Pain in the back and leg

The pain in the back and leg is divided into the following types:

By time characteristics - on acute (with a sudden onset and duration of up to 3 months), subacute (with a slow onset and the same duration), chronic (duration of more than 3 months, regardless of the nature of the debut) and recurrent.

According to the localization and distribution peculiarities, local pains in the lower lumbar and lumbosacral region (most often lumbago and lumbulgia), reflected (pains are felt in an area that has a common embryonic origin with affected tissues and is more often localized in the inguinal, gluteal or anterior, lateral and posterior surface of the thigh, but sometimes it can extend to the knee), radicular (the pain is distributed along the dermatomic distribution of the spinal roots, on the leg most often along the sciatic nerve) and neural; finally, there are pains associated mainly with the pathology of internal organs.

According to the mechanisms of occurrence, all pain syndromes in the Russian literature are also divided into two groups: reflex, having no signs of damage to the peripheral nervous system, and compression (mainly radiculopathy)

Pain that is not associated with the involvement of roots and peripheral nerves, as well as internal organs, refers to musculoskeletal pain (nonspecific age or associated with microdamage, or musculoskeletal dysfunction, musculoskeletal changes). This is the most common type of pain (almost 98% of all back pain cases). In the ICD 10 painful nonspecific syndromes in the back area (with possible irradiation in the limb) are referred to the XIII class "Diseases of the musculoskeletal system and connective tissue".

In addition to taking into account the type of pain, it is important to analyze the pattern of pain (its nature and distribution).

It is important to note that the terminology used in Russian literature in describing pain syndromes in the back does not always correspond to academic requirements, it abounds with neologisms and is not accepted in most developed countries of the world. The term "osteochondrosis" and "neurological manifestations of the osteochondrosis of the spine" are used in the Russian literature in an overly broad sense.

For the diagnosis, pain characteristics such as localization and distribution (irradiation zone) are especially important; the nature (quality) of pain; temporal characteristics (as it began, intermittent or progressive course, periods of relief, remission, exacerbation); severity of pain syndrome and dynamics of pain; provoking and facilitating factors; associated (sensitive, motor, vegetative and other) manifestations (neurological deficit); presence of other somatic diseases (diabetes mellitus, vascular disease, tuberculosis, arthritis, carcinoma, etc.); it is always important to pay attention to the personality of the patient and the possible symptoms of drug dependence.

[1], [2], [3], [4]

V. Other causes of pain in the back and leg

Other causes of pain in the back and leg include phantom pains, reflected pain in diseases of visceral organs (inflammatory infiltrates and tumors in the retroperitoneal space, diseases of the gastrointestinal tract, genitourinary system, aortic aneurysm) and orthopedic disorders. Pain in the leg can be caused by a syndrome of the muscle bed (for example, "anterior tibial syndrome"), a Barre-Masson tumor.

Phantom pains due to specific clinical manifestations rarely serve as a cause of serious diagnostic doubt.

Attention should be paid to some alarming clinical symptoms (in the anamnesis and in the status), which may indicate possible more serious causes of back pain:

I. History:

1. Increased pain at rest or at night.
2. Increasing intensity of pain for a week or more.
3. Malignant tumor in the anamnesis.
4. Chronic infectious disease in the anamnesis.
5. Injury in the anamnesis.
6. Duration of pain over 1 month.
7. Treatment of corticosteroids in the anamnesis.

II. With objective research:

1. An unexplained fever.
2. Unexplained weight loss.
3. Soreness with light percussion of spinous processes.
4. The unusual nature of pain: the feeling of a passing electrical current, paroxysmal, vegetative color.
5. Unusual irradiation of pain (girdle, perineum, abdomen, etc.).
6. Relationship pains with food intake, defecation, sexual intercourse, urination.
7. Associated somatic disorders (gastrointestinal, urogenital, gynecological, hematological, etc.).
8. Rapidly progressive neurological deficit.

Lumbulgia in childhood can be due to the processes associated with the unbearing of the vertebral arches (with cystic form), the syndrome of a rigid terminal thread, rough lumbarization or sacralization, and other orthopedic pathology.

Among the possible somatic causes of pain in the back and leg in adults, the most important are: myeloma, urinary tract and kidney disease, tuberculosis, syphilis, brucellosis, sarcoidosis, polymyositis, exfoliating aortic aneurysm, pancreatic diseases, duodenal ulcer, gynecological diseases, ectopic pregnancy, hormonal spondylopathy, iatrogenic syndromes (post-injection complications), coxarthrosis, femoral artery occlusion.

