Back pain

Introduction Back pain refers to the symptoms of pain in the back caused by injury or pregnancy in a certain body, obesity, poor static posture, and the like. Back pain is a group of clinical symptoms caused by acute injury, chronic strain and degenerative changes, tumors, osteoporosis and the like.

Cause

Classification of causes:

(1) Acute and chronic injury

1, acute injury: such as spinal fracture, ligament, muscle, joint capsule tear, acute disc herniation.

2, chronic damage: such as ligament inflammation, muscle strain, proliferation and degeneration of the spinal joints, spinal spondylolisthesis.

(two) inflammatory lesions

Inflammatory lesions are divided into bacterial inflammation and non-bacterial inflammation.

1, bacterial inflammation: can be divided into suppurative and specific infections such as spinal tuberculosis. Suppurative infections are more common in intervertebral space infections, epidural abscesses, and vertebral osteomyelitis.

2, non-bacterial inflammation: rheumatoid muscle fibrositis, rheumatoid arthritis, the third lumbar vertebrae transverse process syndrome, ankylosing spondylitis, can store joint compact osteitis.

(3) Degenerative changes of the spine

Such as intervertebral disc degeneration, small joint degeneration osteoarthritis, secondary spinal stenosis, senile osteoporosis, pseudo-sliding and spinal instability.

(four) abnormal bone development

Scoliosis, hemivertebra, narrow-necked porpoise, hunchback, lumbosacral or lumbar vertebrae, spina bifida and hook-like spinous processes, horizontal humerus, lower limbs, unequal length, flat feet.

(5) Poor posture

Long-term work at the desk or bent over, pregnancy, obesity caused by the abdomen.

(6) Tumor

Bone and soft tissue tumors, bone marrow or nerve tumors.

(7) Involved pain caused by visceral diseases

Gynecological pelvic disease, prostate disease, etc. can cause low back pain, kidney diseases such as stone J tumor, kidney ptosis, pyelonephritis and retroperitoneal diseases such as abscess, hematoma, etc. can cause back pain, liver and heart disease can cause back pain.

(8) Mental factors

With the progress of society and the acceleration of the rhythm, such diseases gradually increase, such as chronic fatigue syndrome, psychosis spondylitis, neurasthenia, rickets, depression.

mechanism:

First, acute injury

Acute injury can cause small blood vessels to rupture, tissue edema, and exudation. Hematoma can cause a sterile inflammatory response. H, K, prostaglandins, histamine, and osmotic pressure are considered to be the main causes of pain. In the hematoma of the fracture, the pH value can reach below the young, is acidic, has a high H concentration, and thus causes pain. The edema and exudation of the tissue can cause the tissue to infiltrate, and the ruptured cells of the tissue cells release the acidic lysozyme with the grain, causing pain. Acute injury can cause ligament and muscle tear, joint capsule damage and lead to pain in the damaged part, fracture and dislocation, hematoma can compress the spinal cord or nerve and produce compression symptoms causing distal pain or numbness, and severe cases can cause paralysis.

Second, chronic strain and degeneration

Chronic strain and degeneration can cause a series of changes in the disc, facet joints, ligaments and muscles and cause pain.

1, the change of the intervertebral disc

The blood supply to the adult intervertebral disc is only a small amount of blood supply on the surface of the annulus fibrosus. The nutrition depends mainly on the penetration of lymph, and because of the strain on the lower lumbar intervertebral disc, the load is heavy, and it is located at the junction of the active segment and the fixed segment. change. Nachemson's study showed that if the lumbar intervertebral disc pressure is 100% in the standing position, 150% in the sitting position, if it is tilted forward, it will increase to 180%, and if the standing position is slightly forwarded to 150%, this indicates the long-term sitting position or People who have a forward tilting position are more prone to intervertebral disc degeneration. Because the posterior annulus degeneration is most obvious, it is easy to rupture and cause disc herniation. This first stimulates the branch of the sinus nerve behind the disc, causing low back pain. If compression causes nerve roots, it will cause venous return obstruction, nerve root edema, and aseptic inflammation. It is also believed that glycoproteins in the nucleus pulposus can cause chemical inflammation of nerve roots in proteins and histamine, which all increase pain. Sensitivity, causing radioactive sciatica.

