Pain in the lumbar spine and the adjoining areas can disturb the patient at any time of the day while standing, sitting, lying or walking, while exercising or at rest. This symptom is so unspecific that it can occur in so many cases that it requires particular attention from the patient in particular: you must consult a doctor immediately.
Which doctor should I go to?
According to statistics, up to 25% of patients seek medical help precisely related to the occurrence of pain in the lumbar region. 8 out of 10 people in the world have had back pain at least once in their life. In addition, people of working age suffer from these symptoms most often, somewhat less often - people of retirement age and even less often - adolescents (according to various sources, between 8 and 40%).
Therapist, neurologist, traumatologist, rheumatologist
The doctor and neurologist will be the first doctors to see most of the patients with back pain. However, young people with trauma in the recent (or long-term) past are more likely to see a trauma specialist.
Both the diagnosis and treatment tactics differ for these specialists. The therapist often refers the patient to a neurologist, the neurologist defines "his" diagnosis and prescribes the treatment. The traumatologist often works "individually" and uses not only nonsteroidal anti-inflammatory drugs, but also methods of manual therapy and physiotherapy. The main thing for the patient is not to get lost in this situation, not to get carried away with the promises of immediate cure in performing manual techniques, and in the event of failure or, worse, pain arising against the background of such treatmentreinforced not to resort to them again.
In the case of conservative treatment, i. e. with medication, it should be understood that failure of treatment within four weeks is a good reason to revise the diagnosis, contact a rheumatologist, and not for repeated courses of therapy. It is not uncommon for a patient with complaints of lower back pain to receive symptomatic (that is, pain reliever only) treatment based on a specific template without specifying the true cause of the pain.
causes of back pain
The main causes of lumbar pain are
- Changes in the structures of the spine, usually age-related (they are also degenerative), osteochondrosis of the spine (also known as spondylosis), various herniated discs, or inadequate work of the muscle-ligament complex. Such pain is called primary, that is, directly connected to the spine,
- pathological changes in organs near the painful area, but not directly related to the spine (e. g. diseases of the internal organs, skin). This category of causes includes joint inflammation, trauma, endocrine disorders (e. g. diabetes), everything that does not fit into the picture of "natural age-related changes" in the spine. Such pain is called secondary.
Examination and examination at the doctor's appointment
Pain, a feeling of stiffness, or increased painful muscle tension in the area between the lower ribs and the buttocks is commonly referred to as "lumbodynia". When these symptoms are accompanied by leg pain, the condition is usually called lumbar sciatica.
First of all, the severity of the pain is important, that is, how long ago it was. Pain up to 12 weeks (3 months) of age is referred to as acute, and more than 12 weeks as chronic. Chronic pain syndrome can occur with exacerbations and periods of improvement.
How pain is felt is fundamental. It is either a sensation at a specific point or the spread ("projection", "radiation") of pain along the nerve to the thigh, buttocks, knee, foot, or a blurred, "dull" pain. It is necessary to understand whether the movements in the spine are limited or the movements are unimpeded at the moments of pain (this may indicate a mechanical nature of the damage, such as a vertebral fracture). When does pain occur? Does it occur during exertion or at rest during a night's sleep? A positive answer to the last question is generally a "red flag" for a rheumatologist and makes one contemplate diagnosing an inflammatory disease of the spine in a patient (we will get into that a little later). If the pain is aggravated by moving the head, walking, jumping, it is most likely a so-called projection pain, the cause of which is damage to the nerve structures (mostly sciatica).
Osteochondrosis of the spine, or spondylosis, is a condition in which the vertebrae become compressed and deformed, and small outgrowths of bone appear around the edges of the vertebrae that resemble the spine. For a long time it was considered the result of the natural course of degenerative processes, the aging of the body. However, it has been convincingly proven that not only age can be the cause of osteochondrosis. An immobile lifestyle, increased stress on the lumbar spine during prolonged computer work or prolonged driving (e. g. the job of a truck driver) also contribute to the occurrence of osteochondrosis in young people. Under the influence of all these factors, the disc buffers are flattened, and the nerve roots branching off from the spinal cord are compressed and then injured by the marginal bone spines that have grown. 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 of interest to rheumatologists. These mysterious diseases can "smolder" for several years, starting mainly at a young age and mainly in men, and ultimately lead to the patient's immobility and disability. Patients in this group usually endure "to the last" and nighttime pain and morning back stiffness and weakness and an increasing decrease in efficiency. Unfortunately, it takes an average of about seven years from the appearance of the first symptoms of the disease to the correct diagnosis. During this time, changes in the spine can be irreversible and functional (motor) activity can be low. The spine becomes motionless, changes its shape, a hump appears. This pathology does not occur as often as, for example, osteochondrosis, but the cost of treatment and the total time of incapacity for work of such patients are disproportionately higher.
