Spinal pain in the lumbar region (lower back)
Back pain is one of the most common complaints among adults. Its occurrence is primarily associated with lifestyle and previous trauma. There are four types of pain in the lower back region that the patient will most often complain about:
- local pain
- reflected pain
- radicular pain (from spinal nerves)
- fibromyalgia - pain resulting from secondary (protective) muscle spasm
Local pain in the lower back can be associated with any pathological process that affects or irritates the pain receptors of the nerves. Involvement in the pathological process of structures that do not contain sensitive endings is painless. The central part of the vertebral body, which has a cellular structure and contains red bone marrow, which produces blood corpuscles, can be destroyed, for example by a tumor or hemangioma, without causing pain. Fractures of the cortical layer of the vertebra or in the case of rupture and deformation of the periosteum, synovial membranes of the intervertebral joints, muscles, fibrous rings of the intervertebral disc and ligaments are often extremely painful for the patient. Although painful conditions are often accompanied by edema of the affected tissues, it may not be seen if the process is located deep to the skin of the lower back.
Local back pain is often persistent. The pain can change its intensity depending on the change in the position of the body in space or in connection with the movement of the patient. The pain in the lower back may be sharp or aching (dull). Often the pain is diffuse, always felt in the affected part of the back or away from it. Often, back pain is exacerbated by movements or changes in body position (tilting, getting out of bed), which displace damaged and inflamed tissues. Strong pressure or tapping on the surface of the lower back during the examination of the patient also causes soreness, which helps to locate the injury.
There are two types of reflected pain in the lower back:
- pain that radiates from the spine to the areas lying within the zones of the lumbar and upper sacral areas of the sensitive innervation of the ski
- pain that radiates to the spine from the internal organs (pelvis, abdomen)
Reflected pain caused by diseases of the upper lumbar spine usually radiates to the front surfaces of the thighs and lower legs. Reflected pain in case of damage to the lower lumbar and sacral structures of the spine radiates in the buttocks, the back surfaces of the thighs and lower legs can reach the feet. Reflected pain of this type, although the source of its occurrence is located deeply, is felt by the patient as prolonged, dull, not acute, and relatively diffuse. It can often be felt by the patient on the surface.
Reflected pain in its strength and intensity for the patient can be the same as local back pain. Factors that change the nature of local pain (load, movement) similarly affect reflected pain, although this effect may not be as pronounced as with radicular pain. Reflected pain can be confused with pain caused by diseases of the internal organs. With diseases of the internal organs, patients usually describe the pain as deep, pulling, radiating from the abdomen to the back. Pain from internal organs is usually not affected by spinal movements. It does not decrease in the supine position and can change under the influence of activity (intestinal peristalsis, urination, etc.) of the internal organs involved in the painful process.
Root pain occurs when the spinal nerves in the lower back are affected. Root pain is similar to reflected pain, but differs in its greater intensity ("electric shock") and extends from the spine to the periphery. Root pain is localized within the innervation zone of this root and the conditions that cause it. Root pain occurs as a result of mechanical stretching, irritation, or compression of the spinal nerve root. Most often, this effect is experienced by the root when it is mechanically affected in the lumen of the spinal canal. Root pain along the course of the nerve is often aching or prolonged, dull, not too intense. With various influences that increase the degree of compression of the nerve, the pain can significantly increase and become piercing or cutting according to the patient's sensations.
Root pain spreads from the back (from the lumbar spine) to any area on the leg: in the buttock, hip, under the knee, in the shin, fingers on the foot. Concussion when coughing, sneezing, or straining can increase the patient's radicular pain, just as they increase it with local pain. If the movement causes an increase in nerve stretching (bending with straight legs, lifting the straightened leg), the root pain will increase. When the jugular vein is clamped in the neck, the pressure of the cerebrospinal fluid (CSF) increases. This can also cause a displacement of the root or an increase in pressure on it and cause increased root pain.
