Low back pain is a very common symptom, especially in men a lot, the following introduction is more professional, I hope you refer to understand, do not just with your symptoms of raw.
I. Overview
Low back pain is a painful sensation in the low back caused by local inflammation, trauma or certain organs and systemic diseases. Low back tissues from the outside in include skin, subcutaneous tissues, muscles, ligaments, spine, ribs, spinal cord, etc. Lesions of any of the above tissues can cause low back pain. Clinically, spinal diseases (including vertebrae, ligaments, intervertebral discs, etc.) are the most common, followed by radioactive low back pain caused by lesions in the adjacent organs of the low back (such as pleura, lung, kidney, pancreas, rectum, prostate, uterus, etc.).
II. Mechanism of occurrence
Some mechanisms of the occurrence of low back pain are clear, but many are still unknown. With the progress of basic research, there is a new understanding of the complex and fine spinal structure and the multi-origin of low back pain, and further understanding of the intricate connotation and complex mechanism of low back pain. Several biochemicals and neuropeptides can directly stimulate pain or lower the pain threshold, and endogenous substances released from injured or inflamed tissues act as a bridge between injurious stimuli and pain receptor firing.
Local lesion pain is due to stimulation of sensory nerve endings, seen in lesions or strains of the periosteum, ligaments, tendons, muscles, and joints involved; low back pain caused by lesions of the thoracic, abdominal, and pelvic visceral organs is mainly due to entrapment pain: the impulses of visceral pain excite the neurons of the corresponding spinal cord segments via afferent fibers, and pain sensation is reduced so that normal impulses from the same cortex cause nociception or Nociceptive hypersensitivity; nerve root pain is caused by stimulation of spinal nerve roots, often manifesting as radiating pain, with pain radiating along the posterior root distribution area of spinal nerves; pain due to muscle spasm is caused by local or nerve root lesions causing muscle spasm in the relevant local area.
Common causes
The causes of low back pain are complex and diverse, and can be divided into four major categories according to anatomical sites.
(A) Low back pain caused by spinal lesions
Ankylosing spondylitis, proliferative spondylitis, infectious spondylitis (tuberculous or septic), spinal trauma, disc prolapse, spinal tumor or metastatic cancer, congenital malformation of the spine, etc.
(B) Low back pain due to paravertebral soft tissue diseases
Lumbar muscle strain, myofibrosis, pear-shaped muscle injury syndrome, rheumatic polymyalgia, etc.
(C) low back pain caused by spinal nerve root and dermal neuropathy
Spinal cord compression, acute myelitis, herpes zoster, etc.
(iv) Low back pain caused by visceral diseases
Thoracic, abdominal, pelvic and retroperitoneal visceral diseases can cause low back pain, but kidney, pancreatic and pelvic diseases are more common.
IV. Accompanying symptoms
Low back pain with spinal deformity is seen in trauma, congenital deformity, vertebral tuberculosis, etc.; with restricted activity is seen in ankylosing spondylitis, disc prolapse, etc.; with fever is common in systemic diseases (such as acute infectious disease, diffuse connective tissue disease, etc.), with long-term low fever is seen in vertebral tuberculosis, etc;
The presence of intractable back pain and radioactive neuralgia in older people is seen in spinal tumors, and special attention should be paid to metastatic cancer (such as common prostate cancer, breast cancer, kidney cancer, lung cancer metastasis, etc.); low back pain with frequent, urgent and painful urination is seen in urinary tract infection, etc.; low back pain with abnormal menstruation and dysmenorrhea is seen in gynecological diseases such as adnexitis, pelvic inflammatory disease, ovarian or uterine tumors, etc.
V. Differentiation points
(A) Low back pain caused by spinal lesions
1, Ankylosing Spondylitis (AS) is a chronic inflammatory disease that mainly affects the medial joints (especially the bilateral sacroiliac joints), the onset of which is related to genetics, infection and other environmental factors. The disease tends to develop from the bottom up and involves the lumbar, thoracic and cervical spine successively. Low back pain or discomfort is a common manifestation of AS. This discomfort cannot be relieved by rest, but can be relieved by light activity or taking anti-inflammatory and analgesic drugs, which is a significant feature of AS low back pain.