If, in addition to back pain, the patient speaks of joint inflammation (more often of knee joints, joints of hands or feet), pain in the buttocks, unstable stool with unusual impurities, visual disturbances or eye pain, this is also an urgent reason to refer to a rheumatologist forspecific additional examination and to exclude the disease from the group of spondyloarthritis (e. g. seronegative spondyloarthritis or Crohn's disease).
There are diseases that manifest themselves as pain in the lower back and as completely untouched vertebral or nerve structures. One of these diseases is myofascial pain syndrome. Patients (usually young patients) indicate prolonged uncomfortable posture or physical overload that preceded the development of pain. During a medical exam, severe pain is indicated when certain points near the spine are pressed. This condition significantly reduces the quality of life of the patient, but minor changes in muscle tissue (local overload) do not pose a threat to the nerve roots or to the internal organs. Usually, the therapeutic effect can be achieved through the prescription of muscle relaxants, low doses of nonsteroidal anti-inflammatory drugs and localInjection (injection) into the "pain point" of a steroid anti-inflammatory drug.
test
It is generally accepted that a patient who complains of lower back pain and has no "warning signs" (see below) does not need an additional examination and treatment can be performed by a therapist without testing and even without an X-ray. As practice shows, such "signs" can be found in almost every patient, which means that at least for a general (or better - also for an immunological) analysis, blood must be donated and an x-ray of the lumbar spine must be carried out in two projections (ideally- with the "capture" of the pelvic bones).
- Blood testsmay show an increase in the erythrocyte sedimentation rate (ESR), suggesting inflammation, possibly an immune system, or an infection. An increase in the level of leukocytes also indicates infection or inflammation, as well as severe anemia - a possible presence of a tumor process.
- If kidney disease is suspected, a urinalysisis performed. The pain in the lumbar region is inherently painful and often "spreads" to the lower ribs. If there are changes in the urinalysis, an ultrasound of the kidneys is performed and other tactics are discussed in detail with the therapist or urologist.
- Radiography- the cheapest of the instrumental examinations, in this case it is the method of choice in the diagnostic search. On the roentgenogram, you can see a violation of the structures of the spine, signs of inflammation of the vertebral joints, through indirect signs, to determine the place of compression of the nerves. The "transparency" of the vertebrae in the X-ray indicates osteoporosis (fragility) of the skeleton. As you know, against the background of osteoporosis, the most common complication is a vertebral fracture with the subsequent compression of the adjacent nerves. If the fracture unfortunately took place, this will also be visible on the X-ray. The possibilities of this research method are enormous, but if the pathology is found, it will be necessary to clarify how serious the damage is and whether the patient needs surgery on the spine. This already requires a more detailed examination - layer by layer (tomography). There are two types of tomography - computed x-ray and magnetic resonance imaging.
- Computed tomography (CT). An examination method with which you can literally look into the spine. All bone structures that escaped the radiologist's attention during conventional radiography are perfectly visible in the tomogram. If necessary, you can use the received data and a special computer program to reconstruct a 3D model of any structure of interest.
- Magnetic resonance imaging (MRI). Non-X-ray research method. It also differs from computed tomography in that the doctor can assess the condition of the "soft" structures of the spine more precisely (only bone elements are clearly visible on the CT): the spinal cord, the roots. In particular, this examination reveals vertebral hernias, changes in blood vessels and muscles. Usually, it is the MRI specialist who has the final say in the diagnostic search and determines other tactics.
