Pain in the lumbar and lower limbs.

Pain in the lumbar and lower limbs. In the prevalence of lambulgia (pain in the lumbar or lumbosacral division) and lumboishialgia (back pain irradiating to the legs). In acute intensive pain in the lower back, the term "lumbago" (lumbar lumbago) is also used.

Lumbalgia. Acute lumbulgia can be triggered by trauma, lifting of gravity, awkward movement, prolonged stay in nonphysiological position, hypothermia. The pain localized in the back excludes the damage of the spine and can be related to both the spinal cord injury and soft tissue damage (for example, muscle or ligament sprain). Sometimes it is the first manifestation of a herniated intervertebral disc and is associated with irritation of the outer layers of the fibrous ring and posterior longitudinal ligament. The irritation of pain receptors leads to spasm of segmental muscles. Acute lumbalia usually regresses within a few days or weeks. Chronic lumbalgia develops gradually, often after regression of acute pain. Its cause is often served by: spinal instability, myofascial syndrome, arthrosis of the intervertebral (facet) joints (see Pain in the neck and upper extremities), spondylolisthesis.

The instability of the spine leads to an excessive load on the facet joints and muscles. The pain associated with it, usually bilateral, increases with prolonged stays in one position, slopes, lifting of the weight, prolonged sitting and is eased at rest. Its development is promoted by strengthened lumbar lordosis , obesity , weakness of abdominal muscles. The mobility of the lumbar region is usually not limited. Extension is often more painful than flexion.

Osteoarthritis of the facet joints is a common cause of chronic lumbargia in the elderly. It is manifested by bilateral pain, which, in contrast to discogenic pain, is usually localized in the paravertebral, rather than along the midline. Pain can be reflected in the sacroiliac joint and thigh. It increases with prolonged stays in standing, extension, but decreases with sitting or walking, rarely occurs at night. On examination, there may be some restriction of flexion, but more characteristic is the increase in pain during extension, especially with simultaneous rotation. The pain is reduced after bilateral blockade of the facet joints.

Myofascial syndrome can occur against the backdrop of a degenerative process in the spine or independently of it - with prolonged stay in a nonphysiological posture, due to constant microtraumatism, overloading untrained muscles, overstretching or compression of muscles, trauma, prolonged immobilization.

Spondylolysis - a slit in the back of the vertebral arc (most often LV), leading to a divergence of the upper and lower articular processes. It arises as a result of congenital weakness of the interarticular part of the arch, which at the time of childhood (on average, to 6 years) splits. Defect occurs in 5-7% of people and is very rarely manifested clinically, more often in athletes who have to re-twist their back (for example, gymnasts or wrestlers). The diagnosis is confirmed radiologically.

Spondylolisthesis - displacement of the vertebra anterior to the adjacent vertebra. At a young age, spodylolisthesis is more often caused by spodilolysis and is observed at the level of LV-SI, accompanied by a subluxation in the lumbosacral articulation. In the elderly, spondylolisthesis occurs against the background of degeneration of the facet joints, usually at the level of LIV-LV, and leads to stenosis of the spinal canal.

Lumboschialgia is more often of vertebrogenic origin and can be caused by a reflex "reflection" of pain or compression of the root, associated with a disc herniation, degenerative or other diseases of the spine.

Herniated disc is more often manifested in the age of 30 to 50 years. In most cases, LV -SI disks, and LIV-LVs are affected. Pain in a herniated disc is often accompanied by the formation of painful and trigger points on the periphery (in the muscles of the buttocks, thighs, and thighs). Trigger points differ in that when they are irritated, there is reflected pain in a remote zone from them. Reflex pain is associated with irritation of ligamentous, bone, muscular structures that have pain receptors, and its irradiation depends on the level of damage. For example, in the pathology of the LV -SI segment, which is not accompanied by compression of the rootlet, the pain can be irradiated in the leg usually to the level of the knee joint. To defeat the root are characterized by unilateral, intense shooting or piercing pain radiating to the distal zone of innervation of the corresponding rootlet. Characterized by the symptoms of prolapse in the innervation of the spine - numbness, paresthesia, decreased sensitivity, weakness and atrophy of muscles, prolapse of reflexes. Pain in a herniated disc often occurs with sudden movement, tilt, lifting of gravity or falling. In the anamnesis, there are usually indications for repeated episodes of lumbargia and lumboschialgia. The pain is aggravated by movement, stiffening, lifting of the weight, sitting, prolonged stay in one position, coughing and sneezing, pressing on the jugular veins and weakening in peace, especially if the patient lies on a healthy side, bending a sore leg in the knee and hip joint. When viewed, the back is usually fixed in a slightly bent position. Scoliosis is often seen, which increases with tilt anteriorly, but disappears in the prone position. The inclination to the front is sharply limited.

