Lower back pain

In the domestic literature, with pain in the lower back, the term "lumbalgia" is sometimes used, with localization of pain in the lumbar region and leg - "lumboschialgia", and in the presence of signs of lesion of the lumbar roots - "lumbosacral radiculitis" (radiculopathy).

In addition, often with the localization of pain in any area of the back, with the exception of the cervico-brachial region or the combination of several painful areas of the back, you can find the term "dorsalgia" or "dorsopathy". In this case, the term "dorsopathy" defines a pain syndrome in the trunk and limbs of non-visceral etiology, associated with degenerative diseases of the spine.

The term "lower back pain" refers to pain, muscle tension or stiffness localized in the region of the back between the XII pair of ribs and the gluteal folds, with irradiation to the lower limbs or without it.

What causes pain in the lower back?

Pain in the lower back as a clinical manifestation is found in almost a hundred diseases, and, therefore, the generally accepted classification of pain sensations of this localization does not exist. The source of pain impulse in this area can be almost all anatomical structures of the lumbosacral region, abdominal cavity and pelvic organs.

On the basis of pathophysiological mechanisms, the following types of lower back pain are distinguished.

• Nociceptive pain at the bottom of the back occurs when excitatory pain receptors - nociceptors due to damage to the tissues in which they are located. Accordingly, the intensity of nociceptive pain sensations, as a rule, depends on the degree of tissue damage and the duration of the effect of the damaging factor, and its duration on the characteristics of the healing processes. Pain in the lower back can also occur if the CNS structures and / or the peripheral nervous system are damaged or dysfunctional, involved in pain analysis and analysis, i.e. If nerve fibers are damaged at any point from the primary afferent conduction system to the cortical structures of the central nervous system. It persists or arises after the healing of damaged tissue structures, therefore it almost always has a chronic character and does not possess protective functions.
• Neuropathic is called lower back pain, which occurs when peripheral structures of the nervous system are damaged. If the structures of the central nervous system are damaged, central pain arises. Sometimes neuropathic back pain is divided into radicular (radiculoathia) and non-spinal (neuropathy of the sciatic nerve, lumbosacral plexopathy).
• Psychogenic and somatoform pain in the lower back arises regardless of somatic, visceral or neurological damage and is determined primarily by psychological factors.

The most prevalent in our country is a scheme dividing the pain at the bottom of the back into two categories - primary and secondary.

Primary pain in the lower back is a pain syndrome in the back caused by dystrophic and functional changes in the tissues of the musculoskeletal system (articular joints, intervertebral discs, fascia, muscles, tendons, ligaments) with the possible involvement of adjacent structures (roots, nerves). The main causes of the primary pain syndrome in the lower part of the tire are mechanical factors, determined in 90-95% of patients: dysfunction of the musculoskeletal system; spondylosis (in foreign literature this is a synonym for osteochondrosis of the spine): a herniated intervertebral disc.

Secondary pain in the lower back is caused by the following reasons:

• congenital anomalies (lumbarization, spina bifida, etc.);
• traumas (vertebral fractures, protrusion of intervertebral discs, etc.);
• arthritis (Bechterew's disease, reactive arthritis, rheumatoid arthritis, etc.);
• other diseases of the spine (tumors, infections, metabolic disorders, etc.);
• projection pain in diseases of internal organs (stomach, pancreas, intestines, abdominal aorta, etc.);
• diseases of the genito-urinary organs.

On the other hand, A.M. Wayne shared the reasons for the two large groups of vertebrogenic and unverebrogenic.

For vertebrogenic causes of pain, lower back, as the frequency of occurrence decreased, were:

• prolapse or protrusion of the intervertebral disc;
• spondylosis;
• osteophytes;
• sacralization, lumbarization;
• facet syndrome;
• ankylosing spondylitis;
• spinal stenosis;
• instability of the vertebral-motor segment;
• vertebral fractures;
• osteoporosis (due to fractures);
• tumors;
• functional disorders.