With irritation or compression of the nerve roots L4, L5, and S1 (part of the sciatic nerve), the root pain will be transmitted down the posterior surface of the thigh, on the posterolateral, and anterolateral surfaces of the lower leg, in the foot. This type of root pain along the sciatic nerve is called sciatica. Paresthesia (spontaneous unpleasant sensations of numbness, tingling, burning) or decreased skin sensitivity, skin soreness, and tension along the nerve usually accompany pain related to the posterior sensitive fibers of the spinal nerve root. If the motor fibers of the anterior root of the spinal nerve are involved in the pathological process, then loss of reflex, weakness, atrophy (weakening of function), convulsive contractions (involuntary twitching of individual bundles of muscle fibers), sometimes venous edema may occur.
Muscle pain (myofascial syndrome, fibromyalgia)
Muscle pain (myofascial syndrome, fibromyalgia) is a type of pain in the lower back that occurs with muscle spasms. Muscle pain is usually the most common local pain. Muscle spasm is formed in many diseases of the spine, causing significant disturbances in the patient's normal body position. Chronic muscle tension is felt by the patient as aching and sometimes cramping pain. When examining the patient during palpation of the muscles of the lower back, the tension of the sacro-vertebral and gluteal muscles is detected.
A patient with chronic lower back pain is often unable to pinpoint its exact origin. A feeling of muscle tension, convulsive twitching, tearing, throbbing, or stabbing pain in the shins, or a feeling of burning or cold, like paresthesia and numbness, are characteristic of diseases of the spinal nerves or their sensitive roots (neuropathy).
After the patient has established the nature and location of the pain, the doctor determines the factors that aggravate and eliminate this pain. When interviewing the patient, the duration of the pain is specified, its dependence on the position (increased lying, sitting, standing), the influence of the torso tilts forward, coughing, sneezing, and tension. A significant diagnostic value may be the moment of pain and the circumstances that caused it. Due to the fact that many diseases of the lower back are the result of an injury sustained during work activities or in an accident, it is necessary to remember the possibility of exaggerating the severity of the patient's condition in order to obtain compensation for damage or for other personal reasons, as well as as a result of hysterical neurosis or simulation.
There are many diseases in humans that lead to back pain. One of these causes of back pain is congenital abnormalities of the spine (back Bifida, lumbalization, and sacralization). Other causes of back pain are diseases that gradually form in a person with age.
Also, a common cause of back pain in a person is the acute or chronic overload of the spine. These include:
- spinal fracture
- cervico-cranial syndrome (with neck and head injury) chronic overstrain of the back muscles during prolonged uncomfortable positions, sedentary work
Most of the causes of back pain are associated in their origin with the same type of physical activity at work or at home:
- from prolonged driving
- when sedentary work at the computer
- with a sedentary lifestyle
- after lifting weights and overloading while playing sports
- when carrying a child in your arms for a long time
- when caring for patients with limited mobility
- with an uncomfortable sleeping surface (pillows and mattress)
In outpatient practice, in patients with osteochondrosis of the spine, the accumulative mechanism of the occurrence of back pain is most often found. Most often, problems in people accumulate in the neck and lower back. Often, the appearance of such a fairly persistent pain symptom is preceded by the presence of a feeling of discomfort or discomfort for a long period before the exacerbation of the disease.
Such patients often have to endure unpleasant sensations and back pain from time to time for months or years. To relieve pain and eliminate discomfort when moving or at rest, various anti-inflammatory and analgesic medications, rubs, gels, and ointments are often taken. For back pain, bandages and corsets, all kinds of massagers and applicators are also used.
The symptom of back pain is much less common in people who lead a sporty lifestyle. Prevention of the development of osteochondrosis of the spine and the appearance of a pain symptom is primarily promoted by independent gymnastics, active recreation. Gymnastics relieves the daily workload of the same muscles, ligaments, and joints of the lumbar spine.
Common causes of back pain symptoms include:
- muscle spasm (acute or chronic)
- protrusion or herniated disc
- degenerative processes of the spine - osteochondrosis, spondylosis, spondylolisthesis
- lumbago, lumbodynia and lumboischialgia
- Scheerman-Mau disease
- ankylosing spondylitis
- spinal stenosis
- sacroiliitis (inflammation of the sacroiliac joint)
- arthrosis of the sacroiliac joint
- arthrosis of the intervertebral joint (spondyloarthrosis), etc.