Pain in the back and leg, depending on the sources of pain:

I. Pain of vertebrogenic nature:

1. Prolapse and protrusion of the disc.
2. Instability of the vertebral segment and spondylolisthesis.
3. Lumbar stenosis.
4. Ankylosing spondylitis.
5. Spondylitis of another etiology.
6. Fracture of the vertebra.
7. Swelling of the vertebra (primary or metastatic), myeloma.
8. Paget's disease.
9. Recklinghausen disease.
10. Osteomyelitis of the vertebra.
11. Osteophytes.
12. Lumbar spondylosis.
13. Other sondilopathies and congenital deformities.
14. Faceted syndrome.
15. Osteoporosis.
16. Sacralization and lumbarization.

Pathological processes in the spine, capable of sometimes causing compression lesions of the roots, membranes, vessels and substances of the spinal cord.

II. Pain of a non-recurring nature:

1. Tunnel Syndromes:
   • neuropathy of the lateral cutaneous nerve of the thigh;
   • neuropathy of the occlusive nerve;
   • sciatic nerve neuropathy;
   • neuropathy of the femoral nerve;
   • the neuropathy of the common peroneal nerve and its branches;
   • neuropathy of the lumbar nerve;
   • Metatarsalgia Morton.
2. Traumatic neuropathies; herpetic ganillitis (herpes zoster); postherpetic neuralgia.
3. Metabolic mononeuropathy and polyneuropathy.
4. Tumors of the spinal cord (extra- and intraspinal) and the horse's tail.
5. Epidural abscess or hematoma.
6. Carcinomatosis of meninges or chronic meningitis.
7. Neurinoma of the spinal root.
8. Complex regional pain syndrome (reflex sympathetic dystrophy).
9. Spinal syphilis.
10. Central (thalamic) pain.
11. Plexopathy.
12. Syndrome of pain-fascination.
13. Syringomyelia.
14. "Intermittent claudication" (caudation) of the horse's tail.
15. Acute spinal cord blood flow.

III. Myofascial pain syndromes.

IV. Psychogenic pain.

V. Other reasons.

I. Pain in the back and leg of vertebrogenic nature

Damage to this or that lumbar disc can be an accidental radiological finding or cause a variety of pain syndromes. Isolated or combined local pains in the lumbar region, local and reflected pains, radicular pains and an unfolded radicular syndrome with symptoms of falling out can be observed.

Some pathological processes in the spine are manifested by musculoskeletal pain, muscle tension, and mobility changes (block or instability) in the spinal column (disk protrusion, osteophytes, lumbar spondylosis, sacralization and lumbarization) in the spine (in its discs, joints, ligaments and muscles and tendons). , facet arthropathy, osteoporosis, some spondylopathies), while other diseases lead to compression lesions of the root, horse tail, dural sac, spinal cord: disc herniation; age-related changes in the spine, leading to stenosis of the spinal canal; sometimes - facet syndrome, spondylitis; tumors; compression fractures of vertebrae; spondylolisthesis; Spondylopathy, accompanied by deformation of the spine.

The first group of disorders (musculoskeletal pains) occurs much more often than the second. In musculo-skeletal pain, there is no correlation between the clinical manifestations of the pain syndrome and the morphological changes in the structures of the spine.

In the absence of compression symptoms, the affected disc is detected by palpation (local muscle tension) or percussion of spinous processes, as well as by neuroimaging methods. Often the patient takes a pathological posture with a torso in the opposite direction and has limited movements in the vertebral segment. Isolated back pain is more typical for rupture of the fibrous ring, facet syndrome, while pain along the sciatic nerve often indicates protrusion of the disc or lumbar spinal stenosis. Serious disc damage is usually preceded by multiple episodes of lumbar pain in an anamnesis.

More often than not, there are five causes of pain in the back and along the sciatic nerve:

1. Herniated disc.
2. Rupture of the fibrous ring.
3. Myogenic pain.
4. Stenosis of the spinal canal.
5. Facet arthropathy.

