Pain in the lumbar spine and surrounding areas can bother the patient at any time of the day, while standing, sitting, lying or walking, while exercising or at rest. This symptom is so nonspecific, that is, it can occur in such a huge number of cases that it requires special attention, first of all, on the part of the patient: you must immediately consult a doctor.
Which doctor should I go to?
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 globe have experienced back pain at least once in their life. Moreover, most often people of working age suffer from these symptoms, a little less often - people of retirement age and even less often - adolescents (according to various sources, from 8 to 40%).
Therapist, neurologist, traumatologist, rheumatologist
The physician and neurologist will be the first doctors most patients with lower back pain will see. But young people with trauma in the recent (or long-standing) past are more likely to see a trauma specialist.
Both diagnostic and treatment tactics differ for these specialists. Often, the therapist directs the patient to a neurologist, the neurologist defines "his" diagnosis and prescribes treatment. The traumatologist often works "individually", and 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 lost in this situation, not to get carried away with the promises of instant healing when performing manual techniques, not to resort to them again in case of failure or, worse, pain that intensified against the background of such treatment.
When treating conservatively, that is, with drugs, it should be understood that the failure of treatment within four weeks is a good reason for revising the diagnosis, referring to a rheumatologist, and not for repeated courses of therapy. It is not uncommon for a patient with complaints of pain in the lower back to receive symptomatic (that is, just pain relieving) treatment according to a certain template scheme, without specifying the true cause of this pain.
Causes of lower back pain
The main causes of lumbar pain are
- changes in the structures of the spine, as a rule, age-related (they are also degenerative), osteochondrosis of the spine (aka spondylosis), various herniated intervertebral discs or inadequate work of the musculo-ligamentous complex. Such pains are called primary, that is, directly related to the spine;
- pathological changes in organs located near the painful area, but not directly related to the spine (for example, diseases of internal organs, skin). This category of causes includes inflammation of the joints, trauma, endocrine disorders (for example, diabetes), in a word, everything that does not fit into the picture of "natural age-related changes" of the spine. Such pains are called secondary.
Investigation 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 buttocks is commonly referred to as "lumbodynia". If these symptoms are accompanied by pain in the leg, this condition is usually called lumboischialgia.
First of all, the acuteness of pain is important, that is, how long ago it occurred. Pain up to 12 weeks (3 months) old is called acute, more than 12 weeks - 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 certain point, or the spread ("projection", "irradiation") of pain along the nerve to the thigh, buttock, knee joint, foot, or a fuzzy, "dull" pain. It is necessary to understand whether the movements in the spine are limited at the moments of pain, or the movements are unimpeded (this may indicate a mechanical nature of the damage, for example, with a vertebral fracture). When does pain appear? Does it occur during exertion, or at rest, during a night's sleep? An affirmative answer to the last question is generally a "red flag" for a rheumatologist and makes one think about the diagnosis of an inflammatory disease of the spine in a patient (we will dwell on them a little later). If the pain intensifies with head movement, walking, jumping, it is most likely a so-called projection pain, the cause of which is damage to nerve structures (most often sciatica).
Osteochondrosis of the spine, or spondylosis, is a condition in which there is compaction and deformation of the vertebrae, with the appearance of small bone outgrowths, similar to spines, along the edges of the vertebrae. For a long time it was considered to be the result of the natural course of degenerative processes, aging of the body. However, it has been convincingly proven that not only age can be the cause of osteochondrosis. An immobile lifestyle, an increased load on the lumbar spine during prolonged work at the computer or during prolonged 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 discs-buffers flatten, and the nerve roots branching from the spinal cord are compressed and then injured by the grown marginal bone spines. 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, starting mainly at a young age and affecting mainly men, and ultimately resulting in 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 decrease in efficiency. Unfortunately, from the appearance of the first symptoms of the disease to the correct diagnosis, on average, it takes about seven years. During this time, changes in the spine can become irreversible, and functional (motor) activity - low. The spine becomes motionless, changes shape, a hump appears. This pathology does not occur as often as osteochondrosis, for example, but the cost of treatment and the total time of incapacity for work of such patients is disproportionately higher.
If, in addition to back pain, the patient, upon questioning, speaks of joint inflammation (more often it is about the knee joints, 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 reasonrefer him to a rheumatologist for specific additional examination and exclusion of the disease from the group of spondyloarthritis (for example, seronegative spondyloarthritis or Crohn's disease).
There are diseases that manifest themselves as pain in the lower back and completely unaffected 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 examination, attention is drawn to a 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) pose no danger to either the nerve roots or internal organs. Usually, the therapeutic effect can be achieved by prescribing muscle relaxants, low doses of non-steroidal anti-inflammatory drugs, local injection (injection) into the “pain point” of a steroid anti-inflammatory drug.
Examination
It is generally accepted that if a patient complaining of pain in the lower back does not have "warning signs" (described below), then he does not need additional examination, and treatment can be carried out by a therapist without tests and even radiography. But, as practice shows, in almost any patient such "signs" can be found, which means that there is a need to donate blood for at least a general (or better - also for an immunological) analysis, and perform an X-ray of the lumbar spine in two projections (ideally - with the "capture" of the pelvic bones).
- Blood testsmay show an increase in the erythrocyte sedimentation rate (ESR), which indicates inflammation, possibly immune, or infection. An increase in the level of leukocytes also indicates infection or inflammation, and severe anemia - a possible presence of a tumor process.