- back pain during pregnancy
Spinal pain diagnostics
It all starts with a neurological and orthopedic examination by a doctor. During this examination, the patient's neurological status is assessed, as well as possible violations in the biomechanics of the spine are identified with a mandatory assessment of the state of the muscles of the back and gluteal region. Already at this stage of the study, a patient with osteochondrosis of the spine and pain in the back and lower back can be diagnosed and treated.
Normal examination of a healthy spine reveals thoracic kyphosis and lumbar lordosis. In some people, these curvatures of the spine can be significant, with the formation of the so-called "round back". In diseases of the spine, the presence of excessive curvature or, conversely, smoothing of normal lumbar lordosis is closely assessed. A hump is formed with an acute kyphotic angle, which may be the result of a fracture or an anomaly in the development of the thoracic spine, an inclined position or curvature of the pelvis, a difference in the tone of the paravertebral or gluteal muscles. In case of acute pain along the inflamed sciatic nerve (sciatica), it is possible to reveal the forced position of the lower back due to muscle tension. This antalgic scoliosis slightly reduces the severity of pain from nerve tension in the patient.
Asking a patient about old injuries he has received does not always help to identify the causes of lower back pain. Clarification of the time of onset and the circumstances of the onset of pain gives the doctor a neurologist or neurosurgeon much more information necessary for making an accurate diagnosis.
Also, when examining a patient by a doctor, his biomechanics is studied. The spine, hip joints, and legs are assessed as the patient performs certain active movements. Patient movement limitations may be noted when undressing, laying down, or getting up from the examination couch or chair during a consultation. When the trunk is tilted forward from a standing position, normal human lumbar lordosis is smoothed and the curvature of the thoracic spine (thoracic kyphosis) increases. With back pain, when the posterior ligaments or sacrospinous muscles are tense, the articular surfaces of the intervertebral are inflamed, with ruptures of the intervertebral discs of the lumbar spine, protective reflexes prevent stretching of these structures of the spine. As a result, the sacrospinous muscles remain tense and restrict movement in the lumbar spine. Forward flexion for lower back pain will occur at the expense of the hip joints and the thoracolumbar junction. With inflammation of the lumbosacral joints (sacroiliitis) and compression of the roots of the spinal nerves, the patient leans forward to avoid tension in the muscles of the tendons limiting the popliteal fossa from the sides, shifting the main load to the pelvis. With unilateral sciatica, the curvature will be increased towards the source of lower back pain. Movements in the patient's lower back will be accompanied by muscle tension, soreness. The patient will try to tilt the torso forward at the expense of the hip joints. The knee on the affected side can be bent to relieve hamstring spasm, while the pelvis is tilted back to relieve tension on the spinal nerve root and sciatic nerve in general.
If the patient's ligaments or muscles are tense, performing a tilt in the opposite direction will increase the pain due to the tension of the soft tissues of the spine. With lateral and paramedian hernias and protrusions of the intervertebral discs, the inclination towards the injury will be impossible or severely limited due to increased pain. For pain in the lower back, flexion in a sitting position with bent hip joints and knees can usually be done easily until the knees come into contact with the chest. This is because flexion of the knee relieves tension in the patient's hamstrings and also relieves tension on the sciatic nerve.
For lower back pain and sciatica, passive flexion of the lower back in the supine position causes mild pain. If the patient's knees are bent (the tension of the sciatic nerve is reduced), movement occurs freely. With diseases of the lumbosacral and lumbar spine (for example, with arthritis), passive flexion of the hip joints occurs freely or with minor pulling pain in the lower back due to the gluteal muscles. Passive lifting of a straight leg, which in most healthy people occurs without pain up to 80-90 ° (except for those with poor stretching of the muscles of the back of the leg), leads to tension on the sciatic nerve and its roots, causing pain. Low back pain can occur when the pelvis rotates around the transverse axis. This movement increases the load on the joints of the lumbosacral spine. With arthritis or arthrosis, the patient will complain of pain when moving. In diseases of the intervertebral joints of the lumbosacral spine and compression of the roots of the spinal nerves, this movement is limited on the side of the lesion compared to the opposite side of the body.
