Causes of back pain

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

The main causes of back pain:

1. Degenerative and structural - osteochondrosis, spondylosis, spondyloarthrosis, injuries and hernias of the intervertebral discs, congenital or acquired as a result of pathological fracture, spondylolisthesis (spinal vertebra displacement relative to the adjacent vertebra), spondylolysis (intervertebral artery vertebrae defect in the form of a single or bilateral cleft), osteochondropathy of the spine (Sheyerman-Mau disease), compression fractures of the vertebrae, spinal stenosis, trauma (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 with ulcerative colitis, Crohn's disease.
4. Infectious - osteomyelitis of the spine and pelvic bones, spinal tuberculosis, syphilis, paraspinal abscess, abscess of the epithelial coccygeal path, discitis, epidural abscess, paravertebral infections.
5. Tumors are metastases in the spine (prostate, breast, lung, thyroid, kidney, adrenal, melanoma), myeloma, blood system tumors (lymphoma, leukemia), rare tumors (osteosarcoma, osteoid osteoma, aneurysmal bone cyst, hemangioma and others), primary bone neoplasia, humoral affects of bone tumors.
6. Other - hip joint lesion (osteoarthritis, rheumatoid arthritis, aseptic necrosis, tuberculosis, osteomyelitis), cocciogeny.
7. Defeat of the spinal cord - arachnoiditis (after myelitis or postoperative period), epiduritis, tumor, tuberculosis, abscess.
8. Pathology of soft tissues - overexertion of the lumbosacral section, muscle and ligament damage, myofascial syndrome, tendinitis, fibromyalgia, rheumatic polymyalgia, sciatic bursitis.
9. Diseases of the internal organs and vessels - exfoliating aneurysm of the abdominal aorta, kidney and urinary tract diseases (stones, infection, tumor), pancreatitis, peptic ulcer, biliary tract diseases, spleen, retroperitoneal bleeding, retroperitoneal tumor, pelvic abscess, endometriosis, inflammatory and tumor diseases of female genital organs, prostatitis, prostate cancer.
10. Others (shingles, depression, pregnancy, simulation).

[1], [2]

Vertebrogenic causes of back pain

The most common causes of back pain are vertebrogenic pain. They occur in a variety of diseases, and therefore the key to their successful treatment is accurate diagnosis. Under vertebrogenic pain (dorsopathy) is understood pain syndromes in the field of the trunk and extremities of non-vascular etiology associated with diseases of the spine.

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

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

Due to these changes in the spine, dystrophic spondylolisthesis and secondary lumbar stenosis can develop. In the origin of the vertebrogenic pain syndrome, functional interlocking of the intervertebral joints with a secondary musculo-tonic reflex syndrome is also of great importance.

Osteochondrosis

Osteochondrosis is the most common cause of acute back pain. Causes of pain - degenerative damage to intervertebral discs, which subsequently leads to a change in the intervertebral joints and ligaments. When lesions of the lumbar intervertebral discs, the pulpous (pulp) core of the disc through the cracks in the fibrous ring protrudes 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 pelvic nucleus of the disc may protrude into the side of the vertebral canal, which leads to the appearance of lumbar pains, however, compression of the nerve roots usually does not occur. Nevertheless, in this case there is a certain risk of the syndrome of compression of the elements of the horse tail, which is characterized by blunt pain in the upper sacral areas and parasthesia in the buttocks, genitals or thigh area with simultaneous disruption of the bowel and bladder functions.

Recent studies have shown that radicular lumbar pain due to a herniated intervertebral disc in most patients completely disappear or significantly weaken within 6-18 months. Pain in osteochondrosis occurs or worsens after physical exertion (weight lifting or awkward turn), weaken at rest (lying down), spreads over the back surface of the foot, accompanied by restriction of movements. In a history of such patients, as a rule, similar attacks have already been observed.

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

Spondylarthrosis

Spondyloarthrosis often develops in patients over the age of 50 and may accompany osteochondrosis. Major changes develop in the intervertebral joints, which leads to a pronounced restriction of movements. Pain in the lumbar spine is localized in a paravertebrancho, usually dull, aching, provoked and intensified with a physical or prolonged static load (sitting, standing), weakens in a lying, sitting position. X-ray signs of spondyloarthrosis include:

1. Subchondral sclerosis of articular surfaces;
2. Narrowing of the articular fissure until its complete disappearance;
3. Bony growths in the joint zone, deformation of the articular processes.

