Back pain: causes, treatment
- To what doctor to address?
- Causes of low back pain
- Questioning and examination at the doctor's office
- Attributes to which attention should be paid
- Treatment of back pain
- Keep activity and mobility
Pain in the lumbar spine and adjacent areas can bother the patient at any time of the day, standing, sitting, lying down or on the go, with physical activity or at rest. This symptom is so nonspecific, that is, it can occur in such a huge number of cases, which requires special attention first of all from the patient: it is necessary to immediately consult a doctor.
To what doctor to address?
According to statistics, up to 25% of patients seek medical help precisely in connection with the occurrence of pain in the lumbar region. 8 out of 10 inhabitants of the Earth experienced pain in the back, at least 1 time in life. And most often suffer from these symptoms are people of working age, a little less often - people of retirement age and even less often - adolescents (according to different sources, from 8 to 40% in Russia).
Therapist, neurologist, traumatologist, rheumatologist
The first doctors, to which the majority of patients with pain in the lower back will turn, will be a therapist and a neurologist. But young people with trauma in the recent (or long-standing) past often turn to a traumatologist.
Both the diagnostic and therapeutic tactics of these specialists differ. Often the therapist directs the patient to a neurologist, the neurologist determines his "own" diagnosis and prescribes treatment. Traumatologist often works "individually", but in addition to using non-steroidal anti-inflammatory drugs, he uses methods of manual therapy and physiotherapy. The main thing for the patient is not to get confused in this situation, not to get carried away by promises of instant healing when performing manual procedures, not to resort to them again in case of failure or, worse, intensified against such treatment of pain.
When treating conservatively, that is, with drugs, it should be understood that the failure of treatment for four weeks is a weighty argument for revising the diagnosis, referring to a rheumatologist, and not for conducting repeated courses of therapy. There are often situations when a patient with complaints of pain in the lower back receives a symptomatic (that is, just anesthetic) treatment for a certain pattern, without specifying the true cause of this pain.
Causes of low back pain
The main causes of pain in the lumbar region are
- changes in the structure of the spine, usually age (they are degenerative), osteochondrosis of the spine (aka spondylosis), a variety of herniated intervertebral discs or inadequate work of the musculoskeletal complex. Such pains are called primary, that is, directly related to the spine;
- pathological changes in organs located near the painful area, but directly to the spine not related (for example, diseases of internal organs, skin). To the same category of causes include inflammation of the joints, trauma, endocrine disorders (for example, diabetes), in short, anything that does not fit into the picture of "natural age-related changes" in the spine. Such pain is called secondary.
Questioning and examination at the doctor's office
Pain, a feeling of stiffness or an increased painful muscle tension in the area between the lower ribs and buttocks is usually called the term "lumbalgia". If the pain symptoms in the leg are added to these symptoms, this condition is commonly called lumboschialgia.
First of all, the severity of pain, that is, the prescription of its occurrence, is important. The pain up to 12 weeks (3 months) is called acute, more than 12 weeks - chronic. Chronic pain syndrome can occur with exacerbations and periods of improvement.
Of fundamental importance is how pain is felt. This is either feeling at a certain point, or spreading ("projection", "irradiation") pain along the nerve to the thigh, buttock, knee joint, foot, or fuzzy, "dull" pain. It is necessary to understand, the movements in the spine are limited in the moments of the onset of pain, or the movements are unobstructed (this may indicate the mechanical nature of the lesion, for example, in vertebral fracture). In what moments does pain appear? Does it arise during exercise, or at rest, during a night's sleep? The affirmative answer to the last question in general is a "red flag" for the rheumatologist and makes you think about the diagnosis of the inflammatory disease of the spine in the patient (we'll stop on them a little later). If the pain increases with the movement of the head, walking, jumping, it is likely to be about the so-called projection pain, the cause of which is damage to the nerve structures (most often - sciatica).
Osteochondrosis of the spine, or spondylosis is a condition in which compaction and deformation of the vertebrae are observed, with the appearance of small bony outgrowths similar to spines, along the vertebrae margins. For a long time, spondylosis was considered to be the result of the natural course of degenerative processes, the aging of the body. However, it is conclusively proven that not only age can cause osteochondrosis. Motionless lifestyle, increased load on the lumbar spine for prolonged work at the computer or with long-term driving (for example, the profession of a truck driver) contribute to the occurrence of osteochondrosis, even in young people. Under the influence of all these factors, the intervertebral disc-buffers flatten, and the nerve roots branching off from the spinal cord are squeezed and then injured by the growing marginal bone spines. The constant irritation and compression of these roots causes pain. In Latin, the root is called radix, so this inflammation is usually called radiculitis.