Lasegue's symptoms (pain and limited mobility when the hip is flexed with the knee extended) can help diagnose lower back pain. Raising a straightened leg on the opposite side of the lesion can also cause localized pain. This pain will be weaker than on the side of the disease, but it may be a sign of more serious destruction of a fragment of the intervertebral disc, and not just its prolapse (hernia) or protrusion (protrusion). The pain caused by this test in the patient will always radiate (radiate) to the affected side of the lower back, regardless of which leg was raised.
The backward bending of the body is most easily performed when a patient is standing or lying on his stomach. With an exacerbation of the disease, it may be difficult for the patient to straighten the spine in a standing position. A person with tension in the lower back or with a protrusion or herniated disc can usually straighten or bend the spine back without increasing pain. If the damage is localized in the upper lumbar segments of the spine or there is an active inflammatory process or a fracture (crack) of the vertebral body or posterior vertebral structures, then, due to the increasing backward bending, it can be significantly difficult.
Palpation and tapping in the projection of the spine are carried out at the end of the examination of the patient. It is advisable to start palpation from an area that initially cannot serve as a source of pain so that the patient can relax tense back muscles without fear of increasing pain when examined by a neurologist or neurosurgeon. The examining physician, a neurologist or neurosurgeon, should always know which structures can be accessible to the patient by palpation of the lower back. Local pain when pressing with a finger in the lumbar region in a patient is rarely found with a disease of the spine. The structures of the spine in the case of disease at the level of the lumbar are located so deep that they can rarely give soreness on superficial palpation. Mild pain on the surface or poorly localized pain on palpation of the lower back can only indicate a pathological process within the affected segment on the surface of the body in the area of innervation of the skin by this particular nerve.
Pain with pressure in the projection of the costal-vertebral angle can be in case of kidney disease, adrenal glands, or damage to the transverse processes of the LI or LII vertebrae. Increased sensitivity to palpation of the transverse processes of the remaining lumbar vertebrae and the sacrospinous muscles passing over them may indicate a fracture of the transverse process of the vertebra or muscle tension at the points of their attachment to the spine. Pain on palpation of the spinous process of the vertebra or increased pain due to tapping on it is a nonspecific symptom. This pain may indicate damage to the intervertebral disc in its central part, inflammation (discitis), or a fracture. Pain from pressure in the projection of the articular surfaces between the LV and SI vertebrae can occur when the intervertebral discs are affected. Pain in this area is often found in rheumatoid arthritis (infectious nonspecific, progressive, deforming inflammation of the joint).
During palpation of the spinous process, a neuropathologist or neurosurgeon notes any deviation from the central line to the side or up and down, because this may indicate a fracture or arthritis of the intervertebral joint. If the spinous process is displaced forward ("sinks" relative to the surface), the patient may reveal the instability of the spine with the displacement of the vertebra anteriorly relative to the underlying vertebra (spondylolisthesis).
Examination of the abdominal cavity, rectum, and pelvic organs with an assessment of the condition of the peripheral vessels in the legs are also important components of the examination of a patient with complaints of pain in the lower back, which should not be neglected. Without them, you can skip diseases of the vessels, internal organs, the presence of a tumor or inflammation, which can extend to the spine or cause pain, which is reflected in this area.
During a neurological examination, the patient is carefully examined for changes in movement disorders, impaired reflexes, and sensitivity in the legs.
According to the results of a neurological and orthopedic examination of a patient with a pain symptom against the background of osteochondrosis of the spine, the following additional diagnostic procedures can be prescribed:
- X-ray of the lumbosacral spine with functional tests
- CT scan of the lumbosacral spine
- MRI of the lumbosacral spine
The center of the intervertebral disc is a gelatinous nucleus pulposus. It is surrounded and supported by a fibrous ring, consisting of fibrous-cartilaginous and connective tissue. You can read more about this in the article on the anatomy of the human spine and spinal cord.
The thickness of the discs decreases, the vertebral bodies approach each other, reducing the intervertebral foramen and endangering the nerves and vessels located in them (osteochondrosis).