Symptoms of tension are not specific for radicular lesion, but allow to assess the severity of vertebrogenic pain syndrome. Lasegh's symptom is revealed by slowly lifting the patient's straight leg up, expecting pain in the leg to increase along the sciatic nerve. When the LV and SI roots are compressed, the pain arises or sharply increases when the leg is raised to 30 °, and when the leg is bent in the knee and hip joints passes. If the pain does not pass when bending the leg in the knee joint, then it can be caused by the pathology of the hip joint or has a psychogenic character. When performing Lasega reception pain in the lower back and leg can occur with non-ligamentous lesions (for example, with the tension of the paravertebral muscles or the hind muscles of the thigh and lower leg). The front symptom of tension is also checked - a symptom of Wasserman: a patient lying on his stomach, lifting a straight leg upwards, unbending the hip in the hip joint, or bending the leg in the knee joint, achieving radicular pain irradiation. A positive symptom indicates compression of the LIV root or lumbar plexus.

Muscle weakness in discogenic radiculopathies is more often expressed minimally. But sometimes, against the background of a sharp increase in radicular pain, the paresis of the foot can develop (paralyzing sciatica). The development of this syndrome is associated with ischemia of the root caused by the compression of the vessels feeding it. In the vast majority of cases, paresis safely regresses for several months against a backdrop of conservative therapy. With a massive middle hernia of the lower lumbar disc, compression of the roots of the horse tail may occur. It manifests itself with rapidly increasing bilateral asymmetric pain in the legs, a violation of sensitivity in the perineum, lower flaccid paraparesis, delayed urination, and incontinence. This clinical situation requires urgent consultation of a neurosurgeon.

In addition to disc herniation, compression of the root can occur with subluxation in the intervertebral joint, hypertrophy of the articular processes, the formation of osteophytes, hypertrophy of the yellow ligament. This condition is more typical for elderly people with a long history of back pain and manifests itself in a slowly growing pain syndrome, which gradually acquires radicular irradiation (buttock - hip - shin - foot). The pain increases with standing and walking, but, unlike the disc herniation, it is easier when sitting or tilting the trunk anteriorly. The symptom of Lasega is often negative.

Stenosis of the spinal canal can be congenital or acquired. Acquired stenosis is the result of spondylolisthesis or degenerative lesion of the spine with protrusion of intervertebral discs, the formation of osteophytes, hypertrophy of ligaments, arthrosis of the facet joints. Stenosis of the spinal canal at the lower lumbar level causes chronic compression of the roots of the horse tail and vessels feeding it. The main clinical manifestation of stenosis is neurogenic (caudogenic) intermittent claudication, which manifests itself in the appearance of bilateral pains, numbness, paresthesias and weakness in the muscles of the lower thighs or thighs when walking or standing for a long time, if the patient bends anteriorly or sits down. Symptomatic usually develops gradually against the backdrop of many years of back pain. On examination, it is possible to note the flatness of lumbar lordosis, a sharp restriction of mobility of the lumbar region, a decrease or loss of tendon reflexes from the legs. Symptoms of tension are often absent or minimal. Unlike vascular intermittent claudication, pain is always localized in both legs, is less acute, provoked on standing, passes only in the flexion position (or when the patient sits or lies down), but not in a straightened position, is not accompanied by trophic disturbances and lack of pulsation of peripheral Vessels.

Non-alveolar lumbosciatica occurs frequently, and, in addition to disc herniation, is due to degenerative changes in the spine. In contrast to radicular pain, it is bilateral, spreads through the sclerotomous or myotomic zones, but rarely irradiates below the knee. It is not accompanied by symptoms of prolapse, paresthesias, marked symptoms of tension. The cause of non-lumbar lumboschialgia may be instability of the PDS or arthrosis of facet joints in the area of ​​thoracolumbral junction. In this case, the pain can spread to the lower back, buttock, the area of ​​the large trochanter, and on examination reveals local soreness and limited mobility at the specified level.