In foreign studies, radiologic parameters in spondyloarthrosis are often evaluated according to the Kellgren classification, according to which 4 gradations are distinguished - from 1 (absence of osteophytes) to 4 (large osteophytes, sclerosis of the endplates, decrease in the height of intervertebral discs until extinction).

In the treatment of pain relief, special exercises, hydrotherapy, manual therapy are prescribed.

Spinal stenosis

This narrowing of the spinal canal, which leads to ischemia of the nerve roots and promotes the development of neurogenic lameness. Osteoarthropathy of the arcuate (intervertebral) joints and intervertebral discs leads to narrowing of the spinal canal. Excessive workload on functionally inferior intervertebral discs can promote the formation of large osteophytes. Intervertebral joints are hypertrophied, a growing osteophyte deforms them, and the yellow ligament thickens. As a result of these changes, the spinal canal and vertebral apertures narrow. Patients complain of permanent pain in the lumbar region, which sometimes assumes a drilling character and radiates downward into the leg (false lameness). The pain increases in standing and walking.

Spondylolisthesis

This is the displacement of the vertebra anterior to the underlying vertebra (usually the vertebra L5 is shifted anterior to the vertebra S1). The degree of displacement is different. Patients complain of pain that is localized in the lumbar region, on the back of the thigh and lower down the lower limb. Physical activity increases pain. Spondylolisthesis is a very common cause of back pain in patients under the age of 26 and can be easily diagnosed with conventional radiography. Spondylolysis is one of the forms of spondylolisthesis, in which there is a defect in the interarticular portion of the vertebral artery without displacement of the vertebrae anteriorly. It is believed that this defect is caused by a violation of the processes of osteosynthesis and can be detected in young athletes.

At the same time, there are other causes of back pain, which the doctor should remember in order to avoid medical errors. These include: non-infectious inflammatory diseases (ankylosing spondylitis, Reiter's syndrome, rheumatoid arthritis), metabolic bone lesions (osteoporosis, osteomalacia), degenerative dystrophy (intervertebral) joints, pathology of the sacroiliac joint, neoplasm of the spine and spinal cord, infectious lesions of the vertebrae and intervertebral discs (tuberculosis, brucellosis, epidural abscess), growth diseases (scoliosis), spine and soft tissue injuries, pear-shaped muscle syndrome, diseases in the womb Other organs, accompanied by reflected pain, herpes zoster, etc.

Spondyloarthropathies

Spondyloarthropathy refers to a group of diseases that is characterized by damage to the sacroiliac articulations 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. More often young men are ill. Pain localized, bilateral, occurs at rest (worse at night and early morning) and decreases with movement. In the morning, joint stiffness is noted, which does not last long.

Malignant neoplasms

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

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

Metastases in the spine are most often observed in lung, milk and prostate cancer. When primary tumors of the spine, the symptoms appear when the tumor squeezes or sprouts into the spinal roots. In addition to severe pain, there is a change in sensitivity, motor disorders, which are steadily progressing.

Pain relief in patients with malignant neoplasms often requires the appointment of narcotic analgesics. However, in the initial stage of the disease, the use of non-narcotic analgesics is possible to relieve the pain syndrome of mild and moderate severity.

Infections

Osteomyelitis and spinal tuberculosis, although related to rare diseases, nevertheless, one should not forget that they can cause constant back pain that does not change during the day. There are also common signs of the disease: fever and intoxication. Patients require treatment in specialized hospitals.

Violation of posture

The cause of back pain may be a violation of posture. It should be noted that scoliosis is always a pathology. The signs confirming the presence of scoliosis include: visible deformation of the spinous processes of the vertebrae; asymmetry of the shoulders, shoulder blades and folds of Natalia, which do not disappear in the sitting position; asymmetry of the paraspinal muscles; excessive chest kyphosis and deformities in the sagittal plane. Lordosis almost always has a secondary character and is caused either by the inclination of the pelvis forward, or by changes in the hip joints.

Spinal curvatures can be interpreted as functional or anatomical. Functional are found in muscle spasms or short legs in a child. Anatomical same distortions are signs of congenital or acquired pathology.

Spinal cord injury occurs in Prader-Willi syndrome, Sheyermann-Mau disease (juvenile kyphosis), rachitis (non-fixed kyphosis due to the weakness of the ligamentous muscle), tuberculosis spondylitis, spine trauma.