Protrusion of discs (protrusion or prolapse of the intervertebral disc) with their further prolapse into the lumen of the spinal canal (hernia or extrusion of the intervertebral disc) most often leads to compression of the nerve roots, causing pain along the squeezed nerve (pain radiating to the leg, arm, back of the head, neck, intercostal spaces depending on the level of nerve compression) with a weakening of muscle strength in the areas of their innervation and impaired sensitivity.
Often, a protrusion or herniated disc is accompanied by a symptom of muscle pain or radicular pain along the nerve in the leg. With this radicular compression symptom, one nerve root is squeezed or two nerves at once.
In addition to the symptom of nerve compression by a hernia or protrusion of the intervertebral disc in the lumbar spine, the stability of the spinal motor segment may also be impaired. With the instability of the spine, the vertebra is displaced:
- forward displacement of the vertebra (anterolisthesis)
- posterior displacement of the vertebra (retrolisthesis)
To clarify the diagnosis of spinal instability, an X-ray of the lumbosacral spine with functional tests may be required.
Most often, a symptom of compression with a hernia or protrusion of an intervertebral disc is formed by nerve bundles that make up the sciatic nerve. The sciatic nerve consists of fibers L5, S1, S2, S3 - spinal nerves.
A focus of chronic inflammation in the lumen of the spinal canal can lead to the formation of its narrowing (stenosis of the spinal canal) and compression of the nerves and spinal cord passing through it. That is why in case of stenosis of the spinal canal, it is always necessary to carry out a full course of treatment with the use of a whole arsenal of different therapeutic methods, and in case of ineffectiveness, surgical treatment.
Spinal pain treatment
Depending on the severity of the manifestations and causes of back and lower back pain against the background of osteochondrosis of the spine with disc herniation or disc protrusion, the patient may have the following therapeutic actions:
- drug therapy (NSAIDs, analgesics, hormones)
- therapeutic injections - injections of drugs into the cavity of the intervertebral joint, spinal canal, trigger points in the muscles
- manual therapy (non-surgical "reduction" of the vertebral disc herniation using muscle, articular and radicular techniques)
- physiotherapy (UHF, TENS, etc.)
- surgical treatment
The intervertebral joints of the lumbar, thoracic or cervical spine (facet joints) can also be treated with blockages. Therapeutic injections with local anesthetic and hormonal drugs are performed to accelerate the relief of pain and inflammation and obtain an early positive clinical effect.
Usually, for therapeutic injections, low doses of an anesthetic (novocaine, lidocaine) and cortisone, diprospan or renalog, injected into the lumen of the affected joint, are sufficient.
When combined with a properly selected physiotherapy regimen, these therapeutic blocks can have a good and long-term effect on lumbar and sacral pain in a herniated disc or disc protrusion in a patient with spinal osteochondrosis.
In the treatment of pain in the leg and buttock against the background of spinal osteochondrosis with a herniated disc or protrusion of the intervertebral disc, the elimination of soreness, tingling, and restoration of sensitivity in the leg with sciatic nerve neuritis in the case of compression requires the use of physiotherapy.
Wearing a semi-rigid lumbosacral corset in the treatment of back and lower back pain associated with osteochondrosis of the spine with a herniated disc or protrusion of the intervertebral disc helps to limit the range of motion in the lumbar spine. This primarily helps to reduce pain in the area of inflammation of the intervertebral joints and relieve excessive protective tension and spasm of the back muscles.
In such a corset, a patient with back and lower back pain on the background of osteochondrosis of the spine with a herniated disc or protrusion of an intervertebral disc can move independently at home and outdoors, and even sit in the car and at the workplace. The patient no longer needs to wear a corset as soon as the back pain subsides.
But it must be remembered that during the period of exacerbation of pain in the back and lower back against the background of osteochondrosis of the spine with a herniated disc or protrusion of an intervertebral disc, workloads should be avoided and rest should be observed. This is a temporary limitation, but it significantly shortens the recovery time and, against the background of the treatment being carried out, does not allow the disease of the spine to develop further.
There are several types of semi-rigid lumbosacral corsets. All of them are selected individually in size and can be used repeatedly in case of recurrence of pain in the back and lower back against the background of osteochondrosis of the spine, as well as for the prevention of possible exacerbations of the pain symptom.