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Lumbar pain (etiology, clinical picture, diagnosis and treatment)

The most common causes of lumbar pain are diseases of the spine, mainly degenerative-dystrophic (osteochondrosis, spondylosis deformity) and surge of the posterior muscles.In addition, various diseases of the abdominal and pelvic organs, including tumors, can cause the same symptoms as a herniated disc that compresses the spinal root.

It is no coincidence that such patients turn not only to neurologists, but also to gynecologists, orthopedists, urologists, and most of all, of course, to local or family doctors.

Etiology and pathogenesis of lumbar pain

According to modern ideas, the most common causes of lumbar pain are:

  • pathological changes in the spine, mainly degenerative-disstro;
  • Pathological changes in the muscles, most often myofascial syndrome;
  • pathological changes in the abdominal organs;
  • Nervous system diseases.

The risk factors for lumbar pain are:

  • heavy physical activity;
  • uncomfortable work stand;
  • Injury;
  • cooling, drafts;
  • alcohol abuse;
  • depression and stress;
  • Occupational diseases associated with exposure to high temperatures (more special, in hot shops), radiation energy, sudden temperature fluctuations and vibrations.

Among the vertebrae causes of lumbar pain are:

  • Radical ischemia (discogenic radicular syndrome, discogenic radiculopathy), result from root compression through disc herniation;
  • Reflex muscle syndromes, the cause of which can be degenerative changes in the spine.

Various functional disorders of the lumbar spine can play a role in the appearance of back pain when, due to improper posture, blocks from the intervertebral joints occur and their mobility is disturbed.In the joints above and below the block, compensatory hypermobility develops, leading to muscle spasm.

Signs of sharp compression of the spinal canal

  • numbness of the perineal zone, weakness and numbness of the legs;
  • retention of urination and bowel movements;
  • With compression of the spinal cord, there is a decrease in pain, followed by a feeling of tingling in the pelvic belt and limbs.

Lumbar pain in childhood and adolescence is most often caused by abnormalities in the development of the spine.Spinal bifida (spina bifida) occurs in 20% of adults.After the study, hyperpigmentation, birth scars, multiple scars and skin hyperkeratosis in the lumbar region are revealed.Sometimes urine incontinence, trophic disorders and weakness in the legs are noted.

Lumbar pain can be caused by lumbarization - the transition of the S1 vertebrae in connection with the lumbar spine - and the sacralization - the attachment of the L5 vertebrae to the sacrum.These anomalies are formed due to the individual characteristics of the development of the transverse processes of the vertebrae.

Nosological forms

Almost all patients complain of lower back pain.The disease is mainly manifested by inflammation of low -moving joints (intervertebral, costautebral, lumbosacral joints) and spinal ligaments.Gradually develops the ossification in them, the spine loses elasticity and functional mobility, becomes like a bamboo stick, fragile and easily injured.At the stage of pronounced clinical manifestations of the disease, breast mobility during breathing and as a result of the vital capacity of the lungs significantly decreases, which contributes to the development of a number of pulmonary diseases.

Spinal tumors

There is a distinction between benign and malignant tumors, mainly originating from the spine and metastatic.Benign tumors of the spine (osteochondroma, chondroma, hemangioma) are sometimes clinically asymptomatic.In hemangioma, a fracture of the spine may occur even with minor external influences (pathological fracture).

Malignant tumors, mainly metastatic, originate from the prostate, uterus, breast, lungs, adrenal glands and other organs.The pain in this case is much more common than in benign tumors -usually resistant, painful, enhancing with the less movement, deprivation of patients from rest and sleep.It is characterized by a progressive deterioration of the condition, an increase in general exhaustion and pronounced changes in the blood.X -rays, computed tomography and magnetic resonance imaging are of great importance for diagnosis.

Osteoporosis

The main cause of the disease is to reduce the function of the endocrine glands due to an independent disease or against the background of general aging of the body.Osteoporosis can develop in patients taking hormones, aminosine, antituberculosis drugs and tetracycline for a long time.Radicular disorders accompanying back pain occur due to deformity of the intervertebral foramina, and spinal disorders (myelopathy) occur due to compression of radiculomedular artery or vertebrae fracture, even after minor injuries.

Myofasal syndrome

Myofascial syndrome is the main cause of back pain.This can occur due to review (during strong physical activity), excessive lengthening and bruising of muscles, non -physical posture during work, reaction to emotional stress, shortening of one leg and even flat legs.

