Pain in the lower back Nonspecific pain in the lower back
Vertebrogenic lumbodynia is a pathological condition manifested by symptoms of pain in the lumbar region.
Pain syndrome can be associated with a number of diseases, among which the first place in frequency is osteochondrosis.
In general, the lumbar spine is subject to heavy loads, which is why both the muscles and ligaments and the spinal column itself are often affected. The people who suffer the most are those who lead a sedentary, sedentary lifestyle, who are obese, or, conversely, who work a lot physically. This pattern is due to the fact that the muscles of the lumbar girdle are most tense when lifting and carrying heavy objects, as well as when sitting for a long time. To identify the true cause of lumbodynia, a person is prescribed x-ray examinations and magnetic resonance imaging.
Like any disease, lumbodynia has its own ICD-10 code. This is an international classification of diseases, which is used to encrypt diseases in different countries. The classification is regularly revised and supplemented, which is why the number in the name means 10th revision.
Lumbodynia, according to the ICD-10 code, has code M-54.5, the disease is included in the dorsalgia group and refers to pain in the lower back. If we look at code M-54.5 in more detail, the description may include the term lumbar pain, tension in the lower back, or lumbago.
Reasons for the development of pathology
In most cases, lumbodynia is associated with degenerative processes in the spinal column. Most often, pain syndrome is caused by osteochondrosis associated with damage to intervertebral discs and cartilage.
Osteochondrosis is a chronic disease that torments a person for more than one month, and even more than one year. The disease also has its own international ICD code -10 - M42, but such a diagnosis is made only after a comprehensive examination. Osteochondrosis is dangerous due to pinching of nerve roots, blood vessels, destruction of intervertebral discs and a number of other complications when severe lower back pain occurs. So, until the patient has an exact diagnosis, he is given a preliminary diagnosis, that is, vertebrogenic lumbodynia.
Another cause of lower back pain is protrusion and intervertebral hernia. These two states are somewhat similar:
- During protrusion, the fibrous ring of the intervertebral disc is destroyed, causing the semi-liquid core to partially protrude, squeezing the nerve roots, resulting in pain.
- But with an intervertebral hernia, a complete displacement of the nucleus pulposus occurs, while the fibrous ring ruptures and the symptoms are more pronounced.
In any case, these conditions are dangerous due to the appearance of back pain and the development of neurological symptoms. The causes of osteochondrosis, hernia and protrusion are almost the same:
- excessive physical exertion during sports and physical labor;
- getting injured in the lumbar region;
- sedentary lifestyle;
- impaired metabolism;
- infections affecting the musculoskeletal system;
- age-related changes.
This is not the entire list of reasons leading to lumbodynia, which is why if you experience lower back pain, you need to consult a doctor who will not only prescribe treatment, but also help eliminate the causes of pain.
Other pathological conditions leading to lumbodynia include spinal stenosis, arthrosis of the spinal joints, curvature and back injuries.
Characteristic symptoms
Vertebrogenic lumbodynia manifests itself differently in each patient. It all depends on the reason that caused it, on the age of the person and his lifestyle. Of course, the main symptom of the disease is pain, which is most often acute, increases with exercise and decreases at rest. Palpation determines the state of muscle tension in the lumbar spine.
Due to pain and inflammation, the patient shows signs of stiffness in movements. People suffering from an attack of lumbodynia are easily tired and irritable. It becomes difficult for them to bend over and they cannot get up quickly from a bed or chair. With chronic diseases, such as osteochondrosis or arthrosis, a person has periods of exacerbation and remission.
Even if the symptoms are minor and the person can endure the pain, it is recommended that he see a doctor. Most diseases that lead to lumbodynia tend to progress, and the symptoms will only increase over time.
Signs of lumbodynia may appear in a pregnant woman, which leads to the development of pain syndrome. This happens due to muscle strain due to weight gain and load redistribution. Women do not need to panic, but if possible, they should undergo physical therapy.
Diagnosis of patients
The purpose of diagnosis for lumbodynia is to determine the cause of damage to the spinal column and exclude other pathologies. Lower back pain can be associated with diseases of the kidneys, female genital organs, and cancer.
The main diagnostic method is an X-ray examination of the spine. Using an x-ray, it will be possible to examine the bone elements of the spinal column and identify pathological areas. Another modern method of examining patients with back pain is magnetic resonance imaging. Thanks to this procedure, it is possible to detect abnormalities not only in the bone tissue itself, but also in soft tissues. This method is considered the best in diagnosing oncological processes.
Ultrasound techniques are used to examine internal organs. First of all, the kidneys and pelvic organs are examined. All other manipulations are carried out at the discretion of the doctor. And of course, we must not forget about blood and urine tests.
Dorsopathies (classification and diagnosis)
In 1999, in our country, the International Classification of Diseases and Causes Associated with them, the Xth Revision (ICD10), was legislatively recommended. The formulation of diagnoses in medical histories and outpatient cards with their subsequent statistical processing makes it possible to study the incidence and prevalence of diseases, as well as compare these indicators with those of other countries. For our country, this seems especially important, since there is no statistically reliable information on neurological morbidity. At the same time, these indicators are the main ones for studying the need for neurological care, developing standards for the staff of outpatient and inpatient doctors, the number of neurological beds and various types of outpatient care.