2. Degeneration of small facet joints

This joint is a typical synovial joint. Due to the degeneration of the intervertebral disc, the internal water is reduced, the intervertebral space is narrowed, and the pressure of the spine is borne by the articular joint. Due to the super-physiologically resistive compressive stress, the cartilage gradually turns yellow. It is opaque, and then rough and uneven, wear and fall off, compressing the branches of the sinus nerve around it and causing low back pain. Synovial inflammation of the facet joints can also cause lumbar pain.

Third, inflammation caused by low back pain

Some substances in inflammation such as H+, prostaglandins, histamine, bradykinin and other pain receptors that act on the nerve cause pain, and an increase in tissue osmotic pressure can also cause pain. Tissue ischemia can accumulate acidic metabolites in local tissues, and the concentration of H+ in tissues increases and causes pain. Both rheumatoid and trauma can cause cell damage and cell disintegration, releasing acidic lysosomal enzymes to produce pain. The purulent pus juice caused by bacterial infection is acidic, while the painless tuberculous abscess is neutral. Inflammation can also cause tissue congestion, edema, and elevated tissue pressure causing pain.

Fourth, the pain caused by the tumor

The expansive growth of a tumor can cause pain or stimulation of surrounding nerve endings or nerve trunks, and the interior of the tumor is acidic and can cause pain. Spinal tumors can also squeeze nerve roots and cause radiation pain along the nerve. Compression of the spinal cord can cause spinal cord compression and cause sensory dyskinesia below the pressure plane.

5. Low back pain caused by osteoporosis

The relationship between osteoporosis and pain is not well understood. Osteoporosis may cause a vertebral compression fracture that causes low back pain.

an examination

Related inspection

Spinal plain spine MRI

First, simple back pain

Back pain refers to low back pain without pain or numbness of the lower extremities. The main points of its differential diagnosis are as follows:

1. Age and gender

Age and gender are closely related to the cause of back pain. Adolescents are prone to tuberculosis. Long-term sitting can lead to ligament inflammation or muscle fibroinitis. If adolescent males have a history of cold, they are prone to ankylosing spondylitis. Young women have lower back pain. Most of them are dense iliac bones due to pregnancy and strain. inflammation. Young and middle-aged household chores and work are more arduous, and the intervertebral disc. The ligaments and muscles have begun to degenerate, resulting in lumbar disc herniation, myofasthesia, ligament inflammation, and spondylolisthesis. In middle-aged and elderly patients, spine degenerative osteoarthritis and ligamentitis should be considered first. If women should pay attention to osteoporosis and Menopausal syndrome.

2, medical history

The back of the spine is sore on both sides of the spine. If you bend over or sit for a long time, it will be aggravated. If you rest in bed or after a little activity, you can alleviate muscle fiber inflammation. Pain in the back of the back, painless or relieved in the upright position, pain increased during flexion, waist weakness can not be bent for a long time to work, chest and lumbar segments are mostly supraspinous ligament inflammation, mainly lumbosacral segments For interspinous ligament inflammation. If the low back pain suddenly occurs after bending, and it is rapidly aggravated, and the waist is stiff and does not dare to move, it is mostly the incarceration of the lumbar facet joint synovial membrane. If the pain is mainly caused by the sacroiliac joint, sometimes accompanied by pain in the knee or myelopathy, cold or cloudy, the back pain is gradually developing upward, the spine is stiff, and may be accompanied by fatigue, low fever, loss of appetite, etc. Spondylitis. If the back pain gradually worsens, the nighttime pain will pay attention to the spinal tumor. If it is gradually aggravated, it will become a horn deformity, accompanied by low heat and weakness, night sweats, etc. may be vertebral tuberculosis, and some vertebral tuberculosis patients with low back pain There is a painless cold abscess. Lumbar disc herniation, nucleus pulposus removal after a few days to several weeks after the occurrence of severe deep pain in the waist, first consider the intervertebral space infection. Patients with fluorosis-prone areas or long-term drinking industrial pollution should be excluded from fluorosis caused by fluorosis.