Myofascial syndrome is characterized by the presence of so -called "triggering" areas (triggering points), a pressure on which it causes pain, often radiating to the neighboring areas.In addition to myofascial pain syndrome, the cause of the pain may also be inflammatory muscle diseases - myositis.

Lumbar pain is common due to diseases of the internal organs: gastric and twelve ulcers, pancreatitis, cholecystitis, urolithiasis and more.They can be pronounced and imitate the picture of lumbago or discogenic lumbosacral radiculitis.However, there are clear differences, thanks to which it is possible to distinguish the refined pain from that arising from diseases of the peripheral nervous system, which is due to the symptoms of the underlying disease.

Clinical symptoms of lumbar pain

Lumbar pain between the ages of 25 and 44 is most common.There are acute pains that last for 2-3 weeks, and sometimes up to 2 months and chronic pain - over 2 months.

Compression radicular syndromes (discogenic radiculopathy) are characterized by a sudden onset, often after severe lifting, sudden movements or hypothermia.Symptoms depend on the location of the lesion.The onset of the syndrome is based on the root compression of the hernial disc, which occurs as a result of degenerative processes, facilitated by static and dynamic loads, hormonal disorders and injuries (including spinal micro -trauma).Most often, the pathological process involves areas of the spinal roots from Dura Mater to the intervertebral foramers.In addition to disc herniation, bone growth, changes in the scars in the epidural tissue and the flavum of the hypertrophied ligament may participate in root trauma.

The upper lumbar roots (L1, L2, L3) are rarely affected: they represent no more than 3% of all lumbar radicular syndromes.The L4 root is affected twice as often (6%), causing a characteristic clinical picture: mild pain along the inner and anterior surfaces of the thigh, medial surface of the leg, paresthesia (sensation of tingling, burning, crawling) in this area;Mild weakness of the quadriceps muscle.Knee reflexes are preserved and sometimes even increase.The L5 root is most commonly influenced (46%).The pain is localized in the lumbar and gluteal areas, along the outer surface of the thigh, the anterior surface of the lower legs to the foot and the III-V toes.It is often accompanied by a decrease in the sensitivity of the skin of the anterior outer surface of the leg and in the strength in the muscles of the extension of the third to the fifth finger.The patient is difficult to stand on his heel.With long -standing radiculopathy, hypotrophy of the Tibialis the anterior muscle develops.The S1 root is also often influenced (45%).In this case, the pain in the lower back is emitted on the outer rear surface of the thigh, the outer surface of the lower part and the legs.The study often reveals a test of the posterior outer surface of the leg, a decreased strength of the triceps muscles and the flexors of the toes.It is difficult for such patients to stand on their toes.There is a decrease or loss of Achilles reflex.

Vertebral syndrome of lumbar reflex

Can be acute or chronic.Acute lumbar pain (LBP) (Lumbago, "Lumbago") occurs within minutes or hours, often suddenly due to uncomfortable movements.Drilling, firing (as an electric shock) pain is localized in the lower back, sometimes radiating to the iliac region and the buttocks, sharply increases with cough, sneezing and decreases when lying down, especially if the patient is comfortable.Movement in the lumbar spine is limited, lumbar muscles are tense, causing the symptom of Lasegue, often bilateral.Thus, the patient lies on his back with extended legs.The doctor simultaneously bends the affected leg in the knee and hip joint.This does not cause pain, because in this position of the leg the diseased nerve is relaxed.Then the doctor, leaving the legs, bent on the hip joint, begins to straighten it in the knee, thus causing tension to the sciatic nerve, which gives severe pain.Acute lumbodinia usually lasts 5-6 days, sometimes less.The first attack ends faster than the next ones.Repeated Lumbago attacks tend to develop in chronic LBP.

Atypical pain in the lower back

There are a number of clinical symptoms that are atypical of back pain caused by degenerative changes in the spine or myofascial syndrome.These signs include:

  • the onset of childhood and adolescence pain;
  • Back injury shortly before the onset of lower back pain;
  • Back pain, accompanied by fever or signs of intoxication;
  • spine;
  • rectum, vagina, both legs, pain in the onset;
  • Board of pain in the lower back with eating, bowel movements, sexual contact, urination;
  • nnecological pathology (amenorrhea, dysmenorrhea, vaginal discharge) that appeared against the background of lower back pain;
  • increased lower back pain in a horizontal position and decreases in the vertical position (a symptom of a ruin, characteristic of a tumor process in the spine);
  • constant increase in pain for one to two weeks;
  • limbs and the appearance of pathological reflexes.

