Lower back pain: an algorithm for diagnosis and therapy

Lumbar pain with or without irradiation to the leg (low back pain) is the most common pain syndrome in outpatient practice. 30-60% of the population of developed countries suffer from recurrent back pain, and up to 80% of all back pain occurs in the lumbar region of the back. All age groups can suffer from lumbar pain, but the peak incidence occurs between the ages of 30 and 60.

The reasons
Low back pain (LBP) is a non-specific symptom that can be caused by a variety of reasons. For convenience, we will single out the primary and secondary syndromes of BNS. Most BNS are based on musculoskeletal morphofunctional changes (primary BNS syndrome). These are, first of all, degenerative-dystrophic lesions of the spine: 1) osteochondrosis (degenerative lesion of the intervertebral disc and adjacent vertebral bodies with the formation of spondylosis); 2) spondyloarthrosis [arthrosis of the intervertebral (facet) joints, which are common synovial joints)]. It was shown that the processes of degeneration in the intervertebral and peripheral joints are not fundamentally different. Functionally reversible blockage of the intervertebral joints is also of great importance in the origin of pain. Functional blockage of joints may precede the development of spondyloarthrosis and osteochondrosis, this explains the pain syndrome, for example, in adolescents, and can occur in already affected joints, causing clinical manifestations of vertebrogenic pathology. Muscles almost always respond to the appearance of painful impulses with a tonic reflex reaction. Physiological justification of muscle tension that follows any pain is to immobilize the affected area of ​​the body, create a muscle corset. However, the spasmodic muscle itself becomes a source of additional pain. In addition, muscles may suffer primarily, and not after morphological or functional disorders in the spine. Excessive tension in a number of muscle groups, due to a variety of reasons from antiphysiological posture to muscle distress caused by anxiety, leads to dysfunction of myofascial tissues with the formation of pain syndrome. Myofascial pain syndromes can be observed both regardless of vertebral pathology, and complicate almost any vertebral pain. The pain associated with the described causes are relatively benign.

Possible causes of the secondary syndrome LBP
primary and metastatic vertebral tumor, spinal cord, retroperitoneal space
Vertebral fractures
infectious lesion vertebrae and intervertebral discs (tuberculosis, brucellosis, epidural abscess)
Non-infectious inflammatory diseases (ankylosing spondylitis, Reiter’s syndrome, rheumatoid arthritis),
metabolic bone disease (osteoporosis , osteomalacia)
Growth diseases (scoliosis)
Acute disorders of the spinal circulation
Reflected pain in diseases of the pelvic organs (including renal colic, gynecological diseases)

Symptoms are indicators of a serious spinal pathology
Lack of history of back pain
High pain intensity
Independence of pain intensity from body position and movements
Increased pain at night
Age under 20 and over 55
Recent trauma
Risk factors for developing spinal infection (presence of urogenital infection, drug immune suppression (steroid use), HIV)
History of cancer
Fever and unexplained weight loss
General weakness
Pelvic disorders
Progressive neurological deficit
Gait disorder

Clinical manifestations of radiculopathy

1. Intense, sharp, shooting pains, radiating to the toes (“long” pain). The pain intensifies when moving in the lumbar spine
2. Symptoms accompanying the pain: numbness, tingling, burning
3. Symptoms of loss of root functions (hypesthesia, loss of reflexes, muscle weakness and muscle
wasting 4. Lasegue’s test is accompanied by intense pain in the lower back with irradiation along the affected person root
5. On palpation, tension and soreness of the paravertebral muscles

Clinical manifestations of muscle-tonic syndrome

1. Dull, deep pain within the spasmodic muscle (“short” pain). The pain is provoked by movement with the participation of the corresponding muscle
2. The Lasegue test is accompanied by local pain in the lower back or hip
3. On palpation, the muscle is tense, painful, with local hypertonicity.

Psychosocial factors contributing to pain chronicity
Social or financial problems
Emotional stress at the onset of the disease
Avoidant behavior and reduction of the active position in the strategy of coping with conflict situations (secondary benefit from the disease)
Expectation that back pain is a manifestation of a “dangerous” disease and can cause disability
Tendency to depression and social addiction

Pain management strategy

At the same time, there are other significantly rarer, but potentially more dangerous causes of pain in the lower back, which the doctor should remember about in order to avoid diagnostic errors (Table 1).
For example, in elderly patients,
especially in postmenopausal women, who suddenly develop excruciating pain, X-ray examination often reveals pathological vertebral fractures associated with osteoporosis. The possibility of the debut of a serious spinal and visceral pathology with banal back pain requires constant medical vigilance and the immediate intervention of a specialist doctor.

If the patient has symptoms presented in table. 2, he should be immediately referred to a specialist for further examination.
In the absence of symptoms presented in table. 2, there is a high probability that the pain is relatively benign. Pain caused by the musculoskeletal factor has a number of features: there is
no correlation between the severity of osteochondrosis, spondyloarthrosis and the intensity of the pain syndrome, the
pain is unstable while maintaining or even progressing anatomical pathology.