Syndrome of the sacroiliac articulation is manifested by pain in the articulation area radiating in the groin, a large spit, buttock, and the front surface of the thigh. When examined, you can identify soreness in the articulation area with palpation, lateral pressure on the pelvis, hip retraction versus resistance, over-extension or external rotation of the thigh. Pain increases with walking, bending, prolonged sitting or standing. Syndrome of the sacroiliac joint is often manifested in the last months of pregnancy. Its development is facilitated by a shortening of the leg, trauma. In most cases, the joint is only a place of reflected pain in the hernia of the disc.

Osteoarthritis of the hip joint (coxarthrosis) is a common cause of pain in the hip and lower back, it is characterized by soreness and restriction of mobility in the joint.

Pear-shaped muscle syndrome, a relatively rare syndrome, which can have both vertebrogenic and non-malformed nature. It is characterized by compression of the sciatic nerve with an inflamed or shortened pear-shaped muscle or its tendon. The compression is enhanced by internal rotation of the thigh. The syndrome is manifested by pain in the gluteal region radiating over the posterior surface of the thigh and lower leg, sometimes with the weakness of the shin flexors and the paresis of the foot. Blockade muscle, special exercises, ultrasound or phonophoresis with hydrocortisone reduce muscle spasm and lead to a weakening of pain.

Pain in the leg, if it is not accompanied by neurological symptoms (loss of reflexes, decreased sensitivity), is caused by the damage of joints, muscles or other soft tissues, but not of nervous structures. Pain in the leg, accompanied by sensitive or motor symptoms, is more often due to peripheral nerve damage (eg, tunnel neuropathy) or lumbar plexus.

Diagnosis. Although in approximately 90% of cases the pain is benign and is caused by physical exertion against the background of the current degenerative spinal lesion, the main focus should be to not miss a few cases when back pain is caused by more serious causes - a compression fracture (usually in the background Osteoporosis), spinal cord or spinal cord tumor, ankylosing spondylitis, purulent epiduritis, aneurysm or thrombosis of the aorta, pancreatic disease, urogenital system, gastrointestinal tract, retroperitoneal pathology. Special caution is necessary in the following cases: 1) pain first begins before 15 and after 50 years; 2) the pain is not of a mechanical nature (it does not decrease at rest, lying down, at night); 3) the intensity of pain increases with time; 4) a history of malignant neoplasm; 5) immunity is reduced and there is a tendency to repeat infections; 6) fever , weight loss or other systemic manifestations; 7) long stiffness in the morning; 8) the presence of signs of damage to the spinal cord or horse tail (paralysis, extensive areas of sensitivity, pelvic disorders); 9) the presence of changes in laboratory tests of blood or urine.

When examining, you should pay attention to the signs of infection or malignant neoplasm, the condition of those organs whose tumors often give metastases to the spine (breast, lungs, prostate, kidneys, large intestine, bladder). The study of the organs of the abdominal cavity will reveal the source of reflected pain.

It is important to assess the condition of pelvic functions. The main task of radiography of the spine is to exclude fractures, congenital anomalies, infectious or inflammatory diseases, tumors . It is indicated to all patients with trauma, prolonged (more than 3 weeks) or atypical pain syndrome, as well as all patients sent to physiotherapy or manual therapy. According to the testimony, lung radiography is performed, ultrasound examination of abdominal and pelvic organs, retroperitoneal space, excretory urography, and sigmoidoscopy. Women are required to see a gynecologist.

Treatment. With uncomplicated acute lumbargia and non-lump-like lumbosciagia, a significant reduction in pain should be expected within 2 to 4 weeks. In an acute period, treatment is best done at home and does not force patients to visit the polyclinic for injections or physiotherapy. Within 1-3 days, recommend bed rest, while the patient should lie on a hard surface in a position convenient for him. Cold or light dry heat can relieve pain, whereas deep or strong warming up more often. Gradually, the regime is expanded, but it is recommended to limit physical activity for a certain period of time (avoid tilts and rotations of the trunk, lifting of the gravity, prolonged stay in the sitting position). Patients with recurrent pain and signs of instability of the spine are advised to wear a corset for several days. Long wearing of the corset is not advisable, since it creates the danger of weakening the muscles. The patient should be taught how to correctly move, avoiding the burden on the spine. The arsenal of drug therapy includes analgesics - from analgin and paracetamol to tramadol (tramal) and narcotic analgesics, nonsteroidal anti-inflammatory drugs - ibuprofen 600-1800 mg / day, ketoprofen 75-150 mg / day, diclofenac (voltaren) 50-150 mg / Day inside or intramuscularly, piroxicam 20 - 30 mg / day, ketorolac 30 - 60 mg / day inside or intramuscularly, indomethacin 75 - 200 mg / day inside or in the form of rectal suppositories. Analgesic drugs are preferable to take prophylactically, by the hour, and not when there is pain. When you take these drugs to protect the mucous membrane of the stomach can appoint antatsidnye drugs.