Among the non-recurring causes are named;

• myofascial pain syndrome:
• psychogenic pain;
• reflected pain in the lower back with diseases of internal organs (heart, lungs, digestive tract, urogenital organs);
• epidural abscess;
• metastatic tumors;
• syringomyelia;
•  retroperitoneal tumors.

In the duration of pain, the lower backs are divided into:

• acute (up to 12 weeks);
• chronic (over 12 weeks).

Separately stands out:

• recurrent pain in the lower back, occurring at intervals of at least 6 months after the end of the previous exacerbation;
• exacerbation of chronic pain in the lower back, if the indicated interval is less than 6 months.

By specificity, the pain at the lower back is divided into:

• specific;
• nonspecific.

In this case, nonspecific pain in the lower back as a vaccine, such a sharp pain, in which an accurate diagnosis can not be set and there is no need to strive for it. In turn, the specific pain at the lower back is determined in those cases when the pain sensation is a symptom of a certain nosological form, often threatening further health and / or even life to the patient.

Epidemiology

Lower back pain is one of the most common complaints of patients in general practice. According to a number of researchers, 24.9% of active calls for outpatient care of persons of working age are associated with this condition. A special interest in the problem of pain in the lower back is due primarily to the widespread prevalence: at least once in a lifetime these pains are experienced by at least 80% of the adult population of the earth's breadth; approximately 1% of the population is chronically incapacitated and 2 times more - temporarily disabled in connection with this syndrome. In this case, a decrease in the ability to work in the presence of painful sensations is noted by more than 50% of patients. The total incapacity for work of patients - mostly those of a workable age - in turn leads to significant material losses and costs for diagnosis, treatment and rehabilitation, and as a result - significant health care costs and negative effects on the national economy.

Currently, only a few epidemiological studies of pain in the lower back, mainly related to organized groups. Thus, the study of workers and employees of the plant of medium engineering and 1994-1995. Showed that 48% of the respondents complained of pain in the lower back during their lifetime, in the last year - 31.5%, and at the time of the survey, 11.5%, without significant differences between men and women. A high prevalence of pain in the lower back was revealed by a motor vehicle worker (2001) and a metallurgical plant (2004): 43.8 and 64.8%, respectively. The problem of pain in the lower back affects not only the adult part of the population, they are detected in 7-39% of adolescents.

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

How does pain appear at the bottom of the back?

The pain in the lower back according to its characteristics has practically no difference from other pains, except its localization. Typically, the peculiarity of pain is determined by organs or tissues, the pathology or damage which led to its appearance, neurological disorders, as well as the psychoemotional state of the patient himself.

Clinically, there are three types of back pain:

• local:
• projected;
• reflected.

Local pain occurs at the site of tissue damage (skin, muscles, fascia, tendons and bones). Usually they are characterized as diffuse, and they are of a permanent nature. Most often they include musculoskeletal pain syndromes, among which are:

• muscular-tonic syndrome;
• myofascial pain syndrome;
• arthropathic syndrome:
• syndrome of segmental instability of the spine.

Muscular-tonic syndrome

It arises, as a rule, after a long and isometric muscle strain due to a certain motor stereotype, exposure to cold, pathology of internal organs. Prolonged muscle spasm, in turn, leads to the appearance and intensification of pain, which increases the spastic reaction, which further intensifies the pain, etc., that is, the so-called "vicious circle" starts. Most often, the muscle-tonic syndrome occurs in the muscles that straighten the spine, in the pear-shaped and middle gluteal muscles.

