Back pain

Backache is the most common complaint of the patients who seek medical help in Pain Clinic. Many people in the world suffer from chronic pain in the lower part of the spine.

The pain in the lower part of the back is the most frequent reason of loss of labour capacity. Fortunately the backache often decreases or disappears at rest. If the pain does not decrease, the patient should consult a doctor for conservative and invasive treatment. Surgical treatment is used quite rarely.

Pain in the lower back means that the pain is localized between the lower line of the ribs and the lower line of the buttocks. Very often pain, the cause of which is in the lower back, radiating into the leg, sometimes reaching a foot. The pain may increase when you are leaning forward or, on the contrary, straightening, when sitting or walking, turning over in bed. Often, the pain is aggravating by sneezing, coughing.

All causes of pain in lower back can be divided into two groups: specific and non-specific.

Specific pain (there are about 3% of cases) includes:

Pathology of kidney, liver, pancreas, stomach,
Malignant tumors and their metastases
Vertebral fractures, and others.

To non-specific pain (there are approximately 97% of cases) refers:
Pathology of intervertebral discs, with a decrease of the disk height, with or without its bulging (protrusion or herniation of the intervertebral disc), which, in turn, may compress the nerve roots innervating the lower limbs, narrowing of the spinal canal, due to undergone surgery on the spine or due to shift of one vertebra in relation to another, and pathology of intervertebral and pelvic iliac joints.

Non-specific pains:

Pelvic iliac joint (art.sacroiliac).

Pelvic iliac joint connects the spine to the pelvis. In humans, there are two joints - the right and left. Pelvic iliac joint helps to control the position of the pelvis during movement.

Pelvic iliac joint is a frequent cause of pain in the lower part of spine. Also, pain associated with pathology of pelvic iliac joint may radiate into the buttock area, groin, thigh, and even, occasionally, reaches the lower leg and foot.

The prevalence of pain, reason of which is the pelvic iliac joint, is high enough. Pain, caused by the pelvic iliac joint, occurs in 15% - 30% of all cases of pain in the lower back.

The most frequent cause of pain in pelvic iliac joint is osteoarthritis (arthrosis) of this joint. Among the predisposing factors should be noted trauma, scoliosis, previous spinal surgery, and fractures of the pelvis, pregnancy and childbirth as the female pelvis is wider than the male.

Various methods are used for the diagnosis of injured joint: clinical investigation or inspection of a patient with so-called provocative tests, x-ray, and computed tomography.

Unfortunately, the above-mentioned methods don’t guarantee 100% diagnostic of injury of pelvic iliac joint. Therefore, a diagnostic blockade with using of local anesthetic is the gold standard. This procedure is performed under X-ray control in conditions of complete sterility. In the joint cavity, which we see on X-rays, we enter the local anesthetic. Most often it is lidocaine or bupivacaine.

If, after entering of the anesthetic pain disappears, then the probability that the source of pain is exactly this joint, close to 100%. The effect of this procedure can last 1 -2 days.

Once the diagnosis is confirmed, we can move to the next phase - treatment.
Before talking about the treatment of pain associated with the pathology of pelvic iliac joints, it should be noted that the pelvic iliac joint is very well innervated.
One joint innervates about ten nerves. Therefore, when these joints are injured, person is experiencing considerable pain.

The first stage of treatment - conservative, with the use of non-steroidal anti-inflammatory drugs, physical therapy and exercise therapy.

If conservative treatment is ineffective, we recommend invasive methods of pain treatment, which include intraarticular injections of anti-inflammatory drugs, or radiofrequency destruction of the nerves.

Technology of intraarticular injection of anti-inflammatory drugs is similar to the technique of diagnostic blockade. RF destruction - a treatment method in which, using the power of radio frequency waves, the function of the nerve is interrupted. After the destruction the nerve cannot transmit the pain impulse, and the pain will disappear. This procedure is also performed under roentgen control in sterile conditions. Using special techniques and equipment, we find the nerves, which are responsible for pain in the joint, and undertake their destruction.

Lumbosacral radicular pain.

Lumbosacral radicular pain is characterized by pain in lower back, which is accompanied by pain in one of the legs or both legs. RADIX - translated from Latin means a root. A root – this is the initial part of the nerve innervating the lower extremities. Radicular pain makes up 10% to 25% from all pain in the lower back.

