Nonspecific back pain
This form of pain syndrome is characterized by a clear relationship with biomechanics: discomfort significantly increases with movement or, conversely, after prolonged static posture.
During physical examination, a physician may detect the following abnormalities:
- Flattening or accentuation of the physiological curves of the spinal column.
- Lateral curvature of the spinal axis (scoliosis).
- Pronounced pain-induced limitation of normal mobility in the affected spinal segment or limb.
- Local tension and tenderness of muscle groups.
- Pain upon palpation of bony structures on the affected side.
The most critical criterion for nonspecific pain is an absolutely normal neurological status. The patient exhibits no signs of damage to spinal nerve roots, nerve plexuses, or peripheral nerves.
In the vast majority of cases, the disease has a benign course. The acute phase resolves within a few days, or 2–4 weeks at most. However, in 10–20% of patients, the process may become chronic. Diagnosis is based solely on the clinical presentation after ruling out other pathologies. Routine X-ray, CT, or MRI is not required.
Discogenic compressive radiculopathy
Radiculopathy is fundamentally caused by mechanical compression of a spinal nerve root and its supplying blood vessels by a herniated intervertebral disc. Such compression immediately leads to local ischemia, edema development, and aseptic inflammation.
The clinical presentation consists of a complex of sensory, reflex, and motor disorders:
- Pain syndrome: the pain is acute and lancinating. Irradiation is specific — the pain spreads to the distal parts of the limb, often being much more intense in the arm or leg than in the back itself.
- Sensory disturbances: paresthesias and decreased sensitivity (hypesthesia) occur in the innervation zone of the affected root.
- Reflex changes: tendon reflexes decrease down to their complete loss (areflexia).
- Motor disorders: if the motor portion of the root is involved, paresis develops — weakness of the innervated muscles.
Additionally, biomechanical syndromes develop: muscle-tonic tension, scoliosis, altered physiological curves, and restricted mobility.
The diagnosis is confirmed by detecting a herniation on MRI or CT combined with a clear clinical picture of radicular involvement. The pain syndrome can last from several weeks to months. If conservative therapy fails, surgical removal of the herniation is indicated, leading to pain relief. Inadequate treatment risks chronicity and persistent disability.
Fibromyalgia
This is a systemic chronic disease that is diagnosed significantly more often in women. The peak incidence occurs between the ages of 30 and 50 years. The pathology develops gradually, often starting in a single isolated area, and then acquires a chronic relapsing course where exacerbations are frequently triggered by psychogenic factors.
Patients complain of diffuse, symmetrical, aching, or burning pain in the muscles of the trunk and limbs. The pain can be strictly localized or migratory and is always accompanied by a pronounced sensation of stiffness in the muscles and joints.
Diagnostic criteria for fibromyalgia:
- Absence of signs of peripheral nervous system involvement upon neurological examination.
- Presence of tender points — specific sensitive and painful indurations in the muscle tissue. Palpation of these areas causes a sharp increase in pain.
- Positive palpation test: detection of tenderness in at least 11 of 18 symmetrical points (base of the skull, neck, shoulders, elbow creases, buttocks, thighs, knee joints).
- Presence of comorbid disorders: asthenia, sleep disturbances (dyssomnia), chronic tension headaches, and anxiety-depressive states.
Interpretation of instrumental studies
The use of neuroimaging methods requires strict indications. Ordering computed tomography or magnetic resonance imaging for nonspecific pain is justified exclusively for differential diagnosis when it is necessary to rule out:
- spondylolisthesis;
- lumbar stenosis;
- inflammatory spinal diseases;
- primary tumors or metastases.
Important fact: the detection of degenerative-dystrophic changes or a disc herniation on a tomogram does not reflect the severity of the disease and cannot serve as the sole basis for diagnosis, as such changes are commonly found in healthy individuals.
Other methods are used for specific screening: densitometry allows the detection of decreased bone mineral density in osteoporosis, while radionuclide bone scintigraphy is prescribed when metastatic, tumor, or infectious involvement of the spinal structures is suspected.
Briefly: answers to topical questions
Where are the 18 specific symmetrical points (tender points) for diagnosing fibromyalgia located anatomically?
The specific symmetrical points (tender points) for diagnosing fibromyalgia are located in the following areas:
- base of the skull;
- neck;
- shoulder;
- elbow crease;
- upper outer quadrant of the buttocks;
- thigh;
- knee joint — proximal to the joint line.
The points are located symmetrically on both sides; tenderness in at least 11 of the 18 points is required for diagnosis.
What specific diseases and syndromes of the thoracic spine can cause thoracalgia?
Specific vertebrogenic causes and thoracic syndromes associated with thoracalgia include:
- pathological processes in the zygapophyseal and costotransverse joints;
- myofascial syndromes, in particular latissimus dorsi myofascial syndrome resulting from excessive strain;
- thoracic radiculopathy, which manifests as pain and sensory disturbances in the innervation zone of the affected roots and may be associated with spinal cord tumors or thoracic vertebral fractures of various origins.
To remember the fibromyalgia patient profile: 'A 30–50-year-old woman with symmetrical diffuse pain (11 of 18 points), poor sleep, asthenia, and headache, but with healthy nerves.'
Class and exam questions
Is an MRI mandatory for any acute back pain?
No. In cases of nonspecific pain, instrumental examinations are not required. MRI or CT is indicated only when there is suspicion of a herniation with root compression, tumor, infection, or stenosis.
How to differentiate radicular pain from muscle spasm?
In radiculopathy, the pain is acute, lancinating, and radiates to the distal parts of the limb, where it is felt more intensely than in the back. It is accompanied by numbness, loss of reflexes, and muscle weakness.
What are tender points in fibromyalgia?
These are specific painful indurations in muscles, where light palpation causes severe pain. They are located symmetrically (neck, shoulders, elbows, thighs, etc.); confirmation of pain in at least 11 of these 18 points is required for diagnosis.
What else to study on this topic
- Pathophysiology of aseptic inflammation in spinal nerve root compression.
- Differential diagnosis of non-specific dorsalgia and metastatic spinal lesions.
- Mechanisms of muscle tone syndrome and biomechanical disorders.
- The role of psychogenic factors and depressive disorders in the chronification of fibromyalgia.
- Indications for surgical treatment of discogenic radiculopathy.
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