Myofascial pain syndrome

It is characterized by local nonspecific muscle pain, caused by the appearance in the muscle of foci of increased irritability (trigger points), and it is not associated with the damage of the vertebral column itself. Its causes can be, in addition to congenital anomalies of the skeleton and prolonged muscle strain in antiphosphological postures, trauma or direct compression of muscles, their overload and stretching, as well as pathology of internal organs or mental factors. The clinical peculiarity of the syndrome, as already mentioned, is the presence of trigger points corresponding to the zones of local muscular densification - the areas in the muscle, the palpation of which provokes pain in the site remote from the pressure. Activate the trigger points may be "unprepared" movement, a small injury to this area, or other external and internal effects. There is an assumption that the formation of these points is due to secondary hyperalgesia on the background of central sensitization. In the genesis of trigger points, damage to peripheral nerve trunks is also not excluded, since anatomical proximity between these myofascial points and peripheral nerve trunks was noted.

The following criteria are used to diagnose the syndrome.

Great criteria (all five are required):

• complaints of regional pain in the lower back;
• palpable "tight" cord in the muscle;
• site of hypersensitivity within the "tight" strand;
• a characteristic pattern of reflected pain or sensitive disorders (paresthesias);
• limitation of the volume of movements.

Small criteria (one of three is enough):

• reproducibility of pain sensations or sensory disorders during stimulation (palpation) of trigger points;
• local reduction at palpation of the trigger point by them at injection of the muscle of interest;
• reduction of pain with stretching of the muscle, therapeutic blockade, or pricking with a "dry needle".

A classic example of myofascial pain syndrome is the pear-shaped muscle syndrome.

Arthropathy syndrome

The source of pain in this syndrome is facet joints or sacroiliac joints. Usually this pain is of a mechanical nature (it increases with exercise, it decreases at rest, its intensity increases by evening), especially it is strengthened by rotation and extension of the spine, which leads to localized soreness in the area of the affected joint. The pain in the lower back can irradiate into the groin, the coccyx and the outer surface of the thigh. A positive effect is the blockade with a local anesthetic in the projection of the joint. Sometimes (up to about 10% of cases) arthropathic pain in the lower back is inflammatory, especially if there is a spondylitis. In such cases, patients complain, in addition to the "blurred" pain of lumbar localization, to restrict movement and stiffness in the lumbar region, expressed more in the morning.

[10], [11], [12], [13]

Syndrome of segmental instability of the spine

Pain in the lower back with this syndrome occurs due to the displacement of the body of any vertebra relative to the axis of the spine. It arises or intensifies with a prolonged static load on the spine, especially when standing, and often has an emotional color, defined by the patient as "fatigue in the lower back." Often this pain in the lower back is met in persons with hypermobility syndrome and in middle-aged women with signs of moderate obesity. As a rule, with segmental instability of the spine, flexion is not limited, but unbending is difficult, in which patients often resort to the help of hands, "climbing on their own".

Reflex pains are pain in the lower back, which occurs when the internal organs (visceral somatogenic) are damaged (pathology) and localized in the abdominal cavity, small pelvis, and sometimes in the chest. This pain is felt at the bottom of the back in those parts that innervate the same segment of the spinal cord as the affected organ, for example, in the lumbar region with the ulcer of the posterior wall of the stomach, the segregated aneurysm of the abdominal aorta, pancreatitis, etc.

The projected pains are widespread or precisely localized, and according to the mechanism of their origin they are referred to as neuropathic. They arise from damage to nerve structures that conduct impulses into the painful centers of the brain (for example, phantom pains, pain in the innervated compressed first areas of the body). Radicular, or radicular, pain in the lower back - a kind of projected pain, usually have a shooting character. They can be blunt and aching, but movements that increase the irritation of roots, significantly increase the pain: it becomes sharp, cutting. Almost always, the radicular pain in the lower back radiates from the spine to any part of the lower limb, often below the knee joint. The inclination of the trunk forward or the rise of the straight legs, other provoking factors (coughing, sneezing), leading to an increase in the intra-vertebral pressure and displacement of the roots, increase the radicular pain at the lower back.

