Causes of back pain

Back pain may be the result of some retroperitoneal disease (duodenal ulcer, aortic aneurysm, pancreatic cancer; often the pain is localized in the lumbar region of the back, but the movements in the back are full and do not cause pain!). Other causes may include a spinal tumor; infection; pain associated with spondylosis or caused by mechanical factors; intervertebral disc disease, spondyloarthritis, osteoporosis, osteomalacia.

The main causes of back pain are:

1. Degenerative and structural - osteochondrosis, spondylosis, spondyloarthrosis, damage and herniation of intervertebral discs, congenital or acquired as a result of a pathological fracture spondylolisthesis (displacement of the vertebral body relative to the adjacent vertebra), spondylolysis (defect of the interarticular part of the vertebral arch in the form of a unilateral or bilateral gap), osteochondropathy of the spine (Scheuermann-Mau disease), compression fractures of the vertebrae, spinal stenosis, injuries (hemorrhages, fractures, cracks).
2. Metabolic - Paget's disease, osteoporosis, other metabolic bone lesions (osteomalacia, ochronosis, hyperparathyroidism).
3. Inflammatory non-infectious - spondyloarthritis, sacroiliitis, Bechterew's disease, psoriatic spondylitis, reactive arthritis, rheumatoid discitis, arthritis in non-specific ulcerative colitis, Crohn's disease.
4. Infectious - osteomyelitis of the spine and pelvic bones, tuberculosis of the spine, syphilis, paraspinal abscess, abscess of the epithelial coccygeal passage, discitis, epidural abscess, paravertebral infections.
5. Tumor - metastases to the spine (prostate cancer, breast cancer, lung cancer, thyroid cancer, kidney cancer, adrenal cancer, melanoma), multiple myeloma, tumors of the blood system (lymphoma, leukemia), rare tumors (osteosarcoma, osteoid osteoma, aneurysmal bone cyst, hemangioma, etc.), primary bone neoplasia, humoral effects of bone tumors.
6. Others - damage to the hip joint (osteoarthritis, rheumatoid arthritis, aseptic necrosis, tuberculosis, osteomyelitis), coccygodynia.
7. Spinal cord damage - arachnoiditis (after myelitis or in the postoperative period), epiduritis, tumor, tuberculosis, abscess.
8. Soft tissue pathology - lumbosacral strain, muscle and ligament injuries, myofascial syndrome, tendinitis, fibromyalgia, polymyalgia rheumatica, sciatic bursitis.
9. Diseases of internal organs and blood vessels - dissecting aneurysm of the abdominal aorta, kidney and urinary tract diseases (stones, infection, tumor), pancreatitis, peptic ulcer, diseases of the bile ducts, spleen, hemorrhage into the retroperitoneal tissue, retroperitoneal tumor, pelvic abscess, endometriosis, inflammatory and tumor diseases of the female genital organs, prostatitis, prostate cancer.
10. Others (shingles, depression, pregnancy, malingering).

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Vertebrogenic causes of back pain

The most common causes of back pain are vertebrogenic pains. They occur in a variety of diseases, and therefore the key to their successful treatment is accurate diagnostics. Vertebrogenic pain (dorsopathy) refers to pain syndromes in the trunk and limbs of non-visceral etiology associated with diseases of the spine.

The most common cause of vertebrogenic back pain is degenerative-dystrophic lesions of the spine:

1. osteochondrosis (protrusion or prolapse of the intervertebral disc, degenerative lesion of the intervertebral disc and adjacent vertebral bodies);
2. spondyloarthrosis (arthrosis of the facet joints);
3. spondylosis (bone formation under the anterior longitudinal ligament).

As a result of the above changes in the spine, dystrophic spondylolisthesis and secondary lumbar stenosis may develop. Functional blocking of the intervertebral joints with secondary muscular-tonic reflex syndrome is also of great importance in the origin of vertebrogenic pain syndrome.