Another symptom of AS is morning stiffness. Patients feel stiffness in their lower back after waking up in the morning, which can be relieved after activity. The signs are anterior cervical tilt, thoracic kyphosis, flattening of the lumbar spine due to loss of normal physiological curvature, and bowing of the trunk with flexion at the hip joint. Radiologically, all patients with AS have sacroiliac arthritis, and some severe patients may have hip involvement;
The vertebral body may show osteoporosis, blurring of the synovial joint, square changes of the vertebral body, etc. In the advanced stage, it may show “bamboo-like” changes. Early sacroiliac arthritis X-ray is sometimes difficult to determine, feasible CT or MRI examination, to facilitate early diagnosis.
2. Proliferative spondylitis is more prevalent in people over middle age, but the age of onset can be advanced in heavy workers or athletes. The incidence is highest in the lumbar spine, followed by the thoracic and cervical spine. The main manifestation is chronic low back pain, which starts slowly, and the pain is usually not serious, often aggravated by trauma, changing position or cold, etc. The pain can be relieved after a short rest. When the lesion is severe, it is often complicated by nerve root irritation symptoms on one or both sides, and the nerve root pain spreads along the distribution area of the posterior spinal nerve, and the pain can sometimes be quite intense. In severe cases, the spine and paravertebral local pressure pain, muscle spasm, spinal activity caused by pain and restricted movement. x-ray characteristic changes are lipomatous hyperplasia of the vertebral margin, bone superfluous formation, sharp vertebral small joint margins, dense joint surface bone, joint space narrowing.
3, infectious spondylitis
(1) tuberculous spondylitis: spinal tuberculosis has a high incidence in 20-30 years old, often invading the section from the 10th thoracic vertebra to the 1st lumbar vertebra. There may be varying degrees of systemic toxicity, such as night sweats, slight fever, wasting, loss of appetite, and fatigue. The main clinical symptoms are back pain and muscle spasm. Back pain is often the first symptom of the disease, usually limited to the spine of the lesion, and is vague, dull or aching in nature, and is more pronounced at night, intensifying with shock or activity, with painful points in the spinous process, paraspinal process or interspinous process.
In thoracic spine tuberculosis, the pain radiates bilaterally to the chest, manifesting as intercostal neuralgia, and sometimes also radiates to the abdomen causing abdominal pain, which is easily misdiagnosed as abdominal cavity disease; lumbosacral spine tuberculosis often produces sciatica, etc. The back pain is often accompanied by spasm of the paravertebral muscles, resulting in restriction of spinal movement. On examination, the paravertebral muscles become stiff, the spine becomes rigid, spinal motion is impaired, and the pick-up test is positive. In the later stage, the lesion expands and a triad of symptoms appears in addition to back pain: kyphosis, cold abscess and spinal cord compression.
Cold abscesses in the thoracolumbar region may flow along the musculoskeletal sheath of the psoas muscle to the front of the thigh and the groin, but there are no signs of redness or heat, and fistulas may form in late stages and remain untreated for a long time. About 10-20% of patients have complications of spinal nerve root compression, with weakness of both lower limbs and even paraplegia. Early diagnosis of the disease is difficult, but in young people with back pain, poor general condition, slight fever, accelerated blood sedimentation, and a history of tuberculosis of the lungs or other organs, spinal tuberculosis should be suspected and further investigations are needed.
X-rays are very helpful for diagnosis, mainly showing blurred vertebral body edges, osteoporosis of adjacent vertebrae, bone destruction, cavity formation, narrowing of vertebral spaces, wedge-shaped vertebral bodies, fusion of two vertebral bodies with each other, and sometimes blurred edges of the psoas major muscle or shadows of cold abscesses next to the vertebral body. CT examination is more likely to detect early cases.
(2) Septic spondylitis: This disease is mainly a hematogenous infection, individual cases can be caused by infection after intervertebral disc surgery, lumbar puncture or myelography, etc. Occasionally, it can also be caused by the spread of infection in the adjacent tissues of the spine. The pathogen is mostly Staphylococcus aureus, most often involving the lumbar spine, followed by the thoracic spine, and less commonly the cervical and sacral spine. Clinical manifestations are divided into acute, subacute and chronic types.