Among the pains being projected, compression radiculopathies are of particular importance-the pain syndrome in the lumbosacral region with radiating in the leg (a consequence of the compression of the nerve roots of the herniated disc or the narrow spinal canal). Such a pain at the bottom of the back, which is due to the compression of the lumbosacral roots, has a number of characteristics. In addition to the pronounced emotional coloring characteristic of neuropathic pains (burning, piercing, shooting, crawling, crawling, etc.), it is always combined with neurologic symptoms in areas predominantly innervated by the affected spine: sensitivity disorders (hypalgesia), decrease (prolapse) the corresponding reflexes and the development of weakness and "indicator" muscles, at the same time, if the root compression occurs at the level of the corresponding intervertebral foramen, the pain arises not only when walking or movements, but persists at rest, is not amplified when coughing or sneezing and is monotonic.

Sometimes, due to degenerative changes in bone structures and soft tissues of the radicular canals, a narrowing of the spinal canal (lateral stenosis) occurs. The most common causes of this process are hypertrophy of the yellow ligament, arcuate (facet) joints, posterior osteophytes and spondylolisthesis. Since the L5 root most often suffers, this pathology is considered to be a characteristic neurogenic (caudogenic) intermittent claudication with clinical manifestations in the form of pain in one or both legs during a walk localized above or below the knee joint or in the entire lower limb and sometimes sensation weakness or heaviness in the legs. Almost always it is possible to detect a decrease in tendon reflexes and an increase in paresis. Characteristic is a decrease in the pain that arises when the patient tilts forward, and it is diagnostic that the restriction of extension in the lumbar spine is normal, with a normal bending volume.

How is low back pain diagnosed?

Sometimes compression radiculopathy must be differentiated from Bekhterev's disease, which can also manifest pains in the buttock area, spreading over the posterior surfaces of the thighs, and development of limitation of movements in the lower back. As mentioned above, the pain at the lower back is divided into specific and non-specific pain.

Nonspecific pain in the lower back is usually of a local nature, i.e. It can be clearly delimited by the patient himself. In duration, it is usually (up to 90%) acute or subacute. The general well-being of patients can suffer only with a pronounced pain intensity, mainly due to a worsening of the psychoemotional state.

In the overwhelming majority of cases, acute pain and lower back is due to musculoskeletal disorders and is a benign self-limited condition that does not require special laboratory-instrumental diagnostic measures. Typically, these patients have a good prognosis: a full recovery within 6 weeks is noted in more than 90% of cases. However, it should be emphasized that the syndrome of pain in the lower back, as was shown above, causes many causes - both serious, threatening to the health of the patient, and transient, functional, after the disappearance (elimination) of which the person again becomes practically healthy. Therefore, even at the first treatment of the patient, it is necessary to identify the signs that indicate the presence of both a nonvertebrogenic (ie pathogenetically unrelated to the lesion of the spinal column) and a vertebrogenic "serious" pathology that has caused acute back pain. To vertebrogenic "serious" reasons, back pain includes malignant neoplasms (including metastases) of the spine, inflammatory (spondyloarthropathies, including AS) and infectious lesions (osteomyelitis, epidural abscess, tuberculosis), as well as compression fractures of vertebral bodies due to osteoporosis . The causes of non-abortive pain syndromes are internal diseases (gynecological, renal and other retroperitoneal pathology), surrounding herpes, sarcoidosis, vasculitis, etc. Although the frequency of "serious" causes of acute back pain when first seeking medical help is less than 1%, all patients should conduct a survey aimed at identifying possible serious, life-threatening pathology. Currently, this group of diseases include:

• oncological diseases (including in the anamnesis);
• vertebral fractures;
• infection (including tuberculosis);
• abdominal aortic aneurysm;
• horse tail syndrome.

