Back pain in the lumbar region

About 40-80% of people complain of back pain in the lumbar region, but no more than 25% of them seek medical help. In fact, such unpleasant sensations can be caused by both relatively harmless reasons and pathological changes in the spine. Therefore, they should not be treated with contempt.

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, of different nature. In addition, the spinal column is surrounded by paravertebral muscles, a pain in which patients often confuse it with pain in the spine. Thus, the causes of pain can be numerous. It can be overload, natural restructuring of the body during pregnancy, etc. But if the pain occurs regularly, it is worth contacting a vertebrologist or neurologist, because often the fact that the spine systematically hurts in the lumbar region indicates the development of certain diseases.

Most often in such situations patients are diagnosed with:

• pathology of intervertebral discs (reduced disc height, protrusion, intervertebral hernia, dyskitis);
• pathologies of facet joints (spondyloarthritis, joint cysts);
• inflammatory diseases (ankylosing spondylitis or ankylosing spondylitis, reactive arthritis, psoriatic arthritis)
• compression fractures of the spine on the background of osteoporosis;
• neoplastic lesions of the spine.

Pathologies of the intervertebral disc

Degenerative changes in the intervertebral discs or osteochondrosis are very common, especially in younger and middle-aged people. This is mainly due to the need to sit for a long time or to do hard physical work. In old age, the disc dries out and the vertebrae grow together.

Already in the initial stages of the occurrence of degenerative changes on 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 of the outer layers of the disc as well as the posterior longitudinal ligament of the spine. Osteochondrosis often causes an aseptic inflammatory process, which leads to reflex spasm of segmental muscles. As a result, pain in the spine increases, and there are limitations in mobility.

Osteochondrosis tends to progress steadily, especially in the absence of appropriate treatment and lifestyle adjustments. After that, protrusions form, and later intervertebral hernias, which causes the worsening of the existing symptoms and the appearance of new ones.

The lumbar region, due to the fact that it carries the greatest loads in daily activities, is most often affected.

Protrusions are protrusions of the disc while maintaining the integrity of its outer shell, called the annulus fibrosus. While maintaining the influence of provoking factors over time, the fibers of the annulus fibrosus do not withstand the load and pressure of the internal contents of the disc (nucleus pulposus) and burst. As a result, the nucleus crosses the physiological position of the intervertebral disc. At the same time, the spine in the lumbar region always hurts or the pain radiates to the leg, and the discomfort increases with sudden movements, bending, lifting heavy objects, straining, coughing, sneezing, laughing, as well as when sitting for a long time. one position, walking, standing.

Often patients with already formed protrusions and hernias unconsciously take a forced posture, leaning slightly to the healthy side. In this case, the pain in the spine in the lumbar region can reach a high intensity, depriving the person of the ability to work. In such cases, he is forced to adhere to rest in bed, and in order to alleviate the pain, he tightens his leg bent and brought to his stomach.

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

Therefore, often with long-term osteochondrosis, the formation of a hernia in the lumbar region, the pain in the spine gradually not only intensifies, but is also supplemented by other disorders. If a deformed disc or soft tissue swollen as a result of the inflammatory process compresses the spinal root that passes next to them, neurological disorders occur. Therefore, pain in the spine in the lumbar region can be supplemented by radiation to the buttocks, groin, front, inner, outer thigh, lower leg and foot. It depends on what kind of nerve root will be damaged, ie at whose level pathological changes of the spinal movement segment will be noticed. Also, in the corresponding zones of the lower extremities, sensitivity disorders in the form of creeping sensation, numbness, changes in sensitivity to temperature, pain, tactile stimuli and limited mobility can be observed.

Changes in the height and functionality of the 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 is the development of spondylosis, ie calcification of the anterior longitudinal ligament and the formation of bone-cartilage growths on the surface of the vertebral body (osteophytes). They can not only injure the surrounding tissue and compress the spinal roots, causing severe pain in the spine, but also heal. As a result, the adjacent vertebral bodies merge into one whole, which severely limits mobility in the lower back.

Osteochondrosis can be accompanied by reactive changes in the vertebral bodies, especially reactive aseptic spondylitis, leading to osteosclerosis. This is accompanied by compaction of the bone tissue and dramatically increases the likelihood of vertebral fractures.

