Etiology and factors of pain chronification
Non-specific factors dominate among the causes of acute back pain. Specific pathologies, such as discogenic radiculopathy or myelopathy, are much less common, but require special attention from the physician due to an unfavorable prognosis.
If acute pain is not relieved, it can become chronic. Several groups of factors contribute to this process:
- Iatrogenic and behavioral: improper management tactics, for example, unreasonably long bed rest or excessive restriction of physical activity.
- Psychological: the patient's tendency to overestimate the severity of their condition, as well as comorbid emotional disorders (depressive episodes, anxiety). The emotional background can both trigger and maintain pain sensations.
- Social: conscious or subconscious exaggeration of symptoms (aggravation) and the patient's personal interest in obtaining a prolonged sick leave.
Clinical examination: anamnesis and physical examination
Anamnesis collection includes a detailed interview about the nature of the pain, its exact localization, and pathways of radiation. The physician needs to find out how long ago the pain syndrome appeared, under what circumstances, and how changes in body position and movement affect it. Previous injuries and background diseases must be taken into account.
Physical examination of the spine is performed in various positions: standing, sitting, lying on the abdomen and back, as well as during walking. During the examination, the following are evaluated:
- Presence of spinal deformities (scoliosis, changes in physiological lordosis and kyphosis).
- Movement biomechanics, revealing limitations when getting up or walking.
- Range of passive and active movements during bending and twisting.
- Presence of limb asymmetry.
- Tenderness upon local palpation.
To confirm radiculopathy at the lumbar and sacral root levels (for example, in lumbago with sciatica), the Lasègue sign is tested. It is considered positive if lifting the straightened leg at an angle of 30–50° causes pain radiating from the lower back along the posterolateral surface of the leg to the toes. The sign is enhanced (sensitized) by dorsiflexion of the foot and forward flexion of the patient's head.
"Red flags": signs of dangerous conditions
During any presentation with back pain, specific causes must be excluded: infections, oncological processes, and severe somatic diseases. To do this, clinicians look for the following alarming signs:
- Age of pain onset over 50 years.
- Atypical nature of pain (intensification at rest, unusual localization, lack of connection with movements).
- Recent traumatic back injuries.
- Signs of intoxication, fever, infections.
- Unexplained weight loss.
- Oncological diseases (including those previously suffered).
- Pelvic organ dysfunction and symptoms of spinal cord involvement.
- Long-term corticosteroid use, manifestations of osteoporosis.
Instrumental diagnostics and its clinical significance
If red flags are identified in a patient, a comprehensive examination is prescribed: blood tests (complete blood count and biochemistry), radiography, CT or MRI, densitometry, and in some cases, radionuclide bone scintigraphy.
Radiography helps exclude developmental anomalies, fractures, spondylolisthesis (vertebral displacement), spondylitis, and tumors. However, it does not visualize a disc herniation; an indirect sign of herniation is only the reduction of the intervertebral disc height. X-rays clearly show osteophytes (marginal bone growths) and degenerative changes.
CT and MRI have high resolution. They are indispensable for visualizing herniated protrusions (for example, between the L4 and L5 vertebrae), assessing their exact size, and detecting spinal canal stenosis, which can form due to ligamentum flavum hypertrophy and the presence of a hernia.
Key postulate of vertebroneurology: degenerative changes in the spine occur in half of middle-aged people and almost all elderly people. There is no direct correlation between the severity of these changes on imaging and the presence of pain. Tomography data should not be the sole basis for a diagnosis without comparison with the clinical picture.
Differential diagnostics: fibromyalgia
When evaluating pain syndrome, one should remember conditions that mimic vertebrogenic pathology, such as fibromyalgia. This disease manifests as diffuse, predominantly symmetrical pain in the muscles of the trunk and extremities.
Upon palpation, such patients have specific tender points — areas of pronounced local tenderness. The condition is often accompanied by morning stiffness in joints and muscles, chronic fatigue, sleep disorders, and mental disorders, particularly depression.
Briefly: answers to topical questions
How is the Lasègue sign tested and what is its clinical significance in radiculopathy?
The Lasègue sign is tested by lifting the patient's straight leg, and its clinical significance lies in identifying lumbar radiculopathy. The criterion for a positive sign (straight leg raise) is the appearance of pain when lifting the leg from an angle of 30–50°, radiating from the lumbosacral region along the posterolateral surface of the leg to the toes.
- Sensitization of the sign — pain increases with dorsiflexion of the foot and forward flexion of the patient's head.
- Contralateral Lasègue sign (contralateral straight leg raise) — is also used as a provocative test to detect radiculopathy.
What methods of instrumental imaging for intervertebral disc herniations exist?
Tomographic methods and radiography are used for instrumental imaging of intervertebral disc herniations.
- Magnetic resonance imaging — has high resolution, allows obtaining high-quality images without contrast, and precisely determines the size and localization of the herniated protrusion.
- Computed tomography — is used to detect herniations, including the use of reformatted images.
- Radiography — does not allow direct visualization of a hernia, but reveals its indirect sign (reduction of intervertebral disc height).
What main stages and parameters does a physical examination of a patient with vertebrogenic pain syndrome include?
Physical examination of a patient with vertebrogenic pain syndrome includes assessment in standing, sitting, walking, supine, and prone positions. Main stages and parameters:
- Spine assessment — identification of scoliosis, changes in lordosis or kyphosis.
- Assessment of biomechanics and range of motion — determining mobility limitations when getting up, walking, bending, and twisting, and assessing active and passive movements.
- Limb assessment — searching for deformities and asymmetry.
- Palpation — identification of local tenderness of bone structures, muscle tension, and tenderness.
Class and exam questions
Can a disc herniation be seen on a regular X-ray?
No, radiography does not allow for the direct visualization of an intervertebral disc herniation. Its presence can only be inferred from an indirect sign—reduced distance between the bodies of adjacent vertebrae.
Do degenerative spinal changes always cause pain?
No. The detection of degenerative changes does not have a direct correlation with the presence or intensity of the pain syndrome. This is a frequent finding that is present in the majority of elderly patients even without complaints of pain.
What leads to spinal canal stenosis?
Spinal canal stenosis is most often formed by two main elements: an intervertebral disc herniation and a hypertrophied ligamentum flavum.
What else to study on this topic
- Technique of performing and evaluating the Lasègue sign in radicular syndromes
- Pathomorphology of spinal canal stenosis at various levels
- Mechanisms of formation of indirect radiological signs of osteochondrosis
- Differential diagnosis of specific and nonspecific pain
- Influence of psychoemotional status on pain perception
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