3, check and check

The tenderness and the depth of tenderness are the primary methods for finding the lesion. Thumb tenderness is shallow tenderness, and snoring pain is deep tenderness. The superficial tenderness point is mostly supraspinous ligament inflammation in the spinous process, interspinous ligament inflammation in the interspinous process, muscle fibrositis in the muscles on both sides of the spinous process, and the third lumbar transverse process in the third lumbar vertebrae Syndrome, shallow tenderness lesions are mostly in superficial ligament muscles, so no positive findings on X-ray examination, deep tenderness should be examined in patients with no tenderness, and X-ray or CT examination should be performed on deep tenderness. If there is a history of traumatic fractures, the vertebral body should be considered for vertebral tumors. If the flattened vertebral body is fishtail and the bone density is generally reduced, osteoporosis should be considered. The spine has an angular deformity X-ray showing that the vertebral body has bone destruction, the intervertebral space is narrowed, or the paraspinal abscess is visible. It is characterized by vertebral tuberculosis, limited lumbar stiffness, and can cause joint pain, "4" test or The positive waterline of the oblique pull test shows the specific expression of the sacroiliac joint. The early joint space is blurred and widened, the edge is unclear and the bite is broken, and the gap is narrowed. The marginal bone is dense and even fusion can be ankylosing spondylitis. Performance, late X-ray showed that the spine showed a bamboo-like change, and there was osteoporosis. Spinal spondylolisthesis caused by a narrow stenosis can be seen in the lumbosacral region with a kyphosis X-ray lateral radiograph showing spine slippage, double oblique position It is shown that there is no exact relationship between the hyperplasia of the lumbar vertebrae and the low back pain. If the degeneration is obvious and the tenderness is deep, lumbar vertebrae stiffness can be considered for lumbar hyperplastic osteoarthritis. Reflex low back pain has no obvious pain, and lumbar motion is normal.

Second, low back pain accompanied by lower limb pain or numbness

The numbness or pain of the back pain associated with the lower extremities is mostly caused by the compression of the thoracolumbar spinal cord or cauda equina or nerve roots and stems. The first lumbar vertebrae level above the spinal cord, patients may have intercostal neuralgia, high limb tension, femoral reflexes and lower extremity pathological signs positive, the second lumbar vertebrae oppression of the cauda equina or nerve roots, more occurrence of ponytail intermittent break, shares Nerve or sciatic nerve pain or numbness, corresponding femoral reflexes weakened or disappeared, no pathological signs.

Thoracic vertebrae compression is more common in thoracic tuberculosis tumors, intraspinal tumors, severe thoracic scoliosis, thoracic spinal stenosis, thoracic disc herniation and trauma. It should be noted that the thoracic and thoracic joints are roughly upper thoracic. The segment is different from the same number of vertebral bodies, the lower thoracic segment is about two different, the lumbar pith is 1~5 knots in the chest 11~waist 1~the waist is 1~2; between the middle, the pith is located at the waist 1~the waist 1~2 In the meantime, the cause of traumatic thoracic spinal cord compression is clear. There are often complete or incomplete lower extremity paralysis. The J line can show the fracture and displacement of the vertebral body. MR can clearly show the compression of the spinal cord and whether it is completely broken. Patients with thoracic tuberculosis first consciously have back pain, or found that the thoracic spine is deformed into an angular deformity, necrotic intervertebral disc tissue, cheese-like substance, and dead bone can compress the spinal cord backwards. First, there is paralysis of the lower extremity. If not treated, it can be converted into flaccidity. The water line can be seen narrowing the intervertebral space, bone destruction, dead bone, paraspinal abscess, CT can clearly show the dead bone and abscess that is not easy to find in the spinal canal and X-ray. Thoracic spine tumors are more common in middle and old age, with metastatic tumors being the most common, followed by giant cell tumors and hemangioma. Sustained back pain, patients with pain at night or rest, gradually worsening, compression of nerve roots can cause severe intercostal neuralgia, easily misdiagnosed as abdominal organ diseases such as appendicitis, cholecystitis. Tumor compression of the spinal cord can cause paraplegia. X-ray can be expressed as osteolytic and osteogenesis. The main line of osteolytic destruction is S-line. The vertebral body is discoidally flattened, and the left and right can be widened. However, the intervertebral space is normal. CT examination is helpful for early detection of lesions. Vertebral hemangioma is "fence-like" on the X-ray film. The shadow is due to the vertical and rough trabecular bone. The tumor in the spinal canal first stimulates the nerve root, causing radiation pain, and the upper thoracic segment is radiated to the chest. The lower thoracic segment radiates to the abdomen and is easily misdiagnosed as visceral disease. When the spinal cord is compressed, it first appears to be numb under the pressure plane, the lower limbs are weak, and then the sensation and movement that develops below the plane gradually loses. Spinal angiography can determine the diagnosis and localization. After CT, the size of the tumor and intramedullary or extramedullary can be observed. MR can show the shape, size and exact location of the tumor and the compression of the spinal cord, with or without trauma. Thoracic spinal stenosis and thoracic disc herniation are rare, and the symptoms are similar to those in the spinal canal. However, CT and MR examinations of the vertebral canal can be clearly diagnosed.