Characters to watch out for
Secondary back pain, i. e. unrelated to osteochondrosis and "overworked" back, is an alarming symptom that prompts you to look for the main pathological process causing pain as soon as possible. Let's briefly discuss the symptoms that indicate a possible secondary (i. e. , not directly related to the spine) nature of the pain, requiring increased vigilance on the part of both the doctor and the patient:
- rapid sudden weight loss (tumor can be suspected);
- kidney and bladder infections (in which case pain can be a symptom of pyelonephritis);
- increased pain at rest or after a night's sleep (this symptom is of particular interest to rheumatologists as it can be a sign of the development of ankylosing spondylitis);
- Increase in body temperature;
- Changes in blood tests (increased blood clotting detected when a coagulogram was taken, an increase in white blood cell levels or a decrease in hemoglobin, and an increase in ESR (erythrocyte sedimentation rate) in general analysis, an increase in the level of C-reactive proteinin immunological analysis);
- an established diagnosis of osteoporosis or drugs that lower calcium in the bones;
- Age over 50 years (risk of osteoporosis in women during menopause) or younger than 20 years, especially young men;
- Indication of an injury, regardless of their age (e. g. a fall from a height of more than 2 meters, and for the elderly, a significant injury is already a fall from the height of one's own body);
- signs of serious neurological abnormalities (abnormal skin sensation, urination, or bowel movements usually indicate deep spinal cord involvement);
- Failure of the "routine" treatment within 4 weeks
Treatment of back pain
As already mentioned, patients with pain in the lower back are first made aware of this by the therapist and neurologist. According to the available medical standards, doctors of these specialties, especially therapists, treat uncomplicated forms of pain when the aforementioned "danger signs" are missing. Drug therapy consists of the appointment of nonsteroidal anti-inflammatory drugs (NSAIDs, such as meloxicam) or simple analgesics. It is extremely important to convince the patient to reduce the load on the spine - reduce excess weight, exclude work related to lifting and moving heavy weights, reduce the time in a static vertical position ("sedentary" lifestyle, working on theComputer or vice versa "working on the legs"). ). The patient should be prepared for regular physical education, the main thing being not to overdo it: with pain in the lower back, running, jumping, many game sports, such as basketball, volleyball, soccer, are contraindicated.
Neurologists most commonly use complex therapy for lower back pain, including muscle relaxants and B vitamins on the regimen. The main effect of muscle relaxants is to relax spasmodic (tight) muscles and give them rest. It is believed that B vitamins improve the nutrition and regeneration of nerve fibers. These drugs are more effective for acute pain, but for chronic pain, their appointment, although not harmful, has no proven effectiveness.
Very often, doctors (especially surgeons) recommend wearing an orthosis on the lumbar spine (which supports the lower back). In this way, you can protect the patient from unpleasant sensations in the event that physical activity, a long journey, or performance is about to occur, but it does not have any real therapeutic effect. Once the tape is removed, the pain returns or increases. Physiotherapy, "blockade", massage or manipulation of the spine, which are so popular in our country, have a "distracting" effect, relieve painful muscle spasms, but just like the use of a bandage, they have no proven therapeutic effect. For chronic pain, these appointments only need to be combined with physical therapy exercises and swimming.
Serious damage to the structures of the spinal cord, large herniated discs, compression fractures or tumors are treated surgically. Spine operations are diverse - from small operations under local anesthesia to larger operations that are performed by several teams of surgeons in several phases. Over the past twenty years the technique for performing these operations has continued to improve. A lot of experience was gained. Therefore, if there is any indication of surgical treatment of the spine, it does not make sense to wait until the problem is resolved on its own.
Maintain activity and mobility
A common mistake is sticking to bed rest with acute back pain. Movement with this pathology of the musculoskeletal system is not only necessary, it is necessary! In all cases, with the exception of radicular compression syndrome (this diagnosis is made by a neurologist), a horizontal position increases the cost of treatment and delays the recovery period. And in the case of radicular syndrome, the total time of bed rest should not be more than two days.
In inflammatory (rheumatological) diseases of the spine and sacroiliac joints, physical activity is the main means of dealing with the occurrence of a disability. It is worth remembering that this group of diseases gradually progresses, and exercises to maintain flexibility and develop and strengthen the muscular "corset" of the spine can be considered the same effective method of treatment as special therapy with anti-inflammatory drugs of different groups prescribed by rheumatologistswill be.