The hernia of a disk is characterized by: a specific trauma in the anamnesis; pains in the leg are more pronounced than back pain; there are symptoms of loss and a symptom of Lasega; pain increases with sitting, tilting forward, coughing, sneezing and straightening of the foot, plantar flexion of the ipsilateral (and sometimes contralateral) foot; there is a radiological indication of the involvement of the rootlet (CT). Manifestations of a disc herniation depend on its degree (protrusion, prolapse), mobility and directionality (medial, posterolateral, foraminal, extraforaminal).

The rupture of the fibrous ring is characterized by: a trauma in the anamnesis; Back pain is usually more severe than in the leg. Pain in the leg can be bilateral or one-sided. There is a symptom of Lasega (but there is no radiological confirmation of the root compression). Pain increases with sitting, tilting forward, coughing, sneezing and straightening of the leg.

Myogenic pain (pain of muscular origin) is characterized by muscle overstrain in the anamnesis; there is a link between relapses of pain and muscle strain. The tension of the paravertebral lumbar muscles ("myositis") causes pain. The tension of the gluteus maximizes the pain in this area and in the thigh. Pain rather one-sided or two-sided than the middle line does not extend beyond the knee. Tenderness and muscle tension increase in the morning and after rest, and also with cooling. Pain increases with prolonged muscle work; it is most intense after the termination of muscular work (immediately after its end or the next day). Severity of symptoms depends on the degree of muscular load. Palpable local tension in the involved muscles; pain increases with active and passive muscle contraction. CT scan does not show any pathology.

Lumbar stenosis is characterized by the fact that pain in the back and / or in the leg (bilateral or unilateral) appears after walking for a certain distance; symptoms increase with the continuation of walking. There is weakness and numbness in the legs. Flexion alleviates the symptoms. No symptoms of prolapse. CT scans can reduce disc height, hypertrophy of facet joints, degenerative spondylolisthesis.

Facet arthropathy. She has a history of trauma; local tension on one side above the joint. Pain appears immediately when the spine is unbent; it increases with bending to the sore side. It stops when anesthetic or corticosteroid is injected into the joint.

A positive Lasega symptom allows one to assume the involvement of the lumbosacral roots or sciatic nerve. In the presence of radiculopathy, the nature of the neurologic symptoms makes it possible to identify the affected root.

In most cases, the disk L4-L5 (spine L5) or disk L5-S1 (spine S1) suffers. Other disks at the lumbar level are rarely involved: less than 5% of all cases. Protrusions or prolapses of lumbar discs can cause radiculopathy, but can not be the cause of myelopathy, since the spinal cord ends above the disk L1-L2.

In determining the level of the affected root take into account the localization of sensory disorders, the localization of motor disorders (identify the muscles in which weakness is detected, as well as the features of the distribution of pain and the state of reflexes.

Symptoms of protrusion of the disk L3-L4 (compression of the rootlet L4) is the weakness of m. Quadriceps and decreased or absent knee reflex; possible hyperesthesia or hypoesthesia in L4 dermatome.

Signs of protrusion of the disk L1-L5 (compression of the rootlet L5) are the weakness of m. Tibialis anterior, extensor digitorum and hallucis longus. The weakness of the extensor muscles of the toes is characteristic; the weakness of these muscles is also revealed when the spine S1 is compressed. Sensitivity disorders are observed in L5 dermatome.

Symptoms of protrusion of the disk L5-S1 (compression of the spine S1) are manifested by weakness of the hamstrings (biceps femoris, semimembranosus, semitendinosus), extending the thigh and flexing the shin. The weakness of m is also revealed. Dluteus maximus and gastrocnemius muscles. The Achilles reflex decreases or falls out. There is a sensitivity disorder in the dermatome S1.

Large disk prolapse in the central direction can cause bilateral radiculopathy and sometimes leads to acute horse tail syndrome with severe pain syndrome, flaccid leg paralysis, areflexia and pelvic disorders. The syndrome requires as soon as possible rapid neurosurgical intervention.

II. Pain in the back and leg of a non-embryogenic nature

Basic Tunnel Syndromes:

Neuropathy of the lateral cutaneous nerve of the thigh (Roth-Bernhardt's disease). Compression of the nerve at the level of the ligamentous ligament is the most common cause of "paresthetic melalgia". Typical sensations of numbness, burning, tingling and other paresthesias in the antero-external region of the thigh are observed, amplified by compression of the outer part of the puarth ligament.

