Treatment of back pain

Back pain is an extremely widespread symptom that occurs in 80% of the population of Western Europe at any period of life. Out of 1000 industrial workers, 50 are annually disabled due to low back pain at any given time. In the UK, due to this pathology, 11.5 million working days are lost every year. In this regard, the general practitioner annually consults 20 people out of 1000, 10-15% of whom have to be hospitalized. And less than 10% of those hospitalized are undergoing surgical intervention.

In most cases, low back pain itself: among patients who turned to general practitioner, 70% improvement occurs after 3 weeks, in 90% - after 6 weeks, and this does not depend on the treatment received by patients. However, it should be remembered that low back pain may be a manifestation of a serious disease - malignant growth, local infection, compression of the spinal cord or horse tail, and, of course, such cases must be quickly diagnosed. The elderly patient's age makes him take complaints about pain in the lower back more seriously. So, according to one study, among patients aged 20 to 55 years complaining of back pain, only 3% had a so-called spinal pathology (tumor, infection, inflammatory disease), compared with 11% in individuals younger 20 years and from 19% in persons older than 55 years.

Treatment of low back pain includes:

• treatment of acute pain in the lower back;
• bed rest and exercise;
• physical factors;
• medications;
• physiotherapy and procedures;
• surgical intervention;
• training in the prevention of low back pain.

Treatment of low back pain primarily depends on the nature of the underlying disease. It is divided into undifferentiated and differentiated therapy.

Undifferentiated therapy is aimed at reducing pain syndrome or patient reactions to pain and eliminating vegetative reactions. It includes: adherence to bed rest until pain is reduced; dry heat locally; reflex-distracting agents (mustard, cans, ointments); LFK, massage, vitamin therapy, physiotherapy, reflexology, correction of psychological status.

The importance of laboratory studies in differential diagnosis of low back pain

Deviations	Possible diseases
Increased ESR	Spondyloarthritis, rheumatic polymyalgia, malignant tumors, tuberculosis, osteomyelitis, abscess
Increase in activity of alkaline phosphatase	Metastases in the bone, Paget's disease, osteomalacia, primary hyperparathyroidism
Pathological peak on the electrophoregram of whey proteins	Myeloma disease
Positive blood culture	Sepsis with osteomyelitis or abscess development
Detection of a prostatic specific antigen	Prostate Cancer
Identification of HLA-B27	Spondyloarthritis
Changes in urinalysis	Kidney disease (stones, swelling, pyelonephritis), Reiter's disease
Positive tuberculin tests	Tuberculosis of bones or spinal cord

Differential treatment of low back pain

The differentiated treatment of pain in the loins of the vertebrogenic nature depends on their pathogenetic mechanisms. Complex pathogenetic therapy is aimed at the affected segment, the elimination of muscle-tonic manifestations and myogenic tergornic zones, foci of neuromyospirosis, visceral foci of irritation, and autoallergic processes.

In addition, treatment should be differentiated depending on the phase of the disease. In the initial phases or with exacerbation, the treatment is aimed at reducing and then completely removing the pain syndrome, immobilization, anti-edema, desensitizing, spasmolytic agents, therapeutic drug blockades, special types of massage, vitamin therapy (neurorubin) play an important role. The main place is occupied by non-steroidal anti-inflammatory drugs (topical - gels, ointments, oral and parenteral - diclac) and muscle relaxants - tolperisone hydrochloride (midocals) in / m at 100 mg (1 ml) 2 times / day. After parenteral administration, 150 mg of midocular 3 times a day are administered per day.