In order to suspect these pathological conditions, a clinical examination should pay attention to the presence of local soreness fever and an increase in the local temperature in the paravertebral area, which are characteristic for infectious lesions of the spine. His risk is increased in patients receiving immunosuppressive therapy, intravenous infusions, who suffer from HIV infection and drug addiction. The presence of a primary or metastatic tumor can be evidenced by causeless weight loss, malignant neoplasm of any localization in the anamnesis, preservation of pain at rest and at night, as well as the age of the patient over 50 years old. Compression fracture of the spine often occurs as a result of injuries, with the use of glucocorticosteroids and in patients older than 50 years. In the presence of a pulsating formation in the abdomen, signs of atherosclerotic vascular lesion, and relentless pain in the lower back at night and at rest, there is a high probability that the patient develops an aneurysm of the abdominal aorta. If the patient complains of weakness in the leg muscles and has a decrease in sensitivity in the anogenital area ("saddle anesthesia") and pelvic disorders, the compression of the structures of the horse tail should be suspected.

Consequence of neoplasms less than 1% (0.2-0.3%) of all acute pain, while about 80% of patients with malignant tumors are over 50 years old. The presence of a tumor in the anamnesis is a highly specific factor of the neoplastic etiology of pain, which must be eliminated in the first place. Other important signs, allowing to suspect the tumor nature of pain in the lower back:

• unexplained weight loss (more than 5 kg in 6 months):
• no improvement within a month of conservative treatment;
• duration of severe pain more than one month.

In patients younger than 50 years with no oncological history and unexplained weight loss, which conservative therapy has helped for 4-6 weeks - cancer can be excluded as a cause of back pain with a probability of 100%.

Fever with acute pain sensations is detected with a frequency of less than 2%. The probability of the infectious nature of the pain syndrome increases, if:

• in a recent history, intravenous manipulation (including drug addiction);
• there are infections of the urinary tract, lungs or skin.

The sensitivity of fever syndrome to infections in the back area is from 27% for tuberculous osteomyelitis to 83% with epidural abscess. It is shown that in bacterial infections the increased sensitivity and tension in the lumbar region with percussion is 86%, although the specificity of this test does not exceed 60%.

Ponytail syndrome is a very rare pathological condition, whose frequency is lower than 4 per 10,000 patients with lower back pain. The most frequent clinical syndromes are:

• violation of urination; presence of weakness in the muscles of the legs;
• decrease in sensitivity in the anogenital region ("saddle anesthesia").

If they are not present, the probability of this syndrome is reduced to less than 1 per 10 000 patients with lower back pain.

Compression vertebral fracture can be suspected in a patient with pain from a recent significant spine trauma, either in a person with established osteoporosis, or in people over the age of 70. It should be noted that most patients with osteoporotic fracture have no back injury in the history.

The most common form of vascular aneurysm is an aneurysm of the abdominal aorta. Its frequency at autopsy is 1-3%, and among men it is met 5 times more often than among women. The syndrome of pain sensations is a sign of an increase in an aneurysm, warning of a close aortic rupture. Pain in the lower back with an aneurysm often occurs at rest, and the pain sensations themselves can spread to the anterior and lateral surfaces of the abdomen; in addition, there you can palpate the pulsating formation.

With increasing muscle weakness in the extremities of the patient, the neurosurgeon should immediately consult, since this symptom may indicate a marked hernia of the disc, in which timely surgical treatment leads to a more favorable outcome.

Signs of a serious pathology, called "signs of threat" ("red flags" in the Anglophone literature) and indicating a possible secondary character of lower back pain are given below.

Anamnestic data:

• malignant tumors, unmotivated weight loss:
• immunosuppression, including long-term use of glucocorticoids;
• intravenous drug addiction;
• urinary tract infection;
• pain that increases or does not subside at rest;
• fever or constitutional symptoms:
• coagulopathy-thrombocytopenia, the use of anticoagulants (the possibility of developing retroperitoneal, epidural hematoma, etc.);
• An elderly patient with a new pain in the lower back;
• metabolic bone disorders (eg, osteoporosis):
• a significant trauma (a fall from a height or a severe bruise in a young patient, a fall from the height of his own growth or a weight increase in an elderly patient with a probable osteoporosis).