Facet joint diseases

Pathologies of the facet or facet joints of the lumbar spine, especially their arthrosis, can also cause pain in the spine in the lumbar region, including severe pain. Although more often the pain is 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 in the affected area and tends to intensify when bending, extending, turning the body, and standing for a long time. Walking and sitting help reduce their weight. But in some cases, pain can also occur in the groin, backbone, as well as in the back and outer thighs.

Inflammatory diseases of the spine

Inflammatory diseases of the spine are less common than pathologies of the intervertebral discs and facet joints. However, they also hurt the spine. This includes:

• ankylosing spondylitis or ankylosing spondylitis;
• reactive arthritis;
• psoriatic arthritis etc.

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

The most difficult situation is with ankylosing spondylitis, and it is the one that affects the lumbar region more often than other inflammatory diseases. This term refers to inflammation of the intervertebral joints with their subsequent immobilization due to the formation of dense bone, cartilage or fibrous fusion between the articular bone structures.

At the beginning, it is characterized by mild back pain, but over time it gradually spreads, covering the thoracic and then the cervical spine. This is related to the development of restrictions on the mobility of the spine in all planes, because the spinal column, as a result of the changes that occur, seems to be immersed in a specific case. Also noticed:

• alignment of lumbar lordosis (natural curvature of the spine in the lumbar region);
• exacerbation of thoracic kyphosis, which causes bending;
• reflex tension of the back muscles;
• progressive worsening of mobility limitations due to the involvement of facet joints in the pathological process and ossification of intervertebral discs;
• morning stiffness of an hour or more.

Inflammation of the iris (iritis), cornea (keratitis), mucous membranes (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 in the pathological process. As a result, patients are forced to take the so-called petitioner pose. This means a pronounced kyphosis of the thoracic spine, tilting the upper body down, bending the knee with a sharp limitation of the range of motion in the chest, which affects the depth of breathing.

The rate of disease progression depends on the adequacy and completeness of treatment.

Compression vertebral fracture

A compression fracture is a flattening of the vertebral body, causing it to become wedge-shaped. This leads to disruption of the anatomy of the spine, can cause trauma to the spinal cord and its roots, and also becomes a trigger for the rapid progression of degenerative-dystrophic changes.

Lumbar vertebrae 1 and 2 are more susceptible to injury because they take the greatest axial load.

Compression fractures of the spine often occur in the elderly due to the development of osteoporosis, or a decrease in bone density. In such cases, to injure yourself, not only a slight fall, but also weight lifting, unsuccessful movement may be sufficient.

The pathology is characterized by the presence of pain in the spine, which restricts movement, intensifies when sitting, movements and attempts to lift the straight leg up. It usually lasts 1-2 weeks, and then gradually decreases over 2-3 months. In some cases, there is irradiation of pain to the tips of the iliac bones and hips. A decrease in the height of a broken vertebra causes an increase in lumbar lordosis, which also contributes to the appearance of painful sensations.

If the fracture is not diagnosed in time, a decrease in the height of the vertebrae leads to a change in posture, a decrease in growth. This causes reflex tension and shortening of the spine muscles, which causes chronic back pain and requires a long rest.

Neoplastic spinal lesions

Neoplastic lesions of the spine mean the formation of benign and malignant tumors in it, as well as metastases whose source is neoplasms of other organs. It is much less common than pathologies of intervertebral discs, facet joints, ankylosing spondylitis, and even compression fractures, namely only in 1-2% of patients with back pain. But such lesions require early diagnosis and treatment.

Characteristic characteristics of neoplastic lesions of the spine, in addition to pain in it, are:

• increase in body temperature, including to subfebrile values;
• unreasonable weight loss;
• inability to find a comfortable body position;
• the presence of pain at night;
• severe back pain;
• 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 immediately.

In a similar way, the following may occur:

• Chondroma is a malignant tumor that is diagnosed in 20% of patients with cancerous lesions of the spine. It is most often formed in the sacrum and can occur in people of any age and gender.
• Young's sarcoma - occurs in 8% of patients with neoplastic spinal lesions. More common in young men.
• Chondrosarcoma is a malignant neoplasm, which accounts for 7-12% of cases. It is more common in middle-aged men.
• An aneurysmal bone cyst is a benign neoplasm.
• Hemangioma is a benign vascular tumor that is present in 11% of people. It may not be revealed during a person's lifetime. But it increases the risk of vertebral fractures.
• Metastases of other tumors are secondary malignant neoplasms. More often, breast, prostate, lung, and less often cancers of the kidneys, thyroid gland and skin metastasize to the spine.