Research methods

  • External examination and palpation of the lumbar region, identification of scoliosis, muscle tension, pain and trigger points;
  • Determination of the range of movement in the lumbar spine, areas of muscle loss;
  • study of neurological status;Determination of tension symptoms (Laceig, Vasserman, Neri).[Study of the symptom of Wasserman: Bending the leg in the knee joint in a patient in a tendency causes pain in the thigh.Study of the symptom of Neri: the rare bending of the head to the chest of the patient lying on his back with straight legs causes acute pain in the lower back and along the sciatic nerve.];
  • Study of sensitivity, reflex sphere, muscle tone, vegetative disorders (swelling, changes in color, temperature and humidity of the skin);
  • Radiography, computer or magnetic resonance imaging of the spine.

MRI is particularly informative

  • Ultrasound examination of the pelvic organs;
  • gynecological examination;
  • If necessary, additional studies are performed: cerebrospinal fluid, blood and urine, sigmoidoscopy, colonoscopy, gastroscopy and more.
MRI image of hernia disk in the spine

Treatment

Acute pain in the lower back or exacerbation of vertebrae or myofascial syndromes

Non -defined treatment.Gentle engine mode.In the case of severe pain during the first days, rest on the bed and then walking on crutches to unload your spine.The bed should be difficult and a wooden board should be placed under the mattress.For heat, a wool scarf, an electric pad for heating and bags of heated sand or salt are recommended.The iron has a beneficial effect: Finalgon, Tiger, Capsin, Diclofenac, etc., as well as mustard plasters and pepper plaster.Ultraviolet irradiation at eral doses, leeches (taking into account the possible contraindications) and the irrigation of the painful area with ethylchloride are recommended.

Electrical procedures have an analgesic effect: transcutaneous electro -aalgesia, sinusoidal modulated currents, diadynamic currents, electrophoresis with novocaine, etc.The use of reflexology (acupuncture, laser therapy, cauterization) is effective;Novocaine blocks, pressure massage of trigger points.

Drug therapy includes analgesics, NSAIDs;tranquilizers and/or antidepressants;Medicines that reduce muscle tension (muscle relaxants).In the case of arterial hypotension, tizanidine should be prescribed with great caution due to its hypotensive effect.If swelling of the roots of the spine is suspected, diuretics are prescribed.

The main analgesic drugs are NSAIDs, which are often used uncontrollably by patients when pain is exacerbated or repeated.It should be noted that long -term use of NSAIDs and analgesics increases the risk of complications of this type of therapy.There is currently a large selection of NSAIDs.For patients suffering from spinal pain due to the presence, effectiveness and lower likelihood of side effects (gastrointestinal bleeding, dyspepsia), the preferred "non-selective" drugs are diclofenac 100-150 mg/day.Oral, intramuscularly, rectal, topical, ibuprofen and ketoprofen oral 200 mg and locally, and among the "selective" - meloxicam orally 7.5-15 mg/day, nimesulide oral 200 mg/day.

Side effects can occur in the treatment of NSAIDs: nausea, vomiting, loss of appetite, pain in the epigastric region.Possible ulcerogenic effect.In some cases, ulcer and bleeding in the gastrointestinal tract may occur.In addition, headache, dizziness, drowsiness and allergic reactions (skin rash, etc.) are noted.Treatment is contraindicated for ulcerative processes in the gastrointestinal tract, pregnancy and lactation.In order to prevent and reduce dyspeptic symptoms, it is recommended to take NSAIDs during or after a meal and drink milk.In addition, the administration of NSAIDs, when the pain is increased with other medicines that the patient is taken to treat comorbidities, as observed in the long -term treatment of many chronic diseases, to reduce the adherence to treatment and, as a result, insufficient effectiveness of therapy.