Differential diagnosis of low back pain

Symptoms	Reason groups
	Mechanical	Inflammatory	Soft-woven	Focal-infiltrative
Start	Variable, often acute	Podystroie	Podystroie	Gradual
Localization	Diffuse	Diffuse	Diffuse	Focal
Symmetry of the process	Unilateral	Most often bilateral	Generalized	Single-sided or middle line
Intensity	Variable	Moderate	Moderate	Expressive
Neurological symptoms	Typical	No	No	Usually not
Morning stiffness	Up to 30 min	More than 30 min	Variable	No
Reaction of pain at rest	Attenuation	Gain	Variable	No (the pain is constant)
Reaction of Pain to Physician	Gain	Attenuation	Variable	No (the pain is constant)
Pain at night	Weak, depends on the situation	Moderate	Moderate	Strong
Systemic manifestations	No	Characteristic	No	Possible
Possible diseases	Osteochondrosis, hernia / disc damage, vertebral fracture, spondylolisthesis	Spondyloarthritis, rheumatic polymyalgia	Fibromyalgia, myofascial syndrome, overstrain of the musculoskeletal system	Tumor, infection of bones or soft tissues

When the stationary phase and the regression phase are reached, the other methods become dominant, most of which relate to physiotherapy: manual therapy, stretching, traction treatment, massage, various electrotherapy methods, acupuncture, local anesthesia, therapeutic gymnastics, various rehabilitation programs: physical and rational dosage motor activity, teaching the patient a new, individually chosen for him motor regime, the use of bandages, the use of instep arresters in a plane stop. All of them are used in the treatment of similar diseases, and which of them should be preferred - the doctor decides, and chooses the method that he best knows.

At different stages of treatment appoint resorption and stimulants of regeneration, chondroprotectors (teraflex). Many authors throughout the course of treatment recommend using antidepressants regardless of the clinical manifestations of depression.

Errors: the use of ineffective treatment; inadequate use of time when working with a patient; opioids.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Surgical treatment of back pain

The question of surgical intervention in each specific case is solved together with physicians of different specialties: cardiologist, neuropathologist, rheumatologist, orthopedist and neurosurgeon.

Indications for surgical treatment for neurological complications are divided into absolute and relative. Absolute indications for surgical intervention include: acute compression of the horse's tail or spinal cord, an unrecoverable hernia with a complete liquorodynamic and myelographic block. Relative indications are one-sided or bilateral pain, which is not subject to conservative therapy and leads to disability.

Symptoms that may indicate a prognostically severe pathology

Pain caused by physical activity and disappearing after rest is rarely malignant, and vice versa, respectively. Changing sides or bilateral ischialgia, especially if it is accompanied by sensory symptoms or weakness in the lower extremities or feet, leads to the assumption of defeat of the horse's tail (in favor of this, says urination disorder).

Disturbing symptoms can also be attributed to the pain-related limitation of mobility of the lumbar spine in all directions, local palpatory bone tenderness, bilateral neurologic "loss", neurological changes corresponding to the levels of several spinal roots (especially if the sacral nerves are involved), bilateral symptoms of tension of the spinal roots ( for example, the symptom of lifting the straightened leg). Acceleration of ESR (more than 25 mm / h) is a valuable screening test for various serious pathologies.

Patients who are suspected of compression of the spinal cord or ponytail or who have an exacerbation of unilateral symptoms should be referred to a specialist immediately, and patients who are suspected of having an oncologic or infectious lesion should be urgently sent to a specialist.

Treatment with "mechanical" pain in the lower back

Most people with back pain are treated conservatively. Patients should observe peace of mind in a horizontal position or a position with a slightly bent back, preferably on a hard mattress (a mattress can be placed on the board). It is necessary to avoid tension in the back: the patient should gently rise from the bed, do not bend forward, bend, stretch up, sit down on low chairs. To break the vicious circle - muscle pain - spasm will help analgesics: for example, paracetamol up to 4 g / day inward, NSAIDs such as naproxen 250 mg every 8 hours inside after eating, but in acute stages may need opioids. Helps also heat. If spastic muscle contraction persists, then you should think about using diazepam 2 mg every 8 hours inside. Physiotherapy, applied in the acute phase of the disease, can reduce pain and muscle spasms. The recovering patient should be given instructions on how to get up and what physical exercises to strengthen the back muscles. Many patients prefer to seek help from specialists in bone pathology or manual therapists, but they usually resort to the same treatment methods as physiotherapists. Special observations show that manual therapy can remove sharply expressed pain, but this effect is usually not long. If the pain does not leave the patient and after 2 weeks, you should think about radiographic examination, epidural anesthesia or corset. Later, if the pain still does not pass, it may be necessary to consult a specialist to clarify the diagnosis, enhance the effectiveness of treatment activities and to be confident in their actions.