Osteochondrosis

Osteochondrosis is the most common cause of acute back pain. The causes of pain are degenerative damage to the intervertebral discs, which subsequently leads to changes in the intervertebral joints and ligaments. When the lumbar intervertebral discs are affected, the pulpous (pulp) nucleus of the disc protrudes through cracks in the fibrous ring in the form of a hernia in the posterolateral direction towards the posterolateral ligament, which is the weakest, squeezing the roots of the spinal nerves. The pulpous nucleus of the disc can also protrude towards the spinal canal, which leads to lumbar pain, but compression of the nerve roots usually does not occur. However, in this case, there is a certain risk of developing a syndrome of compression of the elements of the equine tail, which is characterized by dull pain in the upper sacral regions and paresthesia in the buttocks, genitals or thigh area with simultaneous dysfunction of the intestines and bladder.

Recent studies have shown that radicular lumbar pain caused by a herniated disc completely disappears or significantly weakens in most patients within 6-18 months. Pain associated with osteochondrosis occurs or intensifies after physical exertion (lifting weights or an awkward turn), weakens at rest (in a lying position), spreads along the back of the leg, and is accompanied by limited movement. Such patients usually have a history of similar attacks.

In case of acute pain, rest for 2-3 weeks and painkillers are prescribed: non-steroidal anti-inflammatory drugs, non-narcotic analgesics. After the pain subsides, a special set of exercises is recommended, if necessary - manual therapy.

Spondyloarthrosis

Spondyloarthrosis often develops in patients over 50 years of age and may accompany osteochondrosis. The main changes develop in the intervertebral joints, which leads to a pronounced limitation of movement. Pain in the lumbar spine is localized paravertebrally, usually dull, aching, provoked and intensified by physical or prolonged static load (sitting, standing), weakened in a lying or sitting position. Radiographic signs of spondyloarthrosis include:

1. Subchondral sclerosis of articular surfaces;
2. Narrowing of the joint space until it completely disappears;
3. Bone growths in the joint area, deformation of the articular processes.

In foreign studies, radiographic parameters for spondyloarthrosis are often assessed using the Kellgren classification, which distinguishes 4 grades - from 1 (absence of osteophytes) to 4 (large osteophytes, sclerosis of the endplates, decrease in the height of the intervertebral discs up to their disappearance).

The treatment includes painkillers, special exercises, hydrotherapy, and manual therapy.

Spinal stenosis

This is a narrowing of the spinal canal, which leads to ischemia of the nerve roots and contributes to the development of neurogenic claudication. Osteoarthropathy of the facet (intervertebral) joints and intervertebral discs leads to narrowing of the spinal canal. Excessive load on functionally defective intervertebral discs can contribute to the formation of large osteophytes. The intervertebral joints hypertrophy, the growing osteophyte deforms them, and the yellow ligament thickens. As a result of these changes, the spinal canal and vertebral openings narrow. Patients complain of constant pain in the lumbar region, which sometimes takes on a boring character and radiates downwards, into the leg (false claudication). The pain intensifies when standing and walking.

Spondylolisthesis

This is an anterior displacement of a vertebra relative to the vertebra below it (usually the L5 vertebra is displaced anteriorly relative to the S1 vertebra). The degree of displacement varies. Patients complain of pain that is localized in the lumbar region, on the back of the thigh, and below, along the lower limb. Physical activity increases the pain. Spondylolisthesis is a very common cause of back pain in patients under 26 years of age and is easily diagnosed using conventional radiography. Spondylolysis is a form of spondylolisthesis in which there is a defect in the interarticular part of the vertebral arch without anterior displacement of the vertebra. It is believed that this defect is caused by a violation of the osteosynthesis processes and can be detected in young athletes.

At the same time, there are other causes of back pain that a doctor should remember to avoid treatment errors. These include: non-infectious inflammatory diseases (ankylosing spondylitis, Reiter's syndrome, rheumatoid arthritis), metabolic bone lesions (osteoporosis, osteomalacia), dystrophy of the facet (intervertebral) joints, sacroiliac joint pathology, tumors of the spine and spinal cord, infectious lesions of the vertebrae and intervertebral discs (tuberculosis, brucellosis, epidural abscess), growing pains (scoliosis), spinal and soft tissue injuries, piriformis syndrome, diseases of the internal organs accompanied by reflected pain, herpes zoster, etc.