The so-called inflammatory diseases of the spine are an area of interest for rheumatologists. These mysterious diseases can "smolder" for several years, beginning mainly at a young age and affecting mainly men, and resulting in the immobility and disability of the patient. Patients of this group usually "endure to the last" and night pains, and morning stiffness in the back, and weakness, and an increasing decline in efficiency. Unfortunately, the appearance of the first symptoms of the disease before the diagnosis is made on average takes about seven years. During this time, changes in the spine can become irreversible, and functional (motor) activity - low. The spine becomes immovable, changes shape, a hump appears. There is this pathology is not as common as osteochondrosis, for example, but the cost of treatment and the total time of incapacity for such patients is incommensurably higher.
If, in addition to back pain, the patient when talking about the inflammation of the joints (more often the knee joints, the joints of the hands or feet), pain in the buttocks, unstable stool with unusual impurities, visual impairment or pain in the eyes, this is also an urgent reason to refer it to rheumatologist for a specific additional examination and exclusion of a disease from the spondyloarthritis group (eg, seronegative spondylitis or Crohn's disease).
There are diseases manifested by pain in the lower back and completely unaffected vertebral or nerve structures. One of these diseases is myofascial pain syndrome. Patients (mostly young patients) indicate a prolonged exposure to an uncomfortable posture or physical overload, which preceded the development of pain. During medical examination, attention is drawn to sharp soreness when pressing on certain points located near the spine. This condition significantly reduces the patient's quality of life, but minor changes in muscle tissue (local overstrain) are not dangerous for nerve roots or for internal organs. Usually, the therapeutic effect can be achieved with the appointment of muscle relaxants (midol), low doses of nonsteroidal anti-inflammatory drugs (meloxicam, diclofenac), local injection (injection) in the "pain point" of a steroidal anti-inflammatory drug (diprospan).
It is considered that if a patient with complaints of pain in the lower back does not have "disturbing signs" (they are described below), he does not need additional examination, and the therapist can be treated without a test or even radiography. But, as practice shows, practically in any patient such "signs" can be found, which means that there is a need to donate blood at least to a general (and better, also immunological) analysis, and perform a radiography of the lumbar spine in two projections ideally - with the "capture" of the pelvic bones).
могут выявить повышение скорости оседания эритроцитов (СОЭ), что свидетельствует о воспалении, возможно иммунного происхождения, или инфекции. - Blood tests can reveal an increase in the rate of erythrocyte sedimentation (ESR), indicating inflammation, possibly of an immune origin, or infection. An increase in the level of leukocytes also indicates infection or inflammation, and severe anemia - about the possible presence of a tumor process.
сдается при подозрении на болезнь почек. - The analysis of urine surrenders at suspicion on illness of kidneys. Pain in the lumbar region in this case is aching, often "spreading" upward, to the lower ribs. If there are changes in the analysis of urine, ultrasound of the kidneys is performed, and further tactics are discussed in detail with the therapist or urologist.
– наиболее дешевое из инструментальных обследований, это метод выбора при диагностическом поиске в данном случае. - Radiography is the cheapest of instrumental examinations, this is the method of choice for diagnostic search in this case. On the roentgenogram, one can see a violation of the spinal structures, signs of inflammation of the vertebral joints, and indirectly determine the site of compression of the nerves. The "transparency" of the vertebrae on the roentgenogram will lead to the idea of osteoporosis (fragility) of the skeleton. As is known, against the background of osteoporosis, the most common complication is vertebral fracture followed by compression of adjacent nerves. If the fracture, alas, took place, it will also be seen on the roentgenogram. The possibilities of this method of research are enormous, but if pathology is found, it is necessary to clarify how seriously the damage is, whether the patient does not need an operative intervention on the spine. This requires a more accurate study - layered (tomography). There are two types of tomography - computer X-ray and magnetic resonance.
. - Computer tomography (CT) . A survey method that allows you to literally look inside the spine. All bone structures that have escaped the attention of the radiologist during routine radiography will be clearly visible on the tomogram. If necessary, using the obtained data and a special computer program, it is possible to reconstruct a 3D model of any structure of interest.
. - Magnetic resonance imaging (MRI) . The non-trial method of research. It differs from computed tomography also in that it allows the doctor to evaluate the condition of the "soft" structures of the spine more thoroughly (only bone elements are clearly visible on the CT): spinal cord, rootlets. In more detail, this examination shows vertebral hernia, changes in blood vessels and muscles. Usually it is the MR specialist who has the final say in the diagnostic search and determination of further tactics.