The acute type is more common, with an acute onset, accompanied by high fever, chills, headache, or septicemia symptoms such as delirium or even confusion, and very intense low back pain. Some cases complain of severe pain in the thoracic back, localized percussion and pressure pain in the spinous processes of the spine, spinal ankylosis, severe pain caused by slight activity, and increased white blood cells; some cases are complicated by abscesses, and cervicothoracic lesions are often complicated by paraplegia. The subacute type has a slower onset than the acute type, and the systemic sepsis symptoms are mild. The chronic form is less common and may have a slight fever, localized spinal pain and movement disorders, rather like tuberculous spondylitis, but the patient’s past history of acute septic infection is an important point of differentiation.
Diagnostic points of septic spondylitis.
(1) A history of sepsis, which is the main clue to the diagnosis;
②positive bacterial culture of blood or pus;
③ typical X-ray signs: vertebral body and accessories can be involved, early osteophytes and sclerosis can appear, posterior convexity deformity of the spine is less common, only 1 to 2 adjacent vertebral body invasion, can be self-fusion.
4, spinal trauma vertebral fracture is often due to a fall from a height, the foot or hip first landing, the spine suddenly excessive forward flexion, and the occurrence of vertebral compression wedge fracture; also such as fixed objects from a high impact on the shoulder or back and lifting heavy objects when the loss of foot slipped, can occur vertebral compression fracture. Such flexion-type vertebral fractures are the most common, accounting for 90% of vertebral fracture cases, most often occurring in the 11th to 12th thoracic vertebrae and the 1st and 2nd lumbar vertebrae. In another case, the patient falls from a height on his back and lands on his waist and back first, causing excessive posterior extension of the spine, resulting in an extension-type vertebral fracture, which is rare. Key points for diagnosis of vertebral fracture: ① clear history of trauma; ② pressure and percussion pain at the fracture site, the spine may have a posterior or lateral convexity deformity, activity disorders, muscle spasm, and rarely local hematoma, and in severe cases, especially when combined with dislocation, often complicated by varying degrees of spinal nerve injury, such as thoracic or lumbar vertebral fractures appear below the fracture site paraplegia; ③ X-ray examination is the most reliable method to diagnose this disease.
5, disc prolapse The occurrence of this disease is closely related to trauma and strain, and patients often have a history of sprains during physical labor such as lifting heavy objects, lifting weights, bending over to carry water, and carrying heavy objects on the shoulder. The most easily prolapsed discs are lumbar 4~5 and lumbar 5~sacral l. The main symptoms are lumbar pain and sciatica, which can coexist or occur separately. The pain is severe like tearing, and is aggravated by coughing, sneezing and abdominal pressure, and relieved when lying in bed.
Lumbar scoliosis, changes in sensory and motor functions and reflexes, a positive straight leg raise test (Lasègue’s sign) and paraspinal pressure pain radiating to the calf or foot are important diagnostic signs. The patient’s complaints of pain in the affected limb when raising the healthy leg and the positive cross Lasègue sign have special significance in the diagnosis of lumbar disc prolapse, and this sign is of great value in establishing the diagnosis.
The presence of pressure points next to the spinous process with radiation to the calf or foot is of particular significance in localizing the diagnosis. It is emphasized that a correct conclusion can be reached based on a complete medical history, a meticulous physical examination, and the results of imaging examinations such as X-ray plain film, CT, and MRI.
6.Spinal tumor or metastatic cancer For older patients with sciatica, malignant tumor metastasis of the spine or multiple myeloma must be considered. Most spinal tumors are metastatic cancers, the most common being prostate cancer, followed by thyroid cancer, breast cancer, kidney cancer, lung cancer, etc. The lumbar spine is the most common site of metastasis.
The first manifestation of metastatic cancer of spine is intractable back pain and radioactive nerve root pain, which is severe and persistent and cannot be relieved by rest, medicine or physical therapy. x-ray examination, in the early stage of metastatic cancer, only osteoporosis is manifested, and in the late stage, bone destruction can appear. Elevated serum alkaline phosphatase is helpful for diagnosis, and bone marrow aspiration may find tumor cells.