Spondyloarthropathy

Spondyloarthropathies are a group of diseases characterized by damage to the sacroiliac joints and joints of the spine. These include: ankylosing spondylitis (Bechterew's disease), Reiter's syndrome, gout, psoriatic arthritis, arthritis in inflammatory bowel diseases, reactive arthritis. Young men are more often affected. The pain is localized, bilateral, occurs at rest (increases at night and early in the morning) and decreases with movement. Joint stiffness is noted in the morning, which does not go away for a long time.

Malignant neoplasms

Malignant neoplasms (myeloma, metastases to the spine, spinal tumors). All malignant neoplasms are characterized by constant, deep pain in the spine, the intensity of which does not change during the day.

Multiple myeloma is a tumor disease of the hematopoietic tissue. The disease usually begins at the age of 50-60 years and is accompanied by pain in the spine and other bones. Severe bone destruction as a result of tumor development can lead to spontaneous fractures.

Spinal metastases are most often observed in lung, breast and prostate cancer. In primary spinal tumors, symptoms appear when the tumor compresses or grows into the spinal roots. In addition to severe pain, there is a change in sensitivity, motor disorders, which steadily progress.

Pain relief in patients with malignant neoplasms often requires the use of narcotic analgesics. However, in the initial stage of the disease, non-narcotic analgesics can be used to relieve mild to moderate pain.

Infections

Although osteomyelitis and tuberculosis of the spine are rare diseases, it should not be forgotten that they can cause constant back pain that does not change during the day. There are also general signs of the disease: fever and intoxication. Patients require treatment in specialized hospitals.

Poor posture

Back pain can be caused by poor posture. It should be noted that scoliosis is always a pathology. Signs that confirm the presence of scoliosis include: visible deformation of the spinous processes of the vertebrae; asymmetry of the shoulders, shoulder blades and Natalia's folds that do not disappear in a sitting position; asymmetry of the paraspinal muscles; excessive thoracic kyphosis and deformations in the sagittal plane. Lordosis is almost always secondary and is caused either by an anterior tilt of the pelvis or by changes in the hip joints.

Spinal curvatures can be interpreted as functional or anatomical. Functional ones occur with muscle spasms or short legs in a child. Anatomical curvatures can be signs of congenital or acquired pathology.

Damage to the spinal column occurs in Prader-Willi syndrome, Scheuermann-Mau disease (juvenile kyphosis), rickets (non-fixed kyphosis caused by weakness of the ligamentous-muscular apparatus), tuberculous spondylitis, and spinal injuries.

Non-vertebrogenic causes of back pain

One of the common causes of such back pain is myofascial pain syndrome, which can complicate almost any vertebrogenic pain or be observed independently of it. Myofascial pain syndrome is characterized by chronic pain sensations that occur in various trigger point areas of muscle and fascial tissue. In this case, patients complain of sharp pains along local zones of pain, which often radiate. This pathology is sometimes confused with radiculopathy (radicular pain). Trigger point areas are most often localized in the upper parts of the trapezius muscle, on the surface of the back extensor muscles, in the muscle tissue of the lower parts of the paravertebral muscles and in the gluteal muscles. Establishing the cause of back pain is based on the results of a clinical examination, radiation diagnostic data and other paraclinical research methods.

Fibromyalgia

Fibromyalgia should most likely be considered as a separate nosological form with primary muscle damage. Literature data indicate that fibromyalgia can be congenital, is more common in women and can develop against the background of physical or emotional trauma. With fibromyalgia, patients complain of diffuse pain, painful areas are palpated, and such symptoms last for at least 3 months. Various psychological disorders can be observed in twenty-five percent of patients suffering from fibromyalgia.

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Muscle and ligament damage

After minor injuries that occurred during physical work or sports, constant superficial diffuse back pain appears, which is significantly alleviated by local application of painkillers - NSAIDs (gel) or their systemic intake. In addition to the pronounced analgesic effect, these drugs have an anti-inflammatory effect, which reduces the rehabilitation time.

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Cardiovascular diseases

Rupture of an abdominal aortic aneurysm or hemorrhage into the retroperitoneal tissue manifests itself in severe back pain, collapse, paresis and sensory disturbances. The anamnesis of patients with hemorrhage indicates the use of anticoagulants. The spilled blood compresses the spinal nerves. Both situations require emergency hospitalization.