The effect on the myofascial (muscular-tonic) pain component involves the use of muscle relaxants: clonazepam 1-2 mg / day, tizanidine (sirdalud) 4-8 mg / day, baclofen 30 - 75 mg / day, diazepam 10 - 40 mg / day, usually not longer than 1-2 weeks, injection of local anesthetic and corticosteroid into trigger and painful points with subsequent stretching of muscles, post-isometric relaxation, applications with dimexide and novocaine, massage, therapeutic gymnastics, including exercises to strengthen the muscular corset or stretching Spasmodic muscles. The impact on the vertebrogenic component of pain includes methods of manual therapy and curative gymnastics, with facet syndrome paravertebrally carry out bilateral blockade of the facet joints. These methods can be combined with reflexology, physiotherapy procedures (electrophoresis with local anesthetics, phonophoresis with hydrocortisone, etc.).

With rootlet syndrome, most often caused by disc herniation, the recovery time is extended to 6-8 weeks. Principles of treatment remain the same - bed rest for several days with subsequent gradual expansion, analgesics and nonsteroidal anti-inflammatory drugs, therapeutic gymnastics. The peculiarity of the treatment consists in the wider use of therapeutic blockades and the use of drugs that affect neuropathic pain - antiepileptic drugs (carbamazepine 200-600 mg / day), antidepressants - doxepin (synevan) at 25 -75 mg per night, mianserin lerivon 30 - 90 mg per night, mexiletine 150 mg 2 - 3 times a day, topical pepper preparations. If the patient is treated in a hospital, then in an acute period, epidural blockades are appropriate. Instead of blockades, applications with dimexidum can be used (its solution is diluted by 0.5% or 2% with novocaine). In severe cases and in the absence of contraindications, a short course of corticosteroids - 100 mg of prednisolone can be given orally for 3 to 5 days, followed by a rapid cancellation. Apply large doses of vitamins B1, B6 and B12, trental (400 mg 2-3 times a day or 100-200 mg intravenously drip on 200 ml of isotonic sodium chloride solution).

Manual therapy in the acute period of disc herniation, especially in the presence of signs of compression of the root, is contraindicated. Although in practice widely used various traction options, there is no conclusive evidence in favor of its effectiveness, and in some cases it provokes deterioration.

Chronic lumbalgia and lumboschialgia, lasting more than 3 months, is a more heterogeneous group of patients, requiring a more individualized approach to treatment. It is important to exclude serious causes of pain (tumors, infections, metabolic disorders). Drug therapy (analgesics, NSAIDs, muscle relaxants), therapeutic blockades are shown in cases of exacerbations. The main goal of treatment for chronic pain is not to stop pain, but to gradually expand the patient's motor abilities. Treatment includes mainly non-drug methods: weight loss measures, therapeutic gymnastics, manual therapy, massage. It is important not only to strengthen the muscles of the back and abdominal press, but also to teach the patient to avoid provocative movements, to change his motor stereotype. An important role belongs to physiotherapeutic, balneological, reflexotherapeutic methods.

With stenosis of the spinal canal, it is recommended to wear a corset, weight loss, NSAIDs. Physiotherapeutic procedures are useful (for example, phonophoresis with hydrocortisone or euphyllin) and therapeutic gymnastics. Sometimes epidural corticosteroids and calcitonin preparations are effective. If the conservative treatment is ineffective, surgical intervention is indicated. Prophylaxis of pain and back consists in correction of the motor stereotype, avoidance of unprepared movements and creation of a muscular corset ensuring the correct distribution of the load on the spine, correcting the posture, correcting the developmental anomalies, reducing body weight, refusing to smoke.