Differential diagnosis with lesions of L2g-L3 roots (which is accompanied, however, by motor falls) and coxarthrosis, in which pain is localized in the upper parts of the external surface of the thigh and there is no typical paresthesia and sensitivity disorders.

Neuropathy of the nerve. A rare syndrome that develops during the compression of the nerve by retroperitoneal hematoma, fetal head, cervical tumor or ovary and other processes, including narrowing the occlusal canal. The syndrome is manifested by pain in the groin and inner surface of the thigh with paresthesias and hypesthesia in the middle and lower third of the inner surface of the thigh. Possible hypotrophy of the muscles of the inner thigh and a decrease in the strength of the muscles that lead the thigh. Sometimes the reflex from the adductors of the hip falls out or falls.

Neuropathy of the sciatic nerve (pear-shaped muscle syndrome). Characterized by soreness of the pear-shaped muscle at the point of exit of the sciatic nerve and blunt pain along the back surface of the leg. In this case, the zone of reduced sensitivity does not rise above the level of the knee joint. When combined pear-shaped muscle and compression radiculopathies of the sciatic nerve roots, lamospasm hyposesia with the spread of sensory and motor disorders (atrophy) to the gluteal region is revealed. With coarse compression of the sciatic nerve, a characteristic pain syndrome (ischialgia) is accompanied by a decrease or loss of the Achilles reflex. Paresis of the foot muscles develops less often.

Neuropathy of the femoral nerve. Compression of the femoral nerve most often develops in the place where the nerve passes between the pelvic bones and the iliac fascia (hematoma, enlarged lymph nodes, tumor, ligature during hernia operation), which is manifested by pain in the groin with irradiation to the thigh and lumbar region, hypotrophy and weakness of the quadriceps muscle of the thigh, abaissement of the knee reflex, and instability in walking. Sometimes the patient takes a characteristic posture in position on the diseased side with flexion of the lumbar spine, as well as the hip and knee joints. Sensitive disorders are revealed mainly in the lower half of the thigh along its anterior and inner surfaces, as well as on the inner surface of the shin and foot.

Neuropathy of the common peroneal nerve and its branches. The lesion of the common peroneal nerve and its major branches (superficial, deep and recurrent peroneal nerves) often occurs near the fibula neck under the fibrous rib of the long fibular muscle. Paresthesias are observed along the outer surface of the shin and foot and hypesisusia in this zone. Compression or effleurage in the area of the superior head of the fibula causes characteristic pain. Paralysis of the extensor of the foot (hanging foot) and the corresponding gait are observed.

Differential diagnosis with L5 spine injury (radiculopathy with paralyzing sciatica syndrome), whose clinical manifestations include paresis not only of the extensor but also of the corresponding gluteal muscles. The latter is manifested by a decrease in the force of pressing the elongated leg to the bed in the lying position.

Neuropathy of the tibial nerve of compression origin (tarsal canal syndrome) usually develops behind and below the medial malleolus and is manifested by pain in the plantar surface of the foot and fingers when walking, often with irradiation upwards along the sciatic nerve, as well as paresthesia and hypesisescence mainly in the sole. The compression and tapping of the ankle, as well as the pronation of the foot, intensifies paresthesia and pain and causes their irradiation into the region of the shin and foot. Rather, motor functions suffer (flexion and spreading of fingers).

Morton Metatarsalgia develops when the plantar finger I, II, or III nerves are pressed against the transverse metatarsal ligament (it is stretched between the metatarsus of the metatarsal bones) and is manifested by pain in the region of the distal parts of the metatarsal bones during walking or during prolonged standing. Nerves of II and III interosseous spaces suffer more often. Characteristic of hypoesthesia in this area.

Traumatic neuropathies in the lower extremities are easily recognized by the presence of trauma in the anamnesis, and herpetic ganglionitis and postherpetic neuralgia - according to the corresponding cutaneous manifestations of herpes zoster.

Metabolic mono- and polyneuropathies. Some variants of diabetic polyneuropathy, for example, multiple mononeuropathy with the predominant involvement of proximal muscles (diabetic amyotrophy) are accompanied by severe pain syndrome.

The pain syndrome in spinal cord tumors (extra- and intraspinal) is recognized by a characteristic progressive course with an increasing neurologic defect. Tumulus of the cauda equina is manifested by a pronounced and persistent pain syndrome in the zone of the corresponding roots, hypostasia of the feet and shins, loss of achilles and plantar reflexes, mainly distal paraparesis, disorders of the pelvic organs.