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Diseases of the pelvic organs

Diseases of the pelvic organs are accompanied by pain in the lower back. Dull pain in the lower back is one of the main symptoms of pyelonephritis. The disease especially often develops in pregnant women, accompanied by frequent, painful urination and the appearance of cloudy urine, chills, an increase in body temperature above 38 ° C. Treatment is carried out with antibiotics and uroseptics.

Lower back pain can become the leading symptom of algomenorrhea and endometriosis. It is necessary to pay attention to the fact that deep, aching, diffuse pain is always associated with the menstrual cycle. Treatment is carried out by a gynecologist. Painkillers (NSAIDs, non-narcotic analgesics) are used to relieve pain.

Back pain is differentiated from abdominal aortic aneurysm, ectopic pregnancy, pancreatitis, perforated gastric ulcer and duodenal ulcer, pyelonephritis and urolithiasis, pelvic tumor (for example, tumor of the ischial tuberosity), inflammatory diseases of the appendages in women.

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"Mechanical" back pain

The spinal column consists of many complex joints between the vertebrae; spongy discs between their bodies that serve to cushion shocks; and many facet joints. Dysfunction in any part of the spine can affect its function as a whole, and spasm of the spinal muscles only increases pain. Since a person spends most of the time in an upright position, significant forces act on the spine, especially when standing up; this can lead to ruptures of the discs (their fibrous rings) in relatively young people and even fractures of the vertebrae in older people.

Disc prolapse

Most often, a rupture of the discs occurs in the lumbar region, especially the last two discs. In typical cases, a few days after a great strain of the back muscles, a person suddenly experiences a sharp pain (in the lower back) when coughing, sneezing or turning sharply (the onset of the disease can be more gradual). The pain can be localized in the lower part of the lower back (lumbago), or it can radiate to the buttocks and down the leg (legs) - then they talk about sciatica, while the prolapsed nucleus of the disc compresses the nerve root.

Signs: limited forward flexion of the trunk, sometimes also limited extension; lateral flexion is impaired to a lesser extent, but if impaired, it is unilateral. With L5/S1 disc prolapse, radicular pain occurs along the S, with characteristic pain in the gastrocnemius muscle, weakening of plantar flexion, decreased sensitivity (with pin prick) on the plantar side of the foot and the back of the leg, and a decrease in the Achilles reflex. With L4/L5 disc prolapse, extension of the big toe is impaired, and sensitivity along the outer surface of the foot is also reduced. If the lower lumbar discs prolapse in the central direction, compression of the equine tail may occur.

In most cases, patients are advised to rest, lying on a hard surface is recommended, painkillers are effective. Myelography and magnetic nuclear tomography can confirm the diagnosis, but they are used when decompression by laminectomy is planned (for example, for decompression of the equine tail) or when conservative treatment is ineffective and the symptoms of the disease are severe.

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Lumbar vertebral lateral recessus stenosis

Osteoarthritis of the facet joints (the only synovial joints in the back) can cause generalized narrowing of the lumbar spinal canal or just its lateral recesses (bulges). Unlike the symptoms of disc prolapse in the lumbar spine, the signs of this narrowing are as follows.

• The pain intensifies when walking, and pain and heaviness are felt in one or both legs, which forces the patient to stop (“vertebral intermittent claudication”)
• Pain occurs when the spine is straightened.
• Negative Lasegue's sign.
• Few symptoms of CNS damage.

Confirmation of diagnosis: Computerized myelography (CT) and magnetic resonance imaging (MRI) can visualize the spinal canal.

Treatment: Decompression of the spinal canal (removal of its posterior wall) gives good results if NSAIDs, steroid injection into the epidural space and wearing a corset (to prevent an increase in lumbar lordosis in a standing position) are ineffective.