Treatment of malignant pain in the lower back

Tumors of the spine

These can be tumors of the spinal cord, its meningeal envelope, nerves or bones. They can squeeze the spinal cord, causing the following symptoms: pain in the shoulder belt, if the thoracic spine is affected; pain in the lower back with a lower location of the tumor, signs of lesion of the lower motoneuron usually correspond to the level of the lesion, and signs of the defeat of the upper motoneuron and sensory defect are at a lower level; disorder of bowel and bladder function. The function of the peripheral nerves may be disturbed, which is accompanied by pain along the course of the affected nerve, weakness of the muscles innervated by this nerve, depressed reflexes and sensitivity disorders in areas innervated by the affected spinal roots. When involved in the pathological process of the horse's tail, urinary retention and saddle anesthesia often occur. If the bony process affects the bones, then there are progressive permanent pain and local bone destruction. Tumors (especially metastatic ones) tend to affect the spongy bone, but small focal lesions are usually not seen on radiographs until at least 50% of the bone mass is destroyed. Since the legs of the arcs of the vertebrae consist of a spongy bone, the early radiographic evidence of a tumor in the spine is a symptom of the "disappearance of these legs." In this case, muscular spasm is often expressed, as well as local soreness of the affected bone with percussion. As a result of the collapse (collapse) of the bone, a local deformation can form, which will cause compression of the spinal cord or nerve. The diagnosis can be confirmed by isotope scanning, bone biopsy and myelography.

Piogenic infection

To make such a diagnosis is sometimes quite difficult, since there may not be any usual signs of infection (fever, local palpatory pain, peripheral blood leukocytosis), but ESR is often increased. The pyogenic infection can be secondary to the primary septic focus. As a result of muscle spasm, pain and restriction of any movement occur. Approximately half of these infections are caused by staphylococcus, but it can also be caused by Proteus, E. Coli, Salmonella typhi and Mycobacterium tuberculosis. On the radiographs of the spine, there is a rarefaction or erosion of the bone, a narrowing of the joint between the joints (in this or that joint) and sometimes a new bone formation under the ligament. The greatest diagnostic informativeness for this pathology is the scanning of bone with technetium. Treatment: as in osteomyelitis plus bed rest, iosheie corset or gypsum "jacket".

Tuberculosis of the spine

Currently, this disease is quite rare in Western Europe. More often, people of young age. There is soreness and restriction of all movements in the back. ESR, as a rule, increased. In this case, there may be an abscess and compression of the spinal cord. Intervertebral discs are affected in isolation or with the involvement of vertebral bodies from both the right and left sides, the front edge of the vertebra is usually affected first. Radiographs show a narrowing of the affected discs and local osteoporosis of the vertebrae, later there is a desfusion of the bone, which subsequently leads to a wedge fracture of the vertebra. With lesions of the thoracic spine and x-ray, paraspinal (paravertebral) abscesses can be seen, and kyphosis can also be seen when the patient is examined. In the case of lesions of the lumbar and lumbar regions, abscesses may form on the sides of the lumbar muscle (psoas abscess) or in the iliac fossa. Treatment - antituberculous chemotherapy with simultaneous drainage of the abscess.

Prolubation (protrusion) of the disc in the central direction

The idea of urgent neurosurgical intervention should arise in bilateral sciatica, perineal or saddle anesthesia, and in violation of bowel movement and bladder function.

To prevent paralysis of both legs, urgent decompression is necessary.