The I.M.

Sechenov First Moscow State Medical University

Chair of nervous diseases

Back pain
Pain

An unpleasant sensory and emotional experience

associated with actual or potential tissue damage
or described in terms of such damage

International association for the study of pain, 1986

Back pain
Acute less than 6 weeks
Subacute 4 12 weeks
Chronic more than 12 weeks

Nociceptive
Neuropathic
Psychogenic
Mixed
Pain formation

Nociceptive system Antinociceptive system

Imbalance of nociceptive and

antinociceptive systems

PAIN
Types of back pain

Non-specific ("benign", musculoskeletal) back pain

- 90%
Compression radiculopathy (damage to spinal
root) - 6%
Specific (tumor, infection, trauma, inflammation of
the spine, spinal cord, meninges and roots,
diseases of the internal organs) back pain - 4%
Mechanisms of non-specific back pain formation

Psychological
distress, fear of
movement

Muscles, ligaments,
fascia, joints, Substance ,
vertebrae, bradykinin, IL1,
intervertebral , 5-, H+, Na+, K
+ and others.
discs, dura mater
Triggers of non-specific back pain
Awkward "unsuspecting" movement
Excessive physical and static load (within
overvoltage)
Supercooling
Emotional stress
Abnormalities (leg length difference, oblique
pelvis, scoliosis, etc.)
Overweight
Degenerative changes in the spine

Degeneration
of the facet
joints
Degeneration
of disk Osteophytes
The formation at joint
of marginal surfaces
osteophytes
Spinal disc herniation
Pain and muscle spasm
Muscles, ligaments,
fascia, joints,
vertebrae,
intervertebral disc,
dura mater
Reflectory
Damage muscle spasm

Arachidonic acid cycle

prostaglandins
prostacyclin
thromboxane
Other pro-inflammatory agents
and algogens PAIN

Spinal
cord
High muscle tone syndrome
Limitation of movement in
the region of the spine, pain
in movement
Muscle is tense and painful
on palpation, without pain
irradiation
Pain provoked by
movement with the
corresponding muscle
Myofascial pain syndrome

Painful palpable cord in the muscle

The pressure on the local area of pain
provoke a typical (discover") for the
patient pain
Identification of trigger points and areas
for reflected pain
The local manipulation for trigger point
(introduction of anesthetics, puncture,
local massage) significantly reduced pain
Spondyloarthropathic facet syndrome

Provoked by extensor and rotatory

movements
The pain usually have paravertebral
location
Triggered by deep palpation of the
amended joint
May irradiate by non radicular type
Pathognomonic sign - a positive effect
from the introduction of a local
anesthetic into the joint under CT or X-
ray control (pain regression > 90%)
Radiculopathy
Intense pain, paresthesia,
irradiating to the distal areas of
5 6
extremity
Symptoms of "loss" in the area
of innervation of the affected
7 8 root (sensory, motor, reflex)
Symptoms of tension

Causes:
Herniated disk
Narrow spinal canal
Neoplasms
Inflammatory diseases
S1 L5 L4 L3
Spinal disc herniation
Symptoms of radiculopathy
L3-L4 L4
herniated
disc

L4-L5
herniated L5
disc

L5-S1
herniated S1

disc
Keim H.A., Kirkaldy-Willis. Les lombalgies / Rueil-Malmaison. 1980. with changes
Spondylolisthesis

Root
compression

X-ray of spine
Spinal stenosis (MRI)

Major factors for stenosis:

Hypertrophy of the yellow ligament
Facet changes
Intervertebral disc protrusion
Posterior osteophytes
Spondylolisthesis
Specific causes of back pain

Diseases of the internal organs with reflected

pain
Spondylitis
Vertebral tumours
Vertebral fractures (trauma, osteoporosis)
Infectious diseases (tuberculous spondylitis)
Neurological diseases (spinal, roots tumors)
Symptoms of dangerous" for acute back
pain ("red flags")
Age 50 and over
Recent trauma
The independence of the intensity of pain on the body position
and movement
Increased pain at night
Lack of effect of medical therapy for 4-6 weeks
Focal neurological deficits that go beyond the typical
radiculopathy - signs of spinal cord lesions
A history of malignancy
Corticosteroids in history
Fever
Drug use
Specific back pain (osteoporosis)

Vertebrae
Intervertebral disk

Compressive
fracture
Specific back pain
Vertebral fracture with spinal cord compression
Specific back pain
Spinal cord tumour
Specific back pain
MRI of a patient with extramedullary tumor (meningioma) at Th4-Th5, which
covers three quarters the spinal canal, compressing the spinal cord at that
level

Image http://www.neuro-med.ru
Investigation of patient with back pain

The history of pain, previously diseases, combined

symptoms
Physical examination
Neurological and neuroorthopedic examination
Radiography of spine
CT or MRI of the spine In indications

General and biochemical blood analysis

Patient survey
Scoliosis
The study of the mobility of the cervical spine
The study of the mobility of the lumbar spine
X-ray of spine
Degenerative changes of the spine is found in the
majority of middle-aged and elderly !
MRI of spine
Herniated disc is found in the majority (76%) patients
without back pain !
Risk factors for chronic pain, long-
term disability
Psychological factors (psychosocial stress, job
dissatisfaction, problems in family life, the
anxiety-depressive disorder)
Misconception of pation about pain
(catastrophization), "pain orientated" type of
personality
Decreased activity, repeated and frequent
episodes of pain
Treatment of acute and subacute non-
specific back pain (up to 12 weeks)
Informing the patient of benign prognosis
Avoidance of bed rest
Nonsteroidal anti-inflammatory drugs (NSAIDs)
(diclofenac, nimesulide, meloxicam and others)
Muscle relaxants (midokalm, sirdalud, baclofen)
Medication blockade
Chiropractic
Exercise
Massage
Treatment of chronic (12 weeks) of
musculoskeletal (non-specific) back pain
Non-drug treatments (psychotherapy, post isometric
relaxation, manual therapy, massage, exercise, physical
therapy, acupuncture)
Antidepressants (TCA, venlafaxine, duloxetine and
others)
NSAIDs, muscle relaxants
Medication blockade
Radiofrequency denervation of facet joints (if
necessary)
Radiofrequency denervation of facet joints
Conservative treatment of radiculopathy
Treatment of the underlying disease
Medication:
anticonvulsants
muscle relaxants, NSAIDs
patches with analgesics (lidocaine, etc.)
opioids for short period (on the strict)
medical blockades
epidural corticosteroid
Non-drug therapy:
physiotherapy
psychotherapy
Physical therapy, massage
Surgical treatment of radiculopathy
Absolute indications: the roots of cauda equina
compression, "saddle" anesthesia, pelvic disorders,
swelling in the legs paresis
Relative indications: failure of conservative treatment

Methods:
discectomy
microdiscectomy
Decompression of the spinal canal
Minimally invasive interventions (laser
vaporization, nucleoplasty)
Prevention of back pain

Correction of
emotional disturbances
and social risk factors
Gymnastics, hiking,
swimming lessons
Limitation of heavy
physical exertion,
prolonged static loads,
non-physiological
postures