Epidural abscess is characterized by pain in the back at the level of the lesion (more often in the lower lumbar and median thoracic areas) followed by attachment of the dilated radicular syndrome and, finally, paresis and paralysis against the background of general symptoms of the inflammatory process (fever accelerated by ESR). Lumbar puncture with epidural abscess is a medical error due to the threat of purulent meningitis with a subsequent disabling neurological defect.

Spinal arachnoiditis is often identified as a radiological finding that has no clinical significance (usually after neurosurgical operations or myelography); rarely they can progress. In most cases, the association of the pain syndrome with the adhesive process in the envelopes is vague and questionable.

Epidural hematoma is characterized by acute development of pain syndrome and symptoms of spinal cord compression.

Carcinomatosis of the meninges at the level of the lumbar dural sac manifests itself as a pain syndrome, a picture of irritation of the meninges and is diagnosed in the cytological study of the cerebrospinal fluid.

Neurinoma of the spinal root is characterized by typical "shooting" pain of high intensity, motor and sensitive manifestations of affection of the corresponding rootlet, often - by a block of subarachnoid space and high protein content (with neurinoma of the lumbar roots).

Complex regional pain syndrome (reflex sympathetic dystrophy) is a combination of burning, breaking, aching pains with sensitive disorders (hypoesthesia, hyperpathy, allodynia, that is, perception of non-bellicose irritants as painful) and vegetative-trophic disorders, including osteoporosis in the field of pain syndrome. The syndrome is often reversed after a sympathetic blockade. It often develops after a microtraumatic limb or its immobilization and may be accompanied by symptoms of involvement of peripheral nerves.

Spinal syphilis (syphilitic meningomyelitis, syphilitic spinal pachymeningitis, spinal vascular syphilis, spinal cord) may include back and leg pain in its clinical manifestations, but the pains usually do not relate to the main manifestations of neurosyphilis and are accompanied by other typical symptoms.

Central (thalamic) pain usually develops in patients who have suffered a stroke, after a long (several months) latent period; it progresses against the background of restoration of motor functions and is characterized by a distribution predominantly in the hemite type with an unpleasant burning hue. Central pain is also described in the case of extra-clinical localization of stroke. She does not respond to the administration of analgesics. The presence of a stroke in the history and the nature of the pain syndrome, reminiscent of the "burning sensation of immersed in icy water hands" determine the clinical diagnosis of this syndrome. Often identified promotional allodynia (the appearance of pain when moving limbs). Pain in the leg with this syndrome is usually part of a more common pain syndrome.

The defeat of the plexus (lumbar and / or sacral) can cause pain in the waist and lower back. In lumbar plexopathy, pain is localized in the waist with irradiation to the groin and inner thighs. Sensitive disorders are observed in the area of the anterior, lateral and inner surface of the thigh. Weakness of flexion and reduction of the thigh, as well as flexion of the tibia, is noted. Decreased knee and adductor reflexes on the affected side. Thus, motor and sensory "symptoms of loss" in plexopathy indicate the lesion of more than one peripheral nerve. Weakness is revealed mainly in the proximal muscles: ileopsoas, gluteus muscles and adductor muscles of the hip are affected.

Sacral pleksopatii is characterized by a painful syndrome in the region of the sacrum, buttocks and perineum with the spread of pain to the back surface of the leg. Sensitive disorders capture the foot, the shin (except the inner surface), the back of the thigh. Weakness in the muscles of the foot and flexor of the lower leg is revealed. Rotation and hip removal are difficult.

Causes of plexopathy: trauma (including birth and surgery), retroperitoneal tumor, abscesses, lymphoproliferative diseases, idiopathic lumbosacral plexopathy, vasculitis in systemic diseases, aneurysms of the abdominal aorta and pelvic arteries, radiation plexopathy, hematoma against anticoagulant treatment and other small organ diseases pelvis. Rectal examination is necessary; at women - consultation of the gynecologist.

Many pathological processes (trauma, malignant tumor, diabetes, etc.) can affect the peripheral nervous system at several levels (roots, plexus, peripheral nerve).