Present state:

• age younger than 20 or over 50;
• the presence of pain in the lower back, increasing at night, while lying on the back, not weakening in any position;
• suspicion of the presence of horse tail syndrome or compression of the spinal cord (disorders of urination and defecation, impaired sensitivity in the perineum and movements in the legs);
• another progressive neurological pathology.

Data of physical examination and laboratory studies:

• pulsating formation in the abdominal cavity;
• fever:
• neurological disorders that do not fit into the picture of normal radiculopathy and persist (growing) during the month:
• tension, stiffness of the spine;
• increased ESR, the level of CRP, unexplained anemia.

A picture that does not fit into the notion of benign mechanical pain in the lower back.

Absence of any positive effect from the conventional conservative treatment of the patient for a month.

Considering the above, the algorithm for diagnostic search and management of a patient with pain can be represented as follows.

• Examination of the patient taking into account the clinical signs of the disease and with a special emphasis on the presence of "threat signs".
• In the absence of "signs of threat," the patient is prescribed symptomatic analgesic therapy.
• Identification of "threat signs" requires further laboratory and instrumental examination, consultations of specialists.
• If the additional examination did not reveal signs that threaten the patient's condition, prescribe non-specific anesthetic therapy.
• When detecting a potentially dangerous condition, specific therapeutic, neurological, rheumatological or surgical measures are prescribed.

It should be stressed once again that according to internationally accepted standards, if the patient does not have "threat signs", then there is no need to conduct laboratory and instrumental examinations, including even radiography of the spine.

Indications for consultation of other specialists

If a patient who has pain in the lower back shows "threat signs", it must be further examined depending on the nature of the alleged pathology and observed by specialists.

How to treat pain in the lower back?

Treatment of pain in the lower back can be divided into two categories.

• The first is used in the presence of a potentially dangerous pathology, and it should be carried out only by narrow specialists.
• The second, when there is nonspecific pain in the lower back without "threat signs", can be performed by general practitioners and general practitioners, it should be aimed at the maximum rapid removal of the pain syndrome.

NSAIDs are essential medicines prescribed to reduce the intensity of pain in the lower back. It should be emphasized: there is no evidence that any NSAID is clearly more effective than others; in addition, there is insufficient evidence for the effectiveness of treatment of chronic pain in the lower back with their help.

Another aspect is the use of muscle relaxants. These drugs are classified as auxiliary analgesics (co-analgesics). Their use is justified with painful myofascial syndromes and spasticity of various genesis, especially with acute pain. In addition, with myofascial syndromes, they can reduce the dose of NSAIDs and achieve the desired therapeutic affect and shorter terms. If the pain in the lower back is chronic, the efficacy of the muscle relaxants is not proven. To this group of drugs is primarily the drugs of the central action - tizanidine, tolperisone and baclofen.

It should also be noted that almost all types of physical effects, including electrotherapy, are considered questionable and their clinical effectiveness in reducing the intensity of pain is not proven. The exception is only therapeutic exercise, which really allows to accelerate recovery and prevent relapses in patients with chronic pain in the lower back.

Assign bed rest with acute pain in the lower back is harmful. It is necessary to convince the patient that the maintenance of daily physical activity is not dangerous, and to advise him as soon as possible to start work the only exception is patients with compression radiculopathy who in the acute period need to achieve maximum discharge of the lumbosacral spine, which is easier to obtain by bed rest (for 1-2 days) with concomitant administration, in addition to analgesic therapy, and diuretics with vasoactive drugs to reduce edema and improve microscopy circulation.

Further management

Uncomplicated pain in the lower back is usually a relatively benign pathological process, which can easily be treated with conventional analgesic drugs and which does not require additional laboratory and instrumental examination methods. These patients should be observed by therapists or general practitioners.

ICD-10 code

Pain in the lower back is a symptom, not a diagnosis, which was included in the ICD-10 as the registration category M54.5 "Lower back pain" because of the high prevalence and frequent inability to establish a specific nosological cause of pain.