Diagnosis of back pain

How to understand all the causes of pain in the back and give the patient a sound recommendation? In the diagnosis of back pain help: a medical history; the identification of serious causes that cause back pain; detection of radiculopathy; the definition of the risk of prolonged pain and disability.

For this, patients with back problems need to ask the following questions:

• Tell us about your problems in the lower back (lower back) area.
• What are your symptoms?
• Have you experienced weakness, numbness, or sudden sharp pains?
• Does pain / numbness give anywhere?
• Did you have any changes in the stool and urination regime?
• How does back problems affect your work / school / housekeeping?
• How do your back problems affect your leisure / entertainment?
• What is your life as a whole?
• Do you have any problems with work or at home?
• Tell me what you know about back problems; Have you experienced back pain before, do you have a relative or an acquaintance with back problems?
• What worries do you have about this problem?
• What tests do you expect?
• What treatment do you expect?
• What changes can you make at work / at home / school to minimize your temporary discomfort?

In addition, it is necessary to pay attention to the following features:

1. Age. The older the patient, the more likely he develops the most frequent diseases of the spine: osteochondrosis and osteoarthritis. However, it should not be forgotten that, together with these "age-related" diseases, the risk of malignant neoplasms increases in the elderly. For young patients, the most common cause of back pain is minor injuries while exercising. Of the diseases of the spine the most common cause is spondyloarthropathy. In addition to back pain, these patients necessarily have other manifestations of the disease (psoriasis, uveitis, urethritis, diarrhea, etc.). In children under the age of 10 years, with the appearance of low back pain, first of all, kidney diseases and organic diseases of the spine (tumor, osteomyelitis, tuberculosis) are excluded.
2. Relation of pain to previous trauma, physical activity. This relationship is present in the development of injuries or manifestations of osteochondrosis.
3. Side of pain. One-sided pain is characteristic for osteochondrosis, bilateral - for osteochondropathies.
4. The nature of pain. The sudden appearance of severe pain that does not decrease with traditional analgesics and is accompanied by collapse, paresis with a decrease in sensitivity, indicates the presence of rupture of the aneurysm of the abdominal aorta or hemorrhage into the retroperitoneal cellulose - situations require emergency medical care.
5. Change of pain during movement, at rest, in different positions. With osteochondrosis, pain increases with motion and in sitting position, it passes in the prone position. Spondyloarthropathies are characterized by a directly opposite relationship to motor activity: pain is increased at rest and passes during movement.
6. The daily rhythm of pain. Most diseases of the spine have a daily rhythm of pain. The exception is malignant neoplasms, osteomyelitis and tuberculosis of the spine, when the pain is constant during the day.

Testing for infringement of nerve endings in the lumbar spine

1. Ask the patient to lie on his back and as much as possible to straighten up on the couch	4. Watch for any movement of the pelvis until complaints appear. True sciatic tension should cause complaints before the hamstring stretches sufficiently to move the pelvis
2. Put one hand over the knee of the leg to be tested, push firmly enough on the knee to straighten the knee as much as possible. Ask the patient to relax	5. Determine the level of lifting of the leg, where complaints from the patient appear. Then determine the most remote place of the test discomfort: back, thigh, knee, below the knee.
3. With the palm of one hand, grasp the heel, slowly raise the straightened limb. Tell the patient: "If it bothers you, let me know, I'll stop"	6. Holding the leg extremely elongated and raised, pull the ankle forward. Determine if this pain causes the rotation of the limb to the inside can also increase the pressure on the nerve sciatic endings

Physical examination - general examination, examination of the back: testing to identify the strangulated nerve endings; sensory testing (pain, numbness) and motor testing.

I would like to emphasize that the causes of back pain can be very different, the back pain often serves as a signal for serious diseases of the internal organs, therefore, when acute back pain occurs, self-medication should be avoided and a number of studies should be performed to establish the correct diagnosis.

To put the correct diagnosis help additional tests and differential diagnostics.

Testing for infringement of the nerve end of the lumbar region

Testing	Nerve Ending
	L4	L5	S1
Motor (motor) weakness	Stretching of quadriceps	Dorsal flexion of the big toe and foot	Flexion of foot and thumb
Screening-Screening	Squat and stand up	Pass on the heels	Walk on your toes
Reflexes	Decreased knee reflex	There is no reliable method	Reduction of ankle reflex

Studies for the diagnosis of pain in the back

Cause of pain syndrome	Research
Non-radical pain: - no history of trauma or risk factors - suspicion of latent infection or neoplastic process - spondylolisthesis, which is not amenable to conservative treatment or accompanied by severe neurologic symptoms	Radiography in anteroposterior and lateral projections. Osteoscintigraphy, MRI Radiography in the positions of flexion-extension, CT, MRI, osteoscintigraphy
Radical pain: - Persistent symptoms of ischialgia with obvious damage to the nerve root - ischialgia with an indeterminate level of lesion of the nerve root	MRI EMG, CT, MRI
Injury: - lesion of the motor nerve trunk with minimal trauma in the patient with possible structural changes in bone tissue	Radiography after the establishment of the mechanism of injury
Suspicion of osteomyelitis - a point is defined above the vertebra, painful on palpation	MRI
Neoplastic processes in anamnesis, clinical manifestations are consistent with metastatic lesions	Osteoscintigraphy, MRI

[1], [2], [3], [4], [5], [6]

Features of the patient survey

It is known that the most common reason for visiting an orthopedic doctor is back pain. When collecting anamnesis, special attention should be paid to clarifying the structure of the pain: its nature, what strengthens it, and what facilitates, in connection with which it arose. It is also important to clarify whether there are violations of the intestine or bladder. When pains in the lower back are quite often pain radiates over the leg (ischialgia): this pain can be accompanied by radicular symptoms (see below).