The syndrome of "muscular pain and facies" (the syndrome "muscle pain - fasciculation", "syndrome of the crump and fasciculation", "benign motor neuron disease") is manifested by the crampial cramps (in most cases - in the legs), by constant fasciculations and / or miocamps. Crumpies are strengthened with physical activity, in more severe cases - even when walking. Tendon reflexes and the sensitive sphere are intact. There is a good effect of carbamazepine or antepeptin. The pathogenesis of this syndrome is not clear. Its pathophysiology is associated with the "hyperactivity of motor units".

Syringomyelia rarely causes pain in the lower back and legs, as the lumbosacral form of this disease refers to rarities. It is manifested by flaccid paresis, marked by trophic disorders and dissociated impaired sensitivities. Differential diagnosis with intramedullary tumor is solved with involvement of neuroimaging methods, investigation of cerebrospinal fluid and analysis of the course of the disease.

"Intermittent claudication" (caudation) of the cauda equina can have both vertebrogenic and non-itrogenic origin. It is manifested by transient pains and paresthesias in the projection of certain roots of the horse tail, developing in the lower limbs when standing or walking. The syndrome develops with mixed forms of lumbar stenosis (a combination of stenosis and disc herniation), in which both the rootlets and their accompanying vessels suffer. This "caudogenic intermittent claudication" should be distinguished from "myelogenous intermittent claudication," which manifests itself mainly as a temporary weakness in the legs. This weakness is provoked by walking and decreases at rest, it can be accompanied by a feeling of heaviness and numbness in the legs, but there is no pronounced pain syndrome, such as with caudogenic lameness or obliterating endarteritis, here.

An acute violation of the spinal circulation manifests itself suddenly developed (although the degree of acuity can vary), flaccid lower paraparesis, impaired pelvic organs, and sensitive disorders. Pain syndrome often precedes or accompanies the first stage of the course of the spinal stroke.

IV. Psychogenic pain in the back and leg

Psychogenic pain in the lumbar region and lower limbs are usually part of a more generalized pain syndrome and are observed in the picture of behavioral disorders associated with emotional-personal (neurotic, psychopathic and psychotic) disorders. Pain syndrome is part of the somatic complaints for depressive, hypochondriac or conversion disorders, rental facilities, anxiety states.

Pain in the back and leg can be a symptom of schizophrenia, personality disorders, dementia.

Strictly localized pain in the absence of mental disorders requires persistent search for somatic sources of pain syndrome.

Pain in the back and leg depending on the topography

I. Back pain (dorsalgia)

Pain mainly in the upper or middle part of the back can be due to Sheyerman's disease, spondylosis of the thoracic spine, Bekhterev's disease. It can be the result of excessive muscle activity, shovel-rib syndrome or traumatic neuropathy of intercostal nerves. The pronounced interscapular pain may be a sign of a tumor of the spine, spondylitis, epidural hematoma, or beginning transverse myelitis.

Pain in the lumbar region most often have orthopedic causes: osteochondrosis; spondylosis; spondylolisthesis and spondylolysis; the phenomenon of Boostrup - an increase in the vertical dimension of the spinous processes of the lumbar vertebrae, which sometimes leads to the contact of the processes of the adjacent vertebrae; sacroiliitis; cocciogonia. Young men may have Bechterew's disease involving the sacroiliac joint (night pain in lying position). Degeneration and damage to the disc is a common cause of pain in the lumbar region. Other possible causes: an arachnoid cyst in the sacral region, local muscular densities in the gluteal muscles, pear-shaped muscle syndrome.

II. Pain in the leg

The pain radiating from the lumbar region to the upper thigh is most often associated with the sciatic nerve or its root irrigation (usually due to protrusion or prolapse of the herniated disc of the lumbar spine). Lumbosacral radicular pain may be a manifestation of chronic adhesive leptomeningitis or a tumor. A similar pattern is observed with tumors of the sacral plexus (for example, with retroperitoneal tumors). Unlike the damage to the roots, the compression of this plexus causes a violation of sweating (the ship's fibers exit the spinal cord through the front roots of L2-L3 and pass through the plexus). Violation of sweating is also characteristic of ischemic neuropathy of the sciatic nerve (vasculitis). In rare cases, the pain of this localization is a manifestation of the tumor of the spinal cord. Other causes: pear-shaped muscle syndrome, bursitis of the gluteus muscle tendons, caudiogenic intermittent claudication (epidural vein varicosis is currently less important).

