Back pain treatment: drug therapy strategies

About the painful sensations in the back, 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 offered surgical 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 1,000 industrial workers, 50 are incapacitated annually because of back pain at one time or another. In the UK, due to this pathology, 11.5 million working days are lost every year.

In most cases, back pain itself: from the number of patients who turned to a 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 back pain can also be a manifestation of a serious disease - malignant neoplasm, 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 you take complaints about pain in your 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 back pain includes:

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

Treatment of 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 the differential diagnosis of 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

Differentiated treatment of back pain vertebrogenic character depends on their pathogenetic mechanisms. Complex pathogenetic therapy is aimed at the affected segment, the elimination of muscle-tonic manifestations and myogenic trigger zones, neuromyospirosis foci, 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 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)
Pain response to physical activity	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.

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.

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

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 for "mechanical" back pain

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.

Piogenic infection

To make such a diagnosis is sometimes quite difficult, because there are no usual signs of infection (fever, local palpation 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, as well as 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 with osteomyelitis plus bed rest, wearing a 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. On the radiographs, narrowing of the affected discs and local osteoporosis of the vertebrae are noted, later bone destruction is detected, which subsequently leads to a wedge fracture of the vertebra. With lesions of the thoracic spine on the radiograph, paraspinal (paravertebral) abscesses can be seen, and when the patient is examined, kyphosis is also revealed. In the case of lesion of the lower thoracic or 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.

Drug therapy for back pain should be combined, taking into account the contribution of nociceptive, neuropathic and psychogenic components; in other words, the most important is not only the evaluation of structural changes in the spine, but also the identification of the leading pathophysiological mechanisms of pain. In practical terms, it is advisable to consider strategies for differentiated pharmacotherapy, depending on structural changes, the pathophysiology of pain, the mechanisms and targets of the action of drugs and methods of their use.

The strategy of drug therapy depending on structural changes

• It is necessary to clarify, neuropathic pain is caused by transient compression of the root and its edema, which is manifested by periodic pains, or there is a constant compression of it. With transient compression, it is advisable to prescribe a local anesthetic (plates with lidocaine), opioid analgesic and NSAIDs. In the case of constant compression of the nerve root, lidocaine plates, tricyclic antidepressants and anticonvulsants are most effective.
• With inflammation of the tissues surrounding the intervertebral disc, and in the facet syndrome, NSAIDs are effective. At the same time, with inflammation of the internal parts of the intervertebral disk, NSAIDs are ineffective, since they practically do not penetrate from the blood into these departments (it is worth recalling that there are no blood vessels in the intervertebral disc, as well as in other cartilaginous tissues). In this case, the best choice may be an opioid analgesic that affects the central mechanisms of pain. With fractures of the vertebrae or during recovery processes after surgery, it is undesirable to prescribe NSAIDs, since they inhibit the formation of bone tissue.

The strategy of drug therapy taking into account the pathophysiology of pain

The analysis of pathophysiological mechanisms allows more precise selection of medications.

• If an obvious inflammatory component is present, an NSAID should be recommended. When the phenomena of allodynia, plates with lidocaine, anticonvulsants and antidepressants are shown. The same funds can be prescribed for sympathetic pain.
• With local muscle hypertension, muscle relaxants are effective, with myofascial pain syndrome - local injections of local anesthetics into trigger points.
• With the continued activation of NMDA receptors, mediated GABA inhibition is impaired. Consequently, drugs GABA-ergicheskogo action can potentially be effective for relief of pain. Among anticonvulsants, such agents include topiramate and partly gabapentin. This group can include baclofen, which has a GABA -ergic effect on the spinal level.

The strategy of drug therapy, taking into account the mechanisms of action of drugs

• NSAIDs and opioids are more effective in peripheral lesions, since the former affect the cascade of pro-inflammatory reactions, and the latter can reduce the release of the substance R.
• As already mentioned, in case of involvement of nervous structures in the process outside the immediate lesion zone, anticonvulsants may be useful. Opioids are most active in the region of the posterior horn of the spinal cord, but it should be remembered that the development of tolerance mediated by the activation of NMDA receptors is possible. To prevent the development of tolerance to opioids, tricyclic antidepressants can be used in small doses, which partially block NMDA receptors.
• GABA-receptor agonists can be recommended for increased anxiety and sleep disorders (benzodiazepines, zolpidem). Depression and anxiety are permanent "satellites" of chronic pain, antidepressants can be used to stop them (sertraline, escitalopram, venlafaxine are the best safety profile).

The strategy of drug therapy, taking into account the different methods of drug administration

Most drugs for the treatment of pain are prescribed orally. However, this is often associated with a risk of systemic side effects, including from the side of the central nervous system. In this respect, preparations that are used topically (for example, lidocaine plates) have an advantage. Another promising method is the use of transdermal systems with an opioid analgesic (in particular, with fentanyl), which ensure a slow intake of the drug for a long time. Intramuscular and intravenous administration of drugs is usually recommended to patients in hospital. Sometimes intrathecal pumps are implanted for the continuous infusion of baclofen and / or opioid analgesics in small doses. This avoids undesirable side effects, but the implantation of the pump itself is a surgical procedure and can be accompanied by complications. In conclusion, it should be noted that at present the main principle of drug therapy for back pain is rational polypharmacy. To stop pain with the help of only one drug is not possible in all cases. When prescribing medicines, it is important to strike a balance between their effectiveness and the risk of unwanted effects, and with combined therapy, consider the possibility of their interaction.