Back pain in the lumbar region

About 40-80% of people complain of spinal pain in the lumbar area, but no more than 25% of them seek medical help. In fact, such unpleasant sensations can be caused both from relatively harmless reasons and from pathological changes in the spine. Hence, you shouldn't treat them contemptuously.

Causes of Back Pain

The spine consists of a whole complex of structural elements: bones, joints, intervertebral discs, ligaments, nerves. Changes in any of them can be accompanied by painful sensations and of other kinds. In addition, the spine is surrounded by paravertebral muscles, pain that patients often confuse with pain in the spine. The causes of pain can therefore be varied. This can be overload, natural restructuring of the body during pregnancy, etc. However, if pain occurs regularly, it is worth contacting a vertebrologist or neurologist, since often the fact that the spine in the lumbar region is systematically painful indicates the development of certain diseases.

Most often, it is diagnosed in such situations in patients:

• Disc pathology (decreased disc height, protrusion, disc hernia, discitis);
• Facet joint pathologies (spondyloarthrosis, joint cysts);
• inflammatory diseases (ankylosing spondylitis or ankylosing spondylitis, reactive arthritis, psoriatic arthritis)
• Compression fractures of the vertebrae against the background of osteoporosis;
• neoplastic lesions of the spine.

Disc disease

Degenerative changes in the intervertebral discs or osteochondrosis are very common, especially in young and medium-sized people. This is mainly due to the need to sit for long periods or do heavy physical labor. With age, the intervertebral disc dries out and the vertebrae grow together.

Even in the initial stages of degenerative changes in the intervertebral discs, which are cartilages of a special configuration that divide the vertebral bodies, pain in the spine can occur. This is due to irritation of the pain receptors in the outer layers of the intervertebral disc and the posterior longitudinal ligament of the spine. Often, osteochondrosis provokes an aseptic inflammatory process, which leads to reflex spasm of the segmental muscles. This increases the pain in the spine and restricts movement.

Osteochondrosis tends to progress all the time, especially if there is not adequate treatment and lifestyle correction. This is followed by the formation of protrusions and later intervertebral hernias, which provoke the exacerbation of existing symptoms and the appearance of new ones.

The lumbar area is most commonly affected, as it bears the greatest stress during daily activities.

Protrusions are protrusions from the intervertebral disc while maintaining the integrity of its outer covering, called the annulus fibrosus. While the influence of provoking factors is maintained over time, the fibers of the annulus fibrosus do not withstand the stress and pressure of the internal contents of the intervertebral disc (nucleus pulposus) and rupture. As a result, the core goes beyond the physiological position of the intervertebral disc. At the same time, the spine in the lumbar area always hurts or the pain radiates into the leg and the complaints take on a position, walking, standing with jerky movements, bending down, lifting heavy objects, exertion, coughing, sneezing, laughing as well as with prolonged sitting.

Often, patients with already formed protrusions and hernias unconsciously adopt a constrained posture that leans slightly to the healthy side. In this case, pain in the spine in the lumbar region can reach a high intensity and make a person fit for work. In such cases, he is forced to rest in bed and, to relieve pain, straighten the leg that is bent and raised to the stomach.

Most often protrusions and hernias are formed in the direction of the spinal canal, in which the spinal cord (cauda equina) and the nerve roots branching off from it run. The latter pass through the natural openings of the vertebral bodies and branch further into the lumbar plexus, which is responsible for the innervation of the lower extremities and various organs (including the genitals).

Therefore, with long-term osteochondrosis, the formation of hernias in the lumbar area, pain in the spine is gradually not only aggravated, but also supplemented by other diseases. Neurological disorders occur when a deformed intervertebral disc or soft tissue swollen from the inflammatory process squeezes the spinal root that is passing near it. Therefore, pain in the spine in the lumbar region can be supplemented by radiating to the buttocks, groin, front, inside, outside of the thigh, lower leg and foot. It depends on what type of nerve root is affected, that is, at what level of the segment of motion of the spine, pathological changes are observed. Sensitivity disorders in the form of crawling sensations, numbness, temperature fluctuations, pain, tactile stimuli and restricted mobility can also be observed in the corresponding zones of the lower extremities.

Changes in the height and functionality of the intervertebral discs that occur in osteochondrosis and its complications lead to damage to the articular apparatus of the spine, as well as degeneration of the vertebral bodies themselves. The consequence of this is the development of spondylosis, i. H. calcification of the anterior longitudinal ligament and the formation of bone-cartilaginous growths on the surface of the vertebral bodies (osteophytes). Not only can they injure the surrounding tissues and squeeze the roots of the spine, causing severe pain in the spine, but they can also grow together. As a result, neighboring vertebral bodies are combined into a whole, which severely restricts mobility in the lower back.

Osteochondrosis can be accompanied by reactive changes in the vertebral bodies, particularly reactive aseptic spondylitis, which leads to osteosclerosis. This is accompanied by a compaction of the bone tissue and increases the chance of vertebral fractures dramatically.