Attributes to which attention should be paid
Secondary back pain, that is, having no connection with osteochondrosis and "overtrained" back - is an alarming symptom, which makes it necessary to start searching for the main pathological process causing pain as soon as possible. Let's briefly dwell on the symptoms that may indicate a possible secondary (that is, not directly related to the spine) nature of the pain and require increased vigilance, both from the doctor and the patient:
- rapid sudden loss of body weight (there may be suspicion of swelling);
- kidney and bladder infections (in this case, pain may be a symptom of pyelonephritis);
- increased pain at rest or after a night's sleep (this symptom is especially of interest to rheumatologists, as it may be a sign of the developing Bekhterev's disease);
- increased body temperature;
- changes in blood tests (increased coagulability, detected during coagulation, increased white blood cell count or a drop in hemoglobin, and an increase in ESR (erythrocyte sedimentation rate) in the general analysis, an increase in the level of C-reactive protein in immunological analysis);
- the established diagnosis of "osteoporosis", or taking medications that reduce the amount of calcium in the bones;
- age over 50 years (risk of osteoporosis in women in menopause) or less than 20 years, especially for young men;
- reference to injury, regardless of its prescription (for example, falling from a height of more than 2 meters, and for the elderly a significant injury is already a fall from the height of its own body);
- signs of serious neurologic abnormalities (a violation of skin sensitivity, urination or defecation usually indicates a deep spinal cord injury);
- inefficiency of "routine" treatment for 4 weeks.
Treatment of back pain
As already mentioned, patients with pain in the lower back are primarily in the field of vision of the therapist and neurologist. According to the available medical standards, the doctors of these specialties, especially therapists, treat uncomplicated forms of the pain syndrome in the absence of the "danger signs" mentioned earlier. Drug therapy is the administration of non-steroidal anti-inflammatory drugs (NSAIDs, for example, meloxicam) or simple analgesics. It is extremely important to convince the patient to reduce the burden on the spine - get rid of excess weight, exclude the work associated with lifting and moving weights, reduce the time spent in static vertical posture ("sedentary" lifestyle, work at the computer or, on the contrary, "work on the legs" ). The patient should be set for regular physical training, and the main thing is not to overdo it: with pain in the lower back, running, jumping, many game sports such as basketball, volleyball, football are contra-indicated.
Neurologists often use complex therapy for pain in the lower back, including the muscle relaxants (for example, midoliths) and B vitamins. The main effect of muscle relaxants is the relaxation of spasms (clamped) muscles, giving them rest. Vitamins of group B, as it is commonly believed, improve nutrition and regeneration of nerve fibers. These drugs are more effective in cases of acute pain, but with a chronic pain syndrome their appointment, although not harmful, but proven to have no effectiveness.
Quite often doctors (especially surgeons) recommend wearing a bandage on the lumbar region (supporting the waist). This allows to save the patient from unpleasant sensations in the event that there is a physical load, a long road or performance, but actually has no therapeutic effect. As soon as the bandage is removed, the pain returns or intensifies. Such physiotherapy procedures, blockades, massage or manipulations on the spine, which are so beloved in our country, have a "distracting" effect, eliminate painful muscle spasm, but just like the bandage, they do not have a proven therapeutic effect. In the case of chronic pain, these appointments simply need to be combined with physical therapy and swimming.
In cases of severe damage to the structures of the spinal cord, large disc hernias, compression fractures or tumors resort to surgical treatment. Operations on the spine are varied - from small, conducted under local anesthesia, to extensive interventions that are conducted by several surgical teams in several stages. Over the past twenty years, the technique of performing these operations is constantly being improved, a lot of experience has been accumulated, therefore, in the presence of indications for surgical treatment of the spine, it makes no sense to wait until the problem is resolved by itself.
Keep activity and mobility
A common mistake is observance of bed rest with acute pain in the back. Movement in this pathology of the musculoskeletal system is not just necessary, but necessary! In all cases, except for compression radicular syndrome (this diagnosis will be established by a neurologist), being in a horizontal position increases the cost of treatment and tightens the recovery period. Yes, and with the root syndrome, the total time of bed rest should not be more than two days.
With inflammatory (rheumatological) diseases of the spine and sacroiliac joints, physical activity is the main means of combating impending disability. Let's remind, the specified group of illnesses has gradually progressing character, and the exercises directed on maintenance of flexibility and development and strengthening of a muscular "corset" of a backbone, it is possible to consider as the same effective method of treatment, as well as special therapy by anti-inflammatory preparations of different groups appointed or nominated by rheumatologists.