Reflex muscular-tonic and myofascial pain syndromes

The most frequently observed in clinical practice are reflex muscle-tonic and myofascial syndromes, which, as a rule, develop within the framework of non-specific back pain, but can also be present in radiculopathy and diseases of internal organs. In the development of this type of pain, the leading role is played by local muscle hypertonicity, which is formed under the influence of prolonged static load (incorrect motor stereotype, uncomfortable posture, spinal deformities, reflex muscle tension in visceral pathology, etc.). The pathognomonic sign of myofascial pain syndrome is the presence of trigger points. The diagnostic criteria for myofascial pain syndrome are as follows.

1. Main criteria (all five must be present).
   • Complaints of local pain.
   • The presence of a “tight” cord in the muscle upon palpation.
   • The presence of an area of increased sensitivity within the “tight” cord.
   • A characteristic pattern of referred pain or sensory disturbances.
   • Limitation of range of motion.
2. Additional criteria (one of the three must be present).
   • Reproducibility of pain or sensory disturbances when stimulating trigger points.
   • Local flinching upon palpation of the trigger point of the muscle involved or upon injection into the trigger point (the “jump” symptom).
   • Reducing pain from stretching or injection into a muscle.

Compression radiculopathy

Radiculopathy is most often associated with compression or stretching of the spinal nerve roots due to the impact of a herniated disc or osteophytes. The pain is usually superficial, localized in the innervation zone of the affected root. Sneezing, coughing, and strain on the spine usually increase the pain. Most often, the lumbosacral roots are affected (75%, and in the vast majority of cases - L5 and/or S1, less often - cervical, extremely rare - thoracic.

The understanding of the mechanisms of pain in nerve root lesions has changed significantly in recent years. There is currently no doubt that the severity of pain does not correlate with the size of the intervertebral disc herniation. In many cases, MRI reveals very minor changes in a patient with intense pain, and the opposite situation is also observed quite often, i.e., the absence or minimal severity of symptoms with a large intervertebral disc herniation.

There are several mechanisms of pain in intervertebral disc herniations with radiculopathy. In addition to direct mechanical compression of the root with the appearance of foci of ectopic pathological activity and excessive expression of potential-dependent sodium channels, pain can be associated with irritation of nociceptors of the intervertebral disc and other adjacent structures (primarily, the posterior longitudinal ligament). In addition, a certain role is played by the aseptic inflammatory process, in which inflammatory mediators, locally affecting nerve endings in tissues, also participate in the generation of pain sensations.

Another mechanism of chronic pain is central sensitization - increased sensitivity and activity of the sensory neurons of the posterior horn. Due to a decrease in the excitation threshold of these neurons, any non-painful peripheral stimulation can lead to the generation of pain impulses, which is clinically manifested by allodynia.

Recently, the hypothesis of early structural changes in the chronicity of pain syndromes has become widespread. It has been shown that intense nociceptive impulses entering the spinal cord lead to the death of spinal inhibitory interneurons, which are normally in constant tonic activity and suppress nociceptive afferentation. With a decrease in the number of these inhibitory neurons, their inhibitory effect on peripheral nociceptive neurons weakens, which leads to the generation of pain even in the absence of pain stimuli.

It is especially important to emphasize the important role of genetic, cultural, psychogenic and social factors in the development and chronization of pain syndrome, described in detail in the specialized literature. All these mechanisms allow us to explain the discrepancy between the intensity of pain and the severity of structural changes in the spine in chronic back pain.

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Facet syndrome

One of the causes of back pain is pathology of the facet joints, the synovial capsule of which is richly innervated. The frequency of facet joint pathology in patients with pain in the lumbosacral region is 15-40%. Pain caused by pathology of the facet joints is usually local (paravertebral) in nature, but can radiate to the groin area, along the back and outer surface of the thigh, to the coccyx area. Pain in the lumbar region increases with extension and rotation. The positive effect of a blockade with local anesthetics in the area of the affected facet joint is of diagnostic value.

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Sacroiliac joint dysfunction

Dysfunction of the sacroiliac joints is detected in 53% of patients with back pain, and in 30% of cases - the causes of back pain in patients with intervertebral disc herniations detected by MRI. Pain from the sacroiliac joint can radiate to the groin, to the S1 dermatome zone. The intensity of pain usually decreases after walking. Pain is usually more intense in the first half of the day and decreases in the evening. The positive effect of a blockade with local anesthetics in the sacroiliac joint area has diagnostic value.

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