Facet joint disease

Pathologies of the facet or facet joints of the lumbar spine, in particular its osteoarthritis, can also cause pain in the lumbar spine area and even severe pain. Although the pain is more painful and localized deep inside. Their appearance is due to the fact that their synovial capsule is richly innervated. In such situations, the pain is usually concentrated directly on the affected area and tends to increase with bending, stretching, turning the body and standing for longer periods of time. Walking and sitting help reduce their severity. In some cases, however, pain in the groin, tailbone, and back and outer thighs may also occur.

Inflammatory diseases of the spine

Inflammatory diseases of the spine are less common than diseases of the intervertebral discs and facet joints. However, they also injure the spine. These include:

• ankylosing spondylitis or ankylosing spondylitis;
• reactive arthritis;
• Psoriatic arthritis, etc.

The symptoms of these diseases usually appear before the age of 40, and more often by the age of 20. This distinguishes them from degenerative-dystrophic pathologies of the intervertebral discs and joints of the spine, which often develop only after 40 years. In this case, the pain is characterized by a gradual increase in intensity. In addition, their severity decreases after physical exertion, but not at rest. Therefore, in inflammatory diseases, the spine in the lumbar region often hurts at night and particularly badly in the morning, immediately after sleep.

The most difficult situation is observed with ankylosing spondylitis, and it affects the lumbar region more often than other inflammatory diseases. This term is understood to mean inflammation of the intervertebral joints with their subsequent immobilization through the formation of dense bone, cartilage or fiber fusion between the articulated bone structures.

Initially it is characterized by mild back pain, but over time it gradually spreads further, covering the thoracic and then the cervical spine. Associated with this is the development of a restriction in the mobility of the spine in all levels, since the spine seems to be immersed in a specific case due to the changes that take place. Also observed:

• Alignment of the lumbar lordosis (natural curvature of the spine in the lumbar region);
• Exacerbation of breast kyphosis, which provokes a stoop;
• Reflex tension of the back muscles;
• progressive exacerbation of the restriction of movement due to the involvement of facet joints in the pathological process and ossification of the intervertebral discs;
• Morning stiffness for an hour or more.

Inflammation of the iris (iritis), cornea (keratitis), mucous membrane (conjunctivitis), iris and ciliary body of the eyeball (iridocyclitis) is observed in 10-50% of patients.

The progression of ankylosing spondylitis leads to the fact that an increasing number of joints are involved in the pathological process. This forces patients to adopt what is known as the supplicant pose. It means pronounced kyphosis of the thoracic spine, tilting the upper body downward, bending the knees with a severe limitation of the range of motion in the chest, which affects the depth of breath.

The progression of the disease will depend on the adequacy and completeness of treatment.

Compression fracture of the vertebrae

Compression fracture is the flattening of the vertebral body, making it wedge-shaped. This leads to a disruption of the anatomy of the spine, can provoke trauma to the spinal cord and its roots and also become a triggering factor for the rapid progression of degenerative-dystrophic changes.

The lumbar vertebrae 1 and 2 are more prone to injury because they absorb the greatest axial load.

Compression fractures of the spine often occur in the elderly due to the development of osteoporosis, i. H. a decrease in bone density. In such cases, not only a slight fall, but lifting weights, an unsuccessful movement, can be enough to injure yourself.

The pathology is characterized by the presence of pain in the spine, which restricts movement, increases with sitting, moving and trying to lift a straight leg. It usually lasts 1-2 weeks and then gradually decreases over 2-3 months. In some cases there is a radiation of pain in the iliac crests and hips. A decrease in the height of a broken vertebra leads to an increase in lumbar lordosis, which also contributes to the appearance of painful sensations.

If a fracture is not diagnosed in a timely manner, then a decrease in the height of the vertebra leads to changes in posture, a decrease in growth. This provokes reflex tension and shortening of the spinal muscles, which causes chronic back pain and requires long periods of rest.

spinal neoplastic lesions

Neoplastic lesions of the spine mean the formation of benign and malignant tumors, as well as metastases, the source of which is neoplasms of other organs. This is much less common than disc, facet joint, ankylosing spondylitis, and even compression fractures, and only occurs in 1-2% of patients with back pain. However, such lesions require the earliest possible diagnosis and treatment.

The characteristic features of neoplastic lesions of the spine, in addition to pain in them, are:

• an increase in body temperature, including up to subfebrile levels;
• inappropriate weight loss;
• Inability to find a comfortable body position;
• the presence of pain at night;
• severe pain in the spine;
• Inability to relieve pain with conventional analgesics.

Even if you have 1 or 2 of these symptoms, you should make an appointment with your doctor right away.