Pain in the lateral region of the thigh may be due to pseudo-radicular irradiation in diseases of the femoral joint (lamp-like pain distribution). This pain can also be associated with the lesion of the upper lumbar spines (for example, in the hernia of the disc) and is manifested by acute lumbago, the corresponding vertebral syndrome, weakness of the quadriceps femoris, decreased knee reflex, pain in the rotation of the straightened leg and sensory deficiency in the L4 spine. Burning pains in the lateral zone of the thigh are characteristic for the parietal Roth-Bernard (R-Bernard) melange (tunnel syndrome of the lateral cutaneous nerve of the thigh).

The pain radiating on the front surface of the thigh is most often due to the predominant lesion of the femoral nerve (for example, after a hernia operation or with other surgical procedures in the lower abdomen). Such lesions are manifested by weakness of the quadriceps muscle of the thigh, reduction or loss of the knee reflex, sensitive disorders typical for the suffering of the femoral nerve.

The differential diagnosis between the rootlet lesion of L3-L4 and the tumor compression of the lumbar plexus is often very difficult. Expressed pain with atrophy of the thigh muscles is most often due to asymmetric proximal neuropathy in diabetes mellitus. Extremely severe pain in this area, appearing together with paresis m. Quadriceps femoris can be caused by retroperitoneal hematoma (usually with anticoagulant treatment).

Pain in the knee joint area is usually associated with orthopedic disorders (patella, meniscus, knee and sometimes hip joint disease). Paresthesia and pain in the innervation zone of the nerve can sometimes extend to the medial region of the knee (prostate or other pelvic organs, pelvic fracture), which is also accompanied by weakness of the hip adductors.

Pain in the region of the shin can be bilateral: restless legs syndrome, muscle pain syndrome and fasciculations, chronic polyneuropathies. One-sided pain syndrome is sometimes associated with muscular lobe syndrome.

Cudogenous intermittent claudication (see above) may be unilateral or bilateral. Myalgic syndrome in the region of the shins is typical for infections that affect the upper respiratory tract (acute myositis). Pain syndrome is characteristic for night cramps (it can be either one-sided or two-sided). Other causes: obliterating endarteritis (characterized by a lack of pulse on a.dorsalis pedis, typical intermittent claudication, trophic disorders), lumbar stenosis, tunnel syndromes on the legs (see above), occlusion of the anterior tibial artery (acute arterial obstruction).

Pain in the foot area is most often caused by orthopedic causes (flat feet, "spurs", hallux valgus, etc.). Bilateral pain in the foot can take the form of burning paresthesia in polyneuropathy, or serve as a manifestation of erythromelalgia (idiopathic and symptomatic). One-sided pain in the foot is characteristic of the syndrome of the tharzal canal and Metatarsalgia Morton.

III. Myofascial pain syndromes in the back and leg

The source of this group of pain syndromes are the muscles of the lumbar and gluteal region are usually accompanied by pain of other localization (reflected pain). It is necessary to search for trigger points in the region of the muscles of the thigh and lower leg and an analysis of the pain pattern for the accurate diagnosis of myofascial syndrome.

Coccidonia (pelvic floor syndrome) is most often a myofascial syndrome in the area of the perineal muscle, manifested by its local spasm with a shortening of the pelvic ligaments.

Diagnostic tests for pain in the back and leg:

1. Neuroorthopedic examination.
2. Radiography of the lumbar and sacral spine with functional tests.
3. CT scan
4. Magnetic resonance imaging
5. Myelography (now used less often).
6. Ultrasound of the abdominal cavity organs
7. Positron Emission Tomography
8. Clinical and biochemical blood test
9. Calcium, phosphorus and alkaline and acid phosphatase
10. Analysis of urine
11. Research and sowing of liquor
12. EMG

You may need: glucose tolerance test, whey protein electrophoresis, coagulation test, limb X-ray, ultrasound examination of blood flow (as well as abdominal and pelvic organs), arteriography, bone scanning, lymph node biopsy (muscle, nerve), blood pressure in lower limbs (exfoliating aneurysm), sigmoidoscopy, consultation of the therapist and other (according to indications) studies.

Back pain in pregnancy can have other causes: a disc herniation (worse with standing and sitting, decreases in lying position); lysis of bone tissue in the region of the pubic joint (pain increases with standing and walking); transient osteoporosis of the thigh; dysfunction of the ilio-sacral joint.