. It is recommended to be strict for the first three days. For acute pain in the lower back, use a brace; for neck pain, use a cervical collar. However, long-term immobilization of the cervical or lumbar spine is not recommended except in certain circumstances, such as vertebral fractures or the presence of spondylolisthesis.As the pain syndrome subsides, the patient undergoes physical therapy: ultrasound, magnet therapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is performed as indicated.If vertebral instability, spinal compression, intervertebral hernia, or tumors are present, surgery may be recommended. The type and extent of surgical intervention are chosen solely by the attending physician or the medical committee. Antibacterial analgesics, nutritional neurovitamins and other drugs are used after surgery, and rehabilitation measures are carried out, including physiotherapy techniques, massage, physiotherapy, etc.