Similarly, the following can appear:

• Chondroma is a malignant tumor that is diagnosed in 20% of patients with cancerous lesions of the spine. Most often, it forms in the sacrum and can occur in people of all ages and genders.
• Young's sarcoma - occurs in 8% of patients with neoplastic lesions of the spine. More common in young men.
• Chondrosarcoma is a malignant neoplasm that makes up 7-12% of cases. It is found more often in middle-aged men.
• An aneurysmal bone cyst is a benign neoplasm.
• Hemangioma is a benign vascular tumor that occurs in 11% of people. It cannot be known all of its life. But it increases the risk of vertebral fractures.
• Metastases from other tumors are secondary malignant neoplasms. Breast, prostate, lung and less often kidney, thyroid and skin cancers metastasize to the spine more often.

diagnosis

If the spine hurts in the lumbar area, it is worth making an appointment with a neurologist or vertebrologist. At the appointment, the doctor first collects an anamnesis and asks questions about the type of pain, the circumstances in which it occurred, the duration of its persistence, the presence of other symptoms, lifestyle, etc.

Then the specialist conducts an examination. He not only scans the spine, determines the localization of the pain, assesses the gait and posture that the patient adopts unconsciously, but also carries out functional tests. With their help, you can identify signs of ankylosing spondylitis, neurological deficit, assess the degree of mobility of the spine and obtain other diagnostic data.

On this basis, the doctor can already guess the possible causes of the pain syndrome. To clarify them and precisely determine the degree of damage, instrumental and sometimes laboratory diagnostic methods are also prescribed. Most often they resort to help:

• X-ray in frontal and lateral projection, some with functional radiological tests;
• CT - allows better visualization of bone structures, so it is more commonly used to diagnose spondylosis, fractures, bone tumors, etc.
• MRI - allows the most accurate assessment of the condition of cartilage structures and soft tissues, so it is widely used to diagnose osteochondrosis, protrusions, intervertebral hernias, spinal cord lesions, etc. ;
• electromyography - indicated for neurological disorders of unknown cause, as well as for assessing the degree of nerve damage;
• Radioisotope bone scintigraphy - used to diagnose malignant tumors and metastases;
• X-ray densitometry is the best way to diagnose osteoporosis;
• Myelography - used to look for signs of compression of the spinal cord and nerves in the cauda equina.

treatment

For each patient, treatment is selected strictly individually and not only on the basis of the diagnosis, but also the type of existing comorbidities. Nevertheless, it is the cause of back pain that determines the tactics of therapy. It can be conservative or involve surgery.

However, the first step is always to make focused efforts to relieve pain, especially if they are strong. To do this, patients are prescribed NSAIDs, antispasmodics, and pain relievers. And in severe cases, spinal blocks are performed - injections of anesthetics and corticosteroids in specific places on the spine.

Bed rest is not shown to all patients. And in the case of intervertebral disc pathologies, this can be completely contraindicated, since a decrease in physical activity contributes to the transformation of acute pain in the spine into chronic.

Only conservative or non-surgical treatment is prescribed for:

• Osteochondrosis;
• Ankylosing spondylitis;
• Arthrosis of the facet joints;
• mild compression fractures.

It is usually complex and consists of:

• drug therapy, the NSAIDs, chondroprotectors, muscle relaxants, immunosuppressants, corticosteroids,
• physiotherapy (UHF, magnetic therapy, laser therapy, traction therapy, etc. );
• Exercise therapy;
• manual therapy.

If the cause of back pain is intervertebral disc hernias, protrusions, spondylosis, severe vertebral fractures, tumors, surgery is often indicated. It is also necessary for:

• Ineffectiveness of conservative therapy for degenerative-dystrophic changes;
• an increase in neurological deficit;
• Instability of the spinal segment of motion;
• the development of complications, especially stenosis of the spinal canal.

Most modern spine surgeries are minimally invasive. As a result, intra- and post-operative risks are greatly reduced, the rehabilitation time shortened and made easier and the effectiveness is not inferior to more traumatic open operations. Depending on the recognized disease, the following can be recommended:

• Discectomy is an operation that is indicated primarily for hernias and bulges, especially those that cause cauda equina syndrome. It can be performed with microsurgical instruments through a 3 cm incision (microdiscectomy) and with endoscopic devices that are introduced into the spine through punctures about 1 cm in diameter (endoscopic discectomy). When the disc is completely removed, it is usually replaced with implants.
• Vertebroplasty and kyphoplasty - indicated for compression fractures of the vertebrae, hemangiomas, and some other diseases. The core of the operation is to inject fast-setting bone cement through a thin cannula into the vertebral body, which strengthens it. With kyphoplasty, it is also possible to restore the normal dimensions of the vertebral body, which is important in the event of a serious decrease in height as a result of a fracture.
• Fixation operations serve to stabilize the spine. For this purpose, metal structures of a different type are used, which usually remain in the patient's body until the end of their life.

The spine in the lumbar region can hurt for a variety of reasons. Therefore, with prolonged persistence of painful sensations, their regular occurrence, increasing pain over time, and even more additional symptoms, it is imperative to contact a vertebrologist or neurologist. Early diagnosis makes it possible to detect pathological changes at the stages when they are easiest to cope with, and if the disease is not completely cured, then at least stop the progression and maintain a high standard of living.