[7], [8], [9], [10], [11],

Inspection of the patient with complaints of back pain

The patient can remain in trousers with suspenders - this does not interfere with the examination and palpation of the back, the determination of skin temperature and the identification of local soreness. The doctor evaluates the following movements: flexion (the patient leans forward and pulls the fingers of his hands to the tips of the toes with straightened knee joints, it should be noted which part of this movement is due to the back, and which - due to flexion in the hips: with the bending of the back it has a smoothly rounded contour), extension (arcuate deviation of the spine back), lateral flexion (the patient tilts sideways, and the brush moves down the corresponding thigh) and rotation (the feet are fixed, and the shoulders perform cr coarse movements in turn in each direction). Movement in the costal-vertebral joints is assessed by the difference in the volume of the chest at the time of maximum inspiration and maximum expiration (at a rate of 5 cm). To assess the condition of the sacroiliac joints, the doctor puts his hands on the scales of the iliac bones (the patient lies on his back) and presses on them so that the bones move in the indicated joints. If something is not right, then there is soreness. Remember: when the body is completely bent forward, the line connecting the points 10 cm higher and 5 cm below L1 should extend by at least 5 cm. If the elongation is less, this is a reliable indication of the limitation of flexion. Then the muscles on both legs are compared (the thigh circumference is to be measured), the muscular strength, the loss of sensitivity and the intensity of the reflexes are evaluated (the knee reflex depends mainly on L4 and the Achilles on S1, and when the plantar reflex is examined, the foot should fall).

Raising a straight leg

When complaining about sciatica, the doctor should ask the patient to lie down on the couch, and lift the straightened leg (maximally unbent in the knee joint). In this case, the sciatic nerve is stretched and in the area of mechanical disturbance there is a radicular pain of a characteristic shooting character that irradiates according to the dermatome and is strengthened by coughing and sneezing. It is necessary to notice the angle at which a straight leg can be raised before the appearance of pain. If it is less than 45 °, then they speak of a positive symptom of Lasega.

Other parts of the body that can be inspected

These are the ileal fossa (which was especially important at times when the tuberculous psoas abscess was common), stomach, pelvis, rectum and large arteries. It should be remembered that bone usually metastasizes tumors from the breast, bronchus, kidneys, thyroid and prostate glands. Consequently, it is these organs that should be examined.

Laboratory and instrumental diagnostics of back pain

First of all determine the level of hemoglobin, ESR (if it is significantly increased, you should think about the possibility of myepic disease), activity in the serum of alkaline phosphatase (usually it is sharply increased in bone tumors and Paget's disease) and the calcium content in the blood. X-ray images of the back are made in the anteroposterior, lateral and oblique projections (pelvis, lumbar spine). Then, myelography and magnetic nuclear tomography are performed, capable of visualizing the pony tail. In this case, the protrusion of the intervertebral disc, tumor and stenosis of the spinal canal should be excluded. In cerebro-spinal fluid obtained in myelography, it is necessary to determine the protein content (it is increased in CSF, taken below the level of localization of the tumor of the spinal cord). The spinal canal is well visualized with ultrasound and CT (computed tomography). Radioisotope scanning can reveal "hot spots" of a tumor or a pyogenic infection. Electromyography (EMG) is used to confirm the violation of innervation along the lumbar or sacral nerves.

The next stage of diagnosis is aimed at identifying signs of compression of the nerve roots (herniated intervertebral disc, stenosis of the spinal canal). Of fundamental importance is a thorough neurological investigation (detection of symptoms of sensitivity disorders in the corresponding dermatomes, reflexes, etc.). Of the additional research methods for back pain, X-rays, CT and MRI are performed.

• X-ray manifestations of degenerative-dystrophic changes of the lumbosacral department:
  • decrease disk height;
  • subchondral sclerosis;
  • formation of osteophytes;
  • calcification of the pulpous nucleus or fibrous ring;
  • arthrosis of arched joints;
  • slanting of vertebral bodies;
  • displacement of the vertebrae.
• Signs of degenerative-dystrophic changes in the lumbosacral spine according to CT:
  • protrusion, calcification of the disc;
  • vacuum phenomenon;
  • front, posterior, lateral osteophytes;
  • central and lateral stenosis of the spinal canal.
• Signs of degenerative-dystrophic changes of the lumbosacral spine according to MRI:
  • bulging of the intervertebral disc;
  • a decrease in the intensity of the signal from the intervertebral disc;
  • folding of the fibrous ring, changing the signal from the end plates;
  • vacuum phenomenon;
  • calcification, spinal stenosis.

It should be emphasized once again that there is no direct connection between the severity of degenerative changes and the severity of the pain syndrome. These or other signs of degenerative-dystrophic changes of the lumbosacral spine (including herniated intervertebral discs) reveal practically all individuals of mature, especially older age, including those who never suffered from back pain. Therefore, the detection of X-ray, CT or MRT changes in itself can not be grounds for any conclusions about the etiology of pain syndrome.