Non-vertebral 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 regardless of them. Myofascial pain syndrome is characterized by chronic pain sensations that occur in different trigger points of the muscular and fascial tissue. Thus patients complain of sharp pains along local zones of morbidity which often irradiate. This pathology is sometimes confused with radiculopathy (root pains). Trigger point sites are most often localized in the upper parts of the trapezius muscle, on the surface of the extensor muscles of the back, in the muscle tissue of the lower sections of the paravertebral muscles and in the gluteal muscles. The determination of the cause of back pain is based on the results of the clinical examination, the data of radiation diagnosis and other paraclinical methods of investigation.

Fibromyalgia

Fibromyalgia most likely should be considered as a separate nosological form with a primary lesion of muscles. Literary data indicate that fibromyalgia can be congenital, more common in women and can develop against a background of physical or emotional trauma. In patients with fibromyalgia, patients complain of diffuse pain, painful zones are determined palpation, and this symptomatology lasts at least 3 months. A variety of psychological disorders can occur in twenty-five percent of patients with fibromyalgia.

[3], [4], [5], [6], [7]

Damage to muscles and ligaments

After minor injuries that occurred during physical work, sports, there is a constant superficial spilled back pain, which is greatly facilitated by local application of painkillers - NSAIDs (gel) or their systemic intake. In addition to the pronounced analgesic effect, these drugs have anti-inflammatory effect, which shortens the rehabilitation time.

[8], [9]

Cardiovascular diseases

The rupture of the aneurysm of the abdominal aorta or hemorrhage into the retroperitoneal tissue is manifested by severe back pain, collapse, paresis, and sensitivity disorders. In anamnesis, patients with hemorrhage have indications of taking anticoagulants. Spilled blood squeezes spinal nerves. Both situations require emergency hospitalization.

[10], [11], [12], [13], [14], [15], [16], [17],

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, fever above 38 ° C. Treatment is carried out by antibiotics and uroseptics.

Back pain can be a leading symptom of algodismenosis and endometriosis. Thus 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. Pain relief is used to relieve pain (NSAIDs, non-narcotic analgesics).

Back pain is differentiated with abdominal aortic aneurysm, ectopic pregnancy, pancreatitis, perforated ulcer of the stomach and duodenum, pyelonephritis and urolithiasis, pelvic tumor (eg, sciatica), inflammatory diseases of the appendages in women.

[18], [19], [20], [21], [22], [23], [24]

"Mechanical" back pain

The vertebral column consists of a number of complex joints between the vertebrae; spongy disks between their bodies, which serve to absorb shock, as well as from a variety of facet joints. Violation of the function in any part of the spine can affect its function as a whole, and spasm of the vertebral muscles only intensifies the pain. Since most of the time a person is in an upright position, considerable forces act on the spine, especially during the rise; In this case, ruptures of the discs (their fibrous rings) in relatively young people and even vertebral fractures can occur in the elderly.

Disc prolapse

Most often, rupture occurs in the lumbar region, especially the last two disks. In typical cases, a few days after a great strain of the back muscles, a sudden pain occurs in the person (in the lower back) when coughing, sneezing or abrupt turning (the onset of the disease can be more gradual). Pain can be localized in the lower lumbago (lumbago), and can irradiate into the buttocks and down the leg (legs) - then talk about sciatica, while the prolapsed nucleus of the disk squeezes the nerve root.

Symptoms: restriction of flexion of the trunk forward, sometimes also restriction of extension; lateral flexion is broken to a lesser degree, but if it is violated, it is one-sided. With prolapse of the L5 / S1 disc, root pain arises along the S path, with characteristic pain in the gastrocnemius muscle, weakening of plantar flexion, a decrease in sensitivity (when the needle is pricked) on the plantar side of the foot and the posterior surface of the tibia, as well as the decrease in the Achilles reflex. With the prolapse of the L4 / L5 disc, the extension of the thumb is broken, as well as the sensitivity on the external surface of the foot decreases. If the lower lumbar discs prolapse in the central direction, the pony tail may be squeezed.

In most cases, the patient shows rest, it is recommended to lie on a hard surface, painkillers are effective. Myelography and magnetic nuclear tomography can confirm the diagnosis, but they are used when decompression with a laminectomy is planned (for example, for the decompression of the horse's tail) or when conservative treatment is ineffective and the symptoms of the disease are pronounced.

[25]

Stenosis of lumbar vertebral-lateral recess

Osteoarthritis of the facet joints (the only synovial joints in the back region) can cause a generalized narrowing of the lumbar spinal canal or only its lateral recesses (protrusions). In contrast to the symptomatology of disc prolaps in the lumbar spine, the signs of this constriction are as follows.