Diagnosis

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

Then the specialist performs an examination. Within this, he not only palpates the spine, determines the localization of pain, assesses the gait and posture that the patient unconsciously takes, but also conducts functional tests. With their help, you can detect signs of ankylosing spondylitis, neurological deficits, assess the degree of spinal mobility, and obtain other diagnostic data.

Based on this, the doctor can already guess the possible causes of the pain syndrome. Instrumental and sometimes laboratory diagnostic methods are additionally prescribed to clarify them, as well as to precisely determine the degree of damage. Most often they resort to help:

• radiography in frontal and lateral projection, sometimes with functional radiological tests;
• CT - enables better visualization of bone structures, so it is more often used to diagnose spondylosis, fractures, bone tumors, etc. ;
• MRI - allows the assessment of the condition of cartilage structures and soft tissues as accurately as possible, so it is often used to diagnose osteochondrosis, protrusions, intervertebral hernias, spinal cord lesions, etc. ;
• electromyography - indicated for neurological disorders of unknown origin, 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 method for diagnosing osteoporosis;
• myelography - used to detect signs of compression of the spinal cord and cauda equina nerves.

Treatment

For each patient, treatment is selected strictly on an individual basis, not only on the basis of diagnosis, but also the nature of existing comorbidities. However, the cause of back pain determines the tactics of therapy. It can be conservative or involve surgery.

But the first step is to always focus your efforts on pain relief, especially if it is strong. For this, patients are prescribed nonsteroidal anti-inflammatory drugs, antispasmodics, painkillers. And in severe cases, spinal blockades are performed - injections of anesthetics and corticosteroids at certain points in the spine.

Bed rest is not indicated for all patients. And in pathologies of intervertebral discs may be completely contraindicated, because the reduction of physical activity contributes to the transformation of acute pain in the spine into chronic.

Exclusively conservative or non-surgical treatment is prescribed for:

• osteochondrosis;
• ankylosing spondylitis;
• arthrosis of facet joints;
• light compression fractures.

It is usually complex and consists of:

• drug therapy, which may include NSAIDs, chondroprotectors, muscle relaxants, immunosuppressants, corticosteroids,
• physiotherapy (UHF, magnetotherapy, laser therapy, traction therapy, etc. );
• Exercise therapy;
• manual therapy.

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

• ineffectiveness of conservative therapy for degenerative-dystrophic changes;
• increase in neurological deficit;
• spinal movement segment instability;
• development of complications, especially spinal canal stenosis.

Most modern spinal surgeries are minimally invasive. Thanks to that, intraoperative and postoperative risks are sharply reduced, the rehabilitation period is shortened and facilitated, and the efficiency is not inferior to more traumatic open operations. Depending on the detected disease, it may be recommended:

• Discectomy is an operation indicated mainly for hernias and protrusions, especially those that cause cauda equina syndrome. It can be performed with microsurgical instruments through a 3 cm incision (microdiscectomy) and endoscopic equipment that is inserted into the spine through puncture punctures about 1 cm in diameter (endoscopic discectomy). When the intervertebral disc is completely removed, it is usually replaced with implants.
• Vertebroplasty and kyphoplasty - indicated for compression fractures of the spine, hemangiomas and some other diseases. The essence of the operation is that a thin hardening of the bone cement is injected into the vertebral body through a thin cannula, which strengthens it. Kyphoplasty additionally makes it possible to restore the normal dimensions of the vertebral body, which is important in the case of a serious reduction in their height as a result of a fracture.
• Fixation surgeries are used to stabilize the spine. For that, metal constructions of different nature are used, which usually remain in the patient's body for the rest of his life.

So, the spine in the lumbar region can hurt for various reasons. Therefore, with prolonged persistence of painful sensations, their regular appearance, increased pain over time, and even more with the addition of other symptoms, it is necessary to consult a vertebrologist or neurologist. Early diagnosis will allow the detection of pathological changes in the stages when they are easiest to deal with, and if the disease is not completely cured, then at least stop its progression and maintain a high standard of living.