In literature you can find such synonyms for lumbosacral radicular pain as radiculitis, radicular pain, sciatica.

In case if the radicular pain becomes astringent, it may cause a radiculopathy, when a disorder of sensitivity and/or motor function of lower extremities are observed. In most of the cases the radicular pain appears due to compression or inflation of the root of the nerve (in the area of its exit from the spinal canal or inside of it). Risk factors that lead to the development of radicular pain: overweight, smoking, depression, weight lifting, prolonged stay in bent position, effect of vibration on spinal column. The most frequent cause of compression or inflation of the root of the nerve and consequently the cause of radicular pain is the pathology of intervertebral disk and narrowing of the openings along the spine, where the spinal nerve passes through (narrowing of the spinal canal). The second cause develops due to degenerative changes in the spine.

When speaking about the symptoms of radicular pain, it should be noted that a patient feels severe pain in the back, which spread to feet. Pain may be acute, pressing, stabbing, stinging.

Radicular pain, caused by pathology of the intervertebral disk (protrusion, herniation, diverticulation etc.), is getting more intensive when bending down, sitting, coughing, and remits when lying, sometimes walking.

Radicular pain, caused by the narrowing of the spinal canal, on the contrary, intensifies when walking and remits when bending down or being in the position of lying on back. For precise diagnosis of radicular pain, the clinical tests (examination of the patient) and X-ray examinations are used, including computed tomography and nuclear magnetic resonance. But none of the above mentioned methods of examination provides a 100% clarity.

Using less invasive diagnostic procedures, the correctness of the diagnosis is close to 100%.

When starting a treatment of radicular pain, it should be noted that acute radicular pain remits or ceases within the first 1-3 weeks without any specific treatment. During this time a conservative therapy is being applied. Anaesthetics, anti-inflammatory and antispasmodic preparations, as well as medicine reducing muscle spasms are prescribed for the patient. Frequently antidepressants are used. If a conservative therapy in the case of acute pain or exacerbation of chronic pain is not effective, minimally invasive procedures are necessary, during which an invasion of medicines aim to depress the source of pain. All minimally invasive procedures take place under the control of X-ray, with a use of contrast agent. Such a technique allows to inject medicine more precisely to the source of the pain and provides safety for the patient.

Minimally invasive procedures, applied for radicular pain, include:
  • Interlaminar (between spinal processes of vertebrae) epidural corticosteroid injection.
  • Transforaminal (intervertebral space, where the nerve passes through) epidural corticosteroid injection.
  • Sphygmic radiofrequency stimulation of nerve roots (dorsal ganglion), responsible for the transmission of pain impulse.
Epidural corticosteroid injection is an effective treatment method of radicular pain. Epidular space– a space between the spinal cord membranes, which is the beginning (roots) of nerves, innervating the lower extremities. The effectiveness of this method, both interlaminar and transforaminal, is based on a strong anti-inflammatory effect of corticosteroids themselves, as well as because the strong anti-inflammatory medicine is injected directly to the inflamed nerve. These procedures takes place in complete sterility and safety for the patient. Local anesthesia is used. It is proved that the effectiveness of the epidural corticosteroid injection is high. Relief or cease of pain may last from 3 months to a year and longer. This method is especially effective in the case of acute pain or exacerbation of chronic pain. Early performed epidural corticosteroid injection provides more significant and lasting results. Therefore, in case a patient is having an acute radicular pain or exacerbation of chronic pain, which can not be treated with the conservative treatment method within the first 2-3 weeks, it is necessary to evaluate the possibility to perform this procedure.

Sphygmic radiofrequency stimulation of dorsal ganglion (dorsal root ganglion – DRG)– this is a minimally invasive procedure, using the energy waves of the radiofrequency. The procedure takes place in complete sterility, under X-ray – a controll that ensures the safety for the patient. The main indicator for this procedure in case of radicular pain is chronic pain. The energy of radiofrequency waves is used in minimally invasive cardiology for already a long time. This method of treatment was used for treatment of pain for a first time in 1950-s. The effectiveness of sphygmic radiofrequency stimulation is as follows: a special needle, conducting the radiofrequency wave, is located very closely to the source of pain. With the help of radiofrequency wave the surrounding tissues are heated up to 42°С, which allows to reduce the transmission of pain impulse along the nerve tissue and reduces inflammation. The effect of this procedure remains from 8 months to several years.