7.Congenital malformation of spine Congenital malformation can occur in any part of the spine, but congenital malformation of lumbar spine is common, such as occult spina bifida, lumbar spine sacralization, sacral spine lumbarization, arch root disconnection, asymmetric lumbosacral joint and so on. Clinicians must be cautious when considering a congenital lumbosacral spinal deformity as a cause of low back pain. In a patient with chronic lower back pain, such congenital deformity is diagnostic only if the x-ray findings match the clinical findings (e.g., site of pressure pain, muscle spasm) and there is no other cause of low back pain. The diagnosis of all types of congenital spinal deformities must rely on radiographic plain films.
(B) Low back pain caused by paravertebral soft tissue diseases
1, lumbar muscle strain Acute lumbar muscle strain includes muscle, ligament and fascia strains or lacerations. Carrying or lifting heavy objects in a bent hip and knee position can easily sprain the sacrospinous muscle and the lumbar interspinous ligament.
Diagnostic points.
①History of trauma;
②Sudden onset of severe pain in the lumbar muscle on one or both sides;
③The main painful area is on the medial side of the posterior superior iliac spine, next to the 4th and 5th lumbar vertebrae, with muscle spasm;
④It may be accompanied by reflex leg pain, which is easily misdiagnosed as disc prolapse, but without signs of sciatica. After injection of procaine at the painful point, the leg pain disappears on its own, which confirms that the leg pain is caused by reflex and not by nerve root compression, so that it can be differentiated from leg pain caused by spinal tuberculosis, disc prolapse and spinal tumor.
Chronic lumbar strain can be the sequelae of incomplete treatment after acute sprains, and can also be caused by muscle ligament tears and strain due to continuous bending labor. The clinical characteristics are chronic intermittent or persistent pain around the lumbar muscles, which is aggravated by exertion and improves after rest, and the pain is not severe, but can last for months or even years.
2.Fibromyalgia syndrome is mainly a fibrous tissue lesion within the muscular membrane, tendons, ligaments and fatty tissues, with no specific pathological changes. The cause is unknown, and can be triggered by cold, humidity, excessive fatigue, improper posture or mental trauma. The most common sites are the low back, neck, shoulder and chest. The main symptoms are localized pain, muscle spasm and movement disorders, and most of them have sleep disorders.
On physical examination, there is limited pressure pain in the affected area, and in some patients, painful or painless nodules of fibrositis can be found. If the lesion is in the lumbar region, it produces low back pain, lumbar stiffness, and difficulty bending around, similar to lumbar muscle strain and early ankylosing spondylitis. The disease often occurs in the early morning, and the pain is significantly reduced or disappears after activity, hot compresses or painkillers. The prognosis is generally good, after a few days and healed, without leaving traces, but easy to recur.
3, pear-shaped muscle injury syndrome Pear-shaped muscle injury is manifested as a symptom of muscle and related nerve damage. Most of the patients have bent down to carry heavy objects or squatting and standing up when the lower limbs “flash”, “twisting” history of trauma. Patients often feel that the affected limb is “shortened”, walk with a limp, and have pain in the lower back and hip area or deep soreness in one hip area, accompanied by radiating pain in the posterior side of the affected thigh and posterior and lateral side of the calf. If the symptoms are severe, the buttocks may have severe “cut-like” pain or “septic-like” throbbing pain.
This disease must be distinguished from lumbar disc prolapse. The straight leg raise test often shows significant pain and limited lifting within 60°, but the pain decreases after exceeding 60°, indicating non-neurogenic pain. The difference with lumbar disc prolapse also lies in: there is no lumbar pressure pain, distorted spinous process and other signs; the lumbar pain is only pulling, and the lumbar function is generally not restricted; the deep affected muscles of the buttocks can be palpated by both thumbs, and the muscle bundles that are elevated into strips can be palpated, dull and thick, with obvious pressure pain.
4.Rheumatic polymyalgia The disease often starts at the age of 50 or above, with myalgia and stiffness in the neck, back or pelvic girdle and scapular girdle, which may be accompanied by fever, discomfort and anorexia. Many patients also have temporal arteritis, headaches and visual disturbances. The disease is characterized by significant relief with low-dose hormone therapy. The diagnosis of this disease can be confirmed only if occult infections (including tuberculosis) and malignancies (such as multiple metastases of cancer) are excluded.