Therefore, in the diagnosis of this category of pain, the main emphasis should be on clinical manifestations, and not on radiological findings. Osteochondrosis of the spine is most often complicated by reflex muscular-tonic syndromes (85%) or significantly less often by compression syndromes in the form of radiculopathy (15%).
Radiculopathies are manifested by the symptoms presented in table. 3. Isolated pains, even strictly corresponding to the zone of innervation of the affected root, cannot be regarded as radiculopathy. The most important symptom for diagnosing radiculopathy is the combination of pain and prolapse symptoms. The pain associated with radiculopathy is not in itself an indication for surgery and is very effectively treated conservatively (treatment can last 6-8 weeks). Therefore, patients with radicular pain and minor neurological deficits are treated conservatively, and only if conservative treatment is ineffective and compression proven by neuroimaging, the possibilities of surgical intervention are discussed.
Reflex muscle-tonic syndromes are characterized by pain of varying intensity. Any paravertebral and extravertebral muscles can be involved in the pathological process, but the leaders are the piriform, gluteus medius and paravertebral at the lumbar level. Clinical features of reflex muscular-tonic syndrome are presented in table. 4.
Myofascial syndromes are especially difficult to diagnose, since they are manifested by “reflected” pain. Diagnostics is based on finding a spasmodic, painful muscle on palpation with characteristic local hypertonicities, pressing on which reproduces the patient’s usual pain at a distance from the spasmodic muscle.

It is extremely important to assess the duration of the pain syndrome: acute or chronic. If pain persists for more than six weeks, chronic pain can be expected. Long-term pain is associated either with the involvement of the root in the pathological process, or with an erroneous diagnosis, and an additional examination of the patient is necessary to exclude serious spinal pathology. But most often the chronicity of pain is associated with psychological reasons. The presence in the patient of the factors presented in table. 5, contributes to the chronicity of pain and can seriously affect the success of treatment.

Examination of the patient includes: determination of the degree of difficulty in movement due to pain, when lifting the leg up, examination of symptoms of tension, muscle tone and local hypertonicity, as well as neurological status. First of all, in the neurological status, the zones of parasthesia and / or hypoesthesia, dorsoflexion of the foot and big toe, knee and Achilles reflexes should be examined. Of the additional methods, clinical analyzes of urine and blood, ultrasound of internal organs and small pelvis play an important role. X-ray of the spine is performed in frontal and lateral projection in states of extreme flexion and extension and is supplemented by CT or MRI studies. Magnetic resonance imaging is more informative for imaging the spinal cord. However, the possibilities of radiological research methods should not be overestimated, the doctor must constantly remember about the “insidiousness” of the pain syndrome and the many reasons that cause it. The presence of osteochondrosis does not exclude other reasons for the manifestation of lumbar pain, for example, renal pathology.
Factors provoking BNS. Overweight, a sedentary lifestyle, smoking, hard physical work, prolonged stay in an antiphysiological position, unsuccessful, sharp turns can cause exacerbation of back pain.
Management of patients with lower back pain. If there is no suspicion or a serious spinal pathology is excluded , it is necessary to inform the patient about the favorable prognosis of the disease and the high probability of complete regression of the acute pain episode.
Treatment consists in effective pain relief of the patient and its early activation. Rapid activation contributes to the regression of symptoms and reduces the risk of chronic pain. The patient should be aware that the return to normal activity should begin as soon as possible. The intensity of the pain syndrome serves as a guideline in increasing motor activity. Expansion of the patient’s motor abilities should not aggravate the pain syndrome.
Non-steroidal anti-inflammatory drugs (NSAIDs) are the gold standard for back pain.
In turn, diclofenac sodium, which combines high efficiency and safety, is considered the “gold standard” among NSAIDs. The duration of use and the method of administration of NSAIDs depend on the intensity of the pain syndrome. With moderate pain syndromes that do not limit the patient’s motor capabilities, it is possible to apply gels and ointments containing diclofenac sodium to the painful areas (spasmodic muscle) for 7-10 days. In case of intense pain, significantly limiting the movement of the patient within the room, injection routes of diclofenac sodium administration are used for 3-7 days with a further transition to oral forms. The average duration of treatment is 3-4 weeks and may increase with radiculopathy.
Severe pain or lack of success from NSAIDs requires the use of stronger analgesics such as tramadol. Depending on the intensity of the pain syndrome, a variety of analgesics are used to relieve it – from NSAIDs to narcotic analgesics (see diagram).
Considering that muscles are almost always involved in the pathological process, it is advisable to combine NSAIDs with muscle relaxants. Such a combination can shorten the duration of treatment and reduce the risk of developing side effects of NSAIDs by reducing the dosage of the latter in combination therapy. At the same time, the muscle relaxant tizanidine has a direct protective effect against irritation of the gastrointestinal tract caused by NSAIDs by suppressing gastric acid secretion. The recommended daily dose of tizanidine is 6 mg per day in 2 or 3 divided doses. In cases of an acute painful episode, a combination of NSAIDs and a muscle relaxant is prescribed for 5-7 days. In chronic pain syndromes, this combination is prescribed depending on the actual needs without limiting the duration of treatment. Physical therapy and physical therapy are essential methods of rehabilitation treatment.
The presence of symptoms of depression in a patient and / or chronicity of pain is an indication for the prescription of antidepressants or psychotherapeutic treatment. Antidepressants are the first-line drugs of choice in the treatment of chronic pain syndromes. The prescription of anticonvulsants also enhances the analgesic effect. Thus, the choice of an analgesic depends on the intensity of the pain syndrome and its duration (see diagram).
It is necessary to encourage the patient to make a positive change in life style (avoidance of antiphysiological postures, rational equipment of the workplace, cessation of smoking, weight control, exercise therapy, annual massage courses, possession of autogenous training with the ability to relax muscles).

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