Differential diagnosis

Ankylosing spondylitis, also known as Marie-strümpell disease, Von Bechterew disease, rheumatoid spondylitis, deformity spondylitis, rheumatoid center type, etc., is now called AS. AS is characterized by inflammation and ossification of the lumbar, cervical, and thoracic spine joints and ligaments, and the ankle joint. The hip joint is often involved, and inflammation can occur in other surrounding joints. The disease is generally negative for rheumatoid factor, so it is associated with Reiter syndrome, psoriatic arthritis, enteropathic arthritis and other seronegative spondylosis. Ankylosing spondylitis is actually a very old disease. As early as thousands of years ago, evidence of ankylosing spondylitis was found from the bones of ancient Egyptians. Before 2000, the Greek doctor Hippocrates described a disease in which the sick had pain in the tibia, spine, and cervical vertebrae.

Thoracic vertebrae compression is more common in thoracic tuberculosis tumors, intraspinal tumors, severe thoracic scoliosis, thoracic spinal stenosis, thoracic disc herniation and trauma. It should be noted that the thoracic and thoracic joints are roughly upper thoracic. The segment is different from the same number of vertebral bodies, the lower thoracic segment is about two different, the lumbar pith is 1~5 knots in the chest 11~waist 1~the waist is 1~2; between the middle, the pith is located at the waist 1~the waist 1~2 In the meantime, the cause of traumatic thoracic spinal cord compression is clear. There are often complete or incomplete lower extremity paralysis. The J line can show the fracture and displacement of the vertebral body. MR can clearly show the compression of the spinal cord and whether it is completely broken. Patients with thoracic tuberculosis first consciously have back pain, or found that the thoracic spine is deformed into an angular deformity, necrotic intervertebral disc tissue, cheese-like substance, and dead bone can compress the spinal cord backwards. First, there is paralysis of the lower extremity. If not treated, it can be converted into flaccidity. The water line can be seen narrowing the intervertebral space, bone destruction, dead bone, paraspinal abscess, CT can clearly show the dead bone and abscess that is not easy to find in the spinal canal and X-ray. Thoracic spine tumors are more common in middle and old age, with metastatic tumors being the most common, followed by giant cell tumors and hemangioma. Sustained back pain, patients with pain at night or rest, gradually worsening, compression of nerve roots can cause severe intercostal neuralgia, easily misdiagnosed as abdominal organ diseases such as appendicitis, cholecystitis. Tumor compression of the spinal cord can cause paraplegia. X-ray can be expressed as osteolytic and osteogenesis. The main line of osteolytic destruction is S-line. The vertebral body is discoidally flattened, and the left and right can be widened. However, the intervertebral space is normal. CT examination is helpful for early detection of lesions. Vertebral hemangioma is "fence-like" on the X-ray film. The shadow is due to the vertical and rough trabecular bone. The tumor in the spinal canal first stimulates the nerve root, causing radiation pain, and the upper thoracic segment is radiated to the chest. The lower thoracic segment radiates to the abdomen and is easily misdiagnosed as visceral disease. When the spinal cord is compressed, it first appears to be numb under the pressure plane, the lower limbs are weak, and then the sensation and movement that develops below the plane gradually loses. Spinal angiography can determine the diagnosis and localization. After CT, the size of the tumor and intramedullary or extramedullary can be observed. MR can show the shape, size and exact location of the tumor and the compression of the spinal cord, with or without trauma. Thoracic spinal stenosis and thoracic disc herniation are rare, and the symptoms are similar to those in the spinal canal. However, CT and MR examinations of the vertebral canal can be clearly diagnosed.

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