- Urinalysisis done if kidney disease is suspected. The pain in the lumbar region is aching in nature, often "spreading" up to the lower ribs. If there are changes in the analysis of urine, an ultrasound of the kidneys is performed, and further tactics are discussed in detail with the therapist or urologist.
- Radiography- the cheapest of the instrumental examinations, this is the method of choice in the diagnostic search in this case. On the roentgenogram, you can see a violation of the structures of the spine, signs of inflammation of the vertebral joints, by indirect signs to determine the place of compression of the nerves. The "transparency" of the vertebrae on the roentgenogram will suggest osteoporosis (fragility) of the bone skeleton. As you know, against the background of osteoporosis, the most common complication is a fracture of the vertebra with subsequent compression of the adjacent nerves. If the fracture, alas, has taken place, this will also be visible on the radiograph. The possibilities of this research method are enormous, but if a pathology is found, it is necessary to clarify how serious the injury is, whether the patient needs surgery on the spine. This already requires a more accurate study - layer-by-layer (tomography). There are two types of tomography - computed x-ray and magnetic resonance imaging.
- Computed tomography (CT). An examination method that allows you to literally look inside the spine. All bone structures that have escaped the attention of the radiologist during conventional radiography will be perfectly visible on the tomogram. If necessary, using the obtained data and a special computer program, you can 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 it allows the doctor to more carefully assess the state of the “soft” structures of the spine (only bone elements are clearly visible on CT): the spinal cord, roots. In more detail, this examination shows vertebral hernias, changes in blood vessels and muscles. Usually, it is the MRI specialist who has the last word in the diagnostic search and determining further tactics.
Signs to watch out for
Secondary back pain, that is, having no connection with osteochondrosis and "overworked" back, is an alarming symptom that makes you start looking for the main pathological process causing pain as soon as possible. Let us 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 from the patient:
- rapid sudden weight loss (tumor may be suspected);
- 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 of particular interest to rheumatologists, as it may be a sign of developing ankylosing spondylitis);
- increase in body temperature;
- changes in blood tests (increased blood clotting detected when performing a coagulogram, an increase in the level of leukocytes or a drop in hemoglobin, as well as an increase in ESR (erythrocyte sedimentation rate) in the general analysis, an increase in the level of C-reactive protein in the immunological analysis);
- an established diagnosis of osteoporosis or medication that decreases calcium in the bones;
- age over 50 years (the risk of osteoporosis in women in menopause) or less than 20 years, especially for young men;
- reference to an injury, regardless of its age (for example, a fall from a height of more than 2 meters, and for older people a significant injury is already a fall from a height of one's own body);
- signs of serious neurological abnormalities (impaired sensation of the skin, urination, or defecation usually indicates deep spinal cord involvement);
- failure of "routine" treatment within 4 weeks
Back pain treatment
As mentioned, patients with lower back pain come first to the attention of the therapist and neurologist. According to available medical standards, doctors of these specialties, especially therapists, treat uncomplicated forms of pain in the absence of the "danger signs" mentioned earlier. Drug therapy consists of the appointment of non-steroidal 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 - to get rid of excess weight, to exclude work associated with lifting and moving heavy weights, to reduce the time spent in a static vertical position ("sedentary" lifestyle, working at a computer or, conversely, "work on legs"). The patient should be tuned in to regular physical education, while 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 contraindicated.
Neurologists most often use complex therapy for pain in the lower back, including muscle relaxants and B vitamins in the regimen. The main effect of muscle relaxants is to relax spasmodic (tight) muscles, giving them rest. B vitamins are believed to improve nutrition and regeneration of nerve fibers. These drugs are more effective in cases of acute pain, but in chronic pain, their appointment, although not harmful, has no proven effectiveness.
Quite often, doctors (especially surgeons) recommend wearing a brace on the lumbar region (supporting the lower back). This allows you to save the patient from unpleasant sensations in the event that physical activity, a long journey or a performance is ahead, but has no actual therapeutic effect. As soon as the band is removed, the pain returns or increases. Physiotherapy, "blockade", massage or manipulations on the spine so beloved in our country have a "distracting" effect, eliminate painful muscle spasms, but just like the use of a bandage, they have no proven therapeutic effect. In the case of chronic pain, these appointments simply need to be combined with physiotherapy exercises and swimming.
In cases of severe damage to the structures of the spinal cord, large herniated discs, compression fractures or tumors, they resort to surgical treatment. Spine surgeries are varied - from small ones performed under local anesthesia to major interventions performed by several teams of surgeons in several stages. Over the past twenty years, the technique of performing these operations has been constantly improving, a lot of experience has been accumulated, therefore, if there are indications for surgical treatment of the spine, it makes no sense to wait until the problem is resolved by itself.
Maintain activity and mobility
A common mistake is adhering to bed rest for acute back pain. Movement with this pathology of the musculoskeletal system is not just necessary, but necessary! In all cases, except for the compression radicular syndrome (this diagnosis will be established by a neurologist), being in a horizontal position increases the cost of treatment and delays the recovery period. And with 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 onset of disability. Recall that this group of diseases has a gradually progressive nature, and exercises aimed at maintaining flexibility and developing and strengthening the muscular "corset" of the spine can be considered the same effective treatment method as special therapy with anti-inflammatory drugs of different groups prescribed by rheumatologists.