Therefore, modern methods of conservative treatment include the mandatory use of drugs that have chondroprotective, chondrostimulatory effects and have a better therapeutic effect from NSAIDs.The drug Teraflex-Advance fully meets these requirements, which is an alternative to NSAIDs for mild to moderate pain.One capsule of the medicinal terafflex-Advance contains 250 mg of glucosamine sulfate, 200 mg chondroitin sulfate and 100 mg ibuprofen.Chondroitin sulfate and glucosamine participate in the biosynthesis of connective tissue, help prevent the processes of cartilage destruction and stimulate tissue regeneration.Ibuprofen has analgesic, anti -inflammatory and antipyretic effects.The mechanism of action occurs due to the selective blockage of cyclooxygenase (COX types 1 and 2), the main enzyme in the metabolism of arachidonic acid, which leads to a decrease in prostaglandin synthesis.The presence of NSAIDs in the drug Theraflex-Advance helps to increase the range of movement in the joints and reduce the morning stiffness of the joints and spine.It should be noted that according to R.J.Tallarida et al., The presence of glucosamine and ibuprofen in Theraflex-Advance provides synergism in terms of the analgesic effect of the latter.In addition, the analgesic effect of the combination of glucosamine/ibuprofen is provided from 2.4 times a lower dose of ibuprofen.

After relieving the pain, it is rational to switch to terafflex, which contains the active ingredients, chondroitin and glucosamine.Teraflex is taken 1 capsule 3 times a day.During the first three weeks and 1 capsule 2 times a day.In the next three weeks.

The greater part of the patients taking terafflex experience positive dynamics in the form of pain relief and reducing neurological symptoms.The drug is well tolerated by patients, no allergic manifestations are noticed.The use of terafflex for degenerative diseases of the spine is rational, especially in young patients, both in combination with NSAIDs and as monotherapy.In combination with NSAIDs, the analgesic effect occurs 2 times faster and the need for therapeutic doses of NSAIDs gradually decreases.

In clinical practice, for lesions of the peripheral nervous system, including those associated with spinal osteochondrosis, B vitamins are used, which have a neurotropic effect, are widely used.The method of alternative administration of vitamins B1, B6 and B12, 1-2 ml each is traditionally used.Intramuscularly with daily alternation.The course of treatment is 2-4 weeks.The disadvantages of this method include the use of small doses of medicines that reduce the effectiveness of treatment and the need for frequent injections.

For discogenic radiculopathy, adhesion therapy is used: adhesion (including under water) at a neurological hospital.For myofascial syndrome, after topical treatment (blockade of novocaine, ethyl chloride irrigation, anesthetic ointments), a hot muscle compress is applied for a few minutes.

Chronic lumbar pain from vertebrogen or myogenic origin

In case of disc herniation, it is recommended:

  • Wearing a solid corset as a "weight lifting belt";
  • avoiding sudden movements and bending, limiting physical activity;
  • Physical therapy to create muscle corset and restoration of muscle mobility;
  • massage;
  • Novocaine blockades;
  • reflexology;
  • Physiotherapy: ultrasound, laser therapy, therapy;
  • intramuscular vitamin therapy (B1, B6, B12), multivitamins with mineral supplements;
  • Carbamazepine is prescribed for paroxysmal pain.

Without medicine

Despite the presence of effective remedies for conservative treatment, the presence of dozens of techniques, some patients need surgical treatment.

Surgical treatment indications are divided into relative and absolutely.The absolute indication of surgical treatment is the development of caudal syndrome, the presence of sequent hernia intervertebral discs, radicular pain syndrome that does not decrease despite treatment.The development of radiculomyeloesemia also requires emergency surgery, but after the first 12-24 hours, the indications for surgery in such cases become relative, first, due to the formation of irreversible changes in the roots, and second, since in most cases during treatment and rehabilitation measures, the process regresses the process within approximately 6 months.The same periods of regression are observed in delayed surgery.

Relative indications include failure of conservative treatment and recurrent sciatica.Conservative therapy should not exceed 3 months of duration.And they last for at least 6 weeks.It is estimated that the surgical approach in cases of acute radicular syndrome and failure of conservative treatment is justified within the first 3 months.After the onset of pain to prevent chronic pathological changes in the root.A relative indication is cases of extremely severe pain syndrome when the pain component is replaced by an increase in neurological deficiency.

Among physiotherapy procedures, electrophoresis with the proteolytic enzyme caripazim is currently widely used.

It is known that therapeutic physical training and massage are an integral part of the complex treatment of patients with spinal lesions.Therapeutic gymnastics pursues the goals of overall strengthening of the body, increases efficiency, improves movement coordination and increase in fitness.In this case, special exercises are aimed at restoring certain motor functions.