(C) Low back pain due to spinal nerve root and dermal neuropathy
1. Spinal cord compression Spinal cord compression can originate from tuberculous spondylitis, spinal arachnoiditis, primary or metastatic tumors in the spinal canal, epidural abscesses, disc prolapse and vertebral fractures. The main features are nerve root irritation signs, sensory and motor conduction disorders. Nerve root irritation signs manifest as neck and back pain or lumbar pain that dissipates along the area of distribution of one or more posterior spinal nerve roots and is sometimes misdiagnosed as pleurisy, angina pectoris, cholecystitis, gastric and duodenal ulcers, or kidney stones.
The radicular pain is mostly unilateral at first and later becomes bilateral, often of a burning or strangulation-like nature, and may also be felt as a fasciculation. Pain can be aggravated by spinal activity, coughing or sneezing, and can be temporarily relieved by appropriate changes in position. Epidural metastatic tumors, especially when the lesion infiltrates into the periosteum, ligaments, spinal membranes and other tissues, often produce persistent and severe unbearable back pain.
Nerve root pain has localizing significance for the diagnosis of this disease, and the area of pain often suggests the site of the beginning of the lesion. Lumbar puncture reveals changes in cerebrospinal fluid and obstruction in the spinal cord cavity, which is a strong basis for the diagnosis of the disease. Spinal X-ray plain film with intra-vertebral canal iodine oil imaging is of great help in differential diagnosis and localization of the cause.
2, acute myelitis Prevalent in young adults, acute or subacute onset. There is often fever, headache, general malaise or upper respiratory tract infection for several days before the onset of the disease, and the corresponding part of the lesion is often painful. The main feature of this disease is paraplegia. If the lesion is in the thoracic or lumbar segment, early onset of low back pain can occur, and the site of pain corresponds to the plane of the lesion; in some cases, severe back pain, accompanied by weakness and numbness of both lower limbs, and complete or incomplete paraplegia and urinary and fecal disorders can occur rapidly within 1~2 days. There may be an allergic band between the normal sensory area and the area of loss, and the patient may have a band-like sensation. There may be mild leukocytosis in the blood picture and a mild to moderate increase in protein and cell count in the cerebrospinal fluid.
3. Herpes zoster Herpes zoster is a viral disease that often occurs suddenly. It may begin with mild systemic symptoms and suddenly appear on the skin as numerous papules, which soon become small blisters with a watery, clear content surrounded by an inflammatory redness. The blisters appear in clusters, often on one side of the body, along the cutaneous nerves, without crossing the midline, or involving only a small part of the contralateral skin.
The affected skin is unusually sensitive and is associated with swollen lymph nodes and neuralgia where they belong. Most commonly, intercostal herpes zoster can cause severe chest pain, while herpes zoster on the abdominal back can cause low back pain. The pain travels along the nerve pathway where the herpes occurs and is severe neuralgia.
(D) Low back pain caused by visceral diseases
1, abdominal and retroperitoneal organ diseases The common ones are pyelonephritis, renal calculus, renal tuberculosis, renal prolapse, nephritis, hydronephrosis, renal pus, etc.; acute abdominal pain of acute pancreatitis and pancreatic cancer often radiates to the left lumbar back; penetrating ulcers often have obvious back pain. However, some ulcers, although not penetrating, can also have back radiating pain, especially the ulcer behind the duodenal bulb is obvious; retroperitoneal malignant tumors with malignant lymphoma are more, the main symptom is low back pain, or accompanied by abdominal pain and fever, ultrasound or CT examination can help diagnose.
2.Pelvic organ diseases Gynecological diseases are common causes of lumbosacral pain in women, the common ones are severe retroversion and retroflexion of the uterus, chronic adnexitis, dysmenorrhea, cervical cancer and uterine cancer, etc.; chronic prostatitis, prostate cancer, etc.
3, thoracic organ disease pleurisy, pleural thickening or adhesion, tuberculosis and lung cancer; angina pectoris is most common after the upper or middle part of the sternum, and occasionally radiates backward to the left scapula and causes back pain.