• Pain increases with walking, with pain and heaviness in one or both legs, which causes the patient to stop ("vertebral intermittent claudication"),
• Pain occurs when the spine is unbent.
• Negative symptom of Lasega.
• A few symptoms of CNS damage.

Confirmation of the diagnosis. Computer (CT) myelography and magnetic nuclear tomography can visualize the spinal canal.

Treatment. Decompression of the spinal canal (remove its posterior wall) gives good results if NSAIDs are ineffective, the introduction of steroids into the epidural space and the wearing of the corset (to prevent the lumbar lordosis in standing position).

Reflex muscular-tonic and myofascial pain syndromes

Most often in clinical practice, there are reflex muscular-tonic and myofascial syndromes, which tend to develop within the framework of nonspecific back pain, but can also be present with radiculopathy and diseases of the internal organs. In the development of this type of pain, the local muscle hypertonus plays a leading role, which is formed under the influence of a prolonged static load (incorrect motor stereotype, uncomfortable posture, deformities of the spine, reflex muscle tension in visceral pathology, etc.). Pathognomonic sign of myofascial pain syndrome - the presence of trigger points. Diagnostic criteria for myofascial pain syndrome are as follows.

1. The main criteria (all five are required).
   • Complaints of local pain.
   • The presence of a "tight" strand in the muscle during palpation.
   • The presence of an area of hypersensitivity within the "tight" strand.
   • A characteristic pattern of reflected pain or sensitive disorders.
   • Limitation of the volume of movements.
2. Additional criteria (one of three is required).
   • Reproducibility of pain or sensory disturbances during stimulation of trigger points.
   • Local shudder when palpating the trigger point of the muscle concerned or when injected into a trigger point (a "jump" symptom).
   • Reduction of pain when stretched or when injected into the muscle.

Compression radiculopathy

Radiculopathy is most often associated with compression or stretching of the roots of the spinal nerves due to the impact of a herniated intervertebral disc or osteophytes. Pains are usually superficial, localized in the innervation zone of the affected root. Sneezing, coughing, loading on the spine usually intensifies the pain. The most commonly affected lumbosacral roots (75%, and in most cases - L5 and / or S1, rarely - cervical, extremely rare - pectoral.

Representations of the mechanisms of pain in the lesion of the nerve root in recent years have changed significantly. At present, there is no doubt that the severity of the pain syndrome does not correlate with the size of the herniation of the intervertebral disc. In many cases, a patient with intense pain during MRI shows very small changes, no less often observe the reverse situation, that is, the absence or minimal severity of symptoms with a large herniated intervertebral disc.

There are several mechanisms of pain in herniated intervertebral disc with radiculopathy. In addition to the immediate mechanical compression of the spine with the appearance of foci of ectopic pathological activity and excessive expression of the potential-dependent sodium channels, pain can be associated with the irritation of the 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 acting on nerve endings in tissues, also participate in the generation of pain sensations.

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

Recently, the hypothesis of early structural changes in chronic pain syndromes has become widespread. It is shown that intense nociceptive impulses entering the spinal cord lead to the death of spinal inhibitory intercalary neurons, normally in a constant tonic activity and suppressing 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 a pain sensation even in the absence of pain stimuli.

Particularly should be emphasized the important role of genetic, culturological, psychogenic and social factors in the development and chronic pain syndrome, described in detail in the specialized literature. All these mechanisms make it possible to explain the discrepancy between the intensity of pain and the severity of structural changes in the spine with chronic back pain.

[26]

Faceted syndrome

One of the causes of back pain is the pathology of the arcuate (facet) joints, the synovial capsule of which is richly innervated. The frequency of facet joint pathology in patients with pain and in the lumbosacral region is 15-40%. Pain caused by abnormal arthropathy pathology usually has a local (paravertebral) nature, but can irradiate into the inguinal region, along the back and outer surface of the thigh, into the coccyx region. Pain in the lumbar region is strengthened by extention and rotation. Diagnostic value has the positive effect of blockade with local anesthetics in the area of the affected arcuate joint.

[27], [28]

Dysfunction of sacroiliac joints

Dysfunction of the sacroiliac articulations is found in 53% of patients with back pain, and in 30% of cases - the causes of back pain in patients with MRI of herniated intervertebral discs. Pain from the sacroiliac joint can be irradiated in the groin, into the zone of the dermatome S1. The intensity of pain, as a rule, decreases after walking. Pains are usually more intense in the morning and decrease by the evening. Diagnostic value has the positive effect of blockade with local anesthetics in the area of the sacroiliac joint.

[29], [30], [31]