Anatoly Ivanovich Fedin
Professor, head Department of Neurology and Neurosurgery FUV RSMU
The term "dorsopathies" refers to pain syndromes in the torso and extremities of non-visceral etiology and associated with degenerative diseases of the spine. Thus, the term “dorsopathies” in accordance with ICD-10 should replace the term “spinal osteochondrosis”, which is still used in our country.
The most difficult thing for practicing doctors is to formulate diagnoses for patients with pain syndromes associated with degenerative diseases of the spine. From a historical perspective, these diseases have different interpretations and diagnoses. In textbooks on nervous diseases of the late nineteenth and early twentieth centuries. pain in the lumbar region and lower limb was explained by an inflammatory disease of the sciatic nerve. In the first half of the twentieth century. The term “radiculitis” appeared, which was associated with inflammation of the spinal roots. In the 60s, Ya.Yu. Popelyansky, based on the works of German morphologists H. Luschka and K. Schmorl, introduced the term “osteochondrosis of the spine” into the domestic literature. In the monograph by H. von Luschka. Die Halbgelenke des Menschlichen Korpers.
Berlin: G. Reimer, 1858) degeneration of the intervertebral disc was called osteochondrosis, while Ya.Yu. Popelyansky gave this term a broad interpretation and extended it to the entire class of degenerative lesions of the spine. In 1981, our country adopted the proposed I.P. Antonov’s classification of diseases of the peripheral nervous system, which included “osteochondrosis of the spine.” It contains two provisions that fundamentally contradict the international classification: 1) diseases of the peripheral nervous system and diseases of the musculoskeletal system, which include degenerative diseases of the spine, are independent and different classes of diseases; 2) the term “osteochondrosis” is applicable only to disc degeneration, and it is inappropriate to use it to describe the entire spectrum of degenerative diseases of the spine.
In ICD10, degenerative diseases of the spine are included in the class “diseases of the musculoskeletal system and connective tissue (M00-M99)”, highlighting: “arthropathy (M00-M25); systemic lesions of connective tissue (M30-M36); dorsopathies (M40- M54); diseases of soft tissues (M60-M79); osteopathies and chondropathy (M80-M94); other disorders of the muscular system and connective tissue (M95-M99). The term "dorsopathies" refers to pain syndromes in the trunk and extremities of non-visceral etiology and associated with degenerative diseases of the spine. Thus, the term “dorsopathies” in accordance with ICD10 should replace the term “spinal osteochondrosis”, which is still used in our country.
Dorsopathies in ICD10 are divided into deforming dorsopathies, spondylopathies, other dorsopathies (intervertebral disc degeneration, sympathalgic syndromes) and dorsalgia. In all cases, the basis for diagnosis should be data from a clinical examination and radiological diagnostics (spondylography, X-ray computed tomography or magnetic resonance imaging of the spine). Dorsopathies are characterized by a chronic course and periodic exacerbations of the disease, in which various pain syndromes are leading.
Various structures of the spinal motion segments may be involved in the degenerative process: intervertebral disc, facet joints, ligaments and muscles. In cases of concomitant damage to the spinal roots or spinal cord, there may be focal neurological syndromes.
Deforming dorsopathies
The section "deforming dorsopathies (M40-M43)" includes:
As you can see, this section of the classification contains various deformations associated with pathological alignment and curvature of the spine, disc degeneration without protrusion or herniation, spondylolisthesis (displacement of one of the vertebrae relative to the other in its anterior or posterior version) or subluxations in the joints between the first and second cervical vertebrae. In Fig. Figure 1 shows the structure of the intervertebral disc, consisting of the nucleus pulposus and the fibrous ring. In Fig. Figure 2 shows a severe degree of osteochondrosis of the cervical intervertebral discs with their degenerative lesions.
The presence of deforming dorsopathies is confirmed by radiological diagnostic data. In Fig. Figure 3 shows magnetic resonance imaging (MRI) of the spine with osteochondrosis of the intervertebral discs, evidenced by their flattening and a decrease in the intervertebral distance. In Fig. Figure 4 shows a spondylogram of the lumbar spine in a 4-year-old patient with idiopathic scoliosis of the spine. In the "spondylopathies (M45-M49)" section, the most common degenerative change is spondylosis (M47), which includes spinal arthrosis and degeneration of the facet joints. In Fig. Figure 5 shows a vertebral motion segment, which includes two vertebrae with a disc located between them and their articulation using joints.
Rice. 1. The structure of the intervertebral disc (according to H. Luschka, 1858).
Rice. 2. Severe degeneration of cervical intervertebral discs (according to H. Luschka, 1858).
Rice. 3. MRI for osteochondrosis of intervertebral discs (arrows indicate degenerative discs).
Rice. 4. Idiopathic scoliosis of the spine.
Rice. 5. Spinal motion segment at thoracic level.
Rice. 6. Cervical dorsopathy.
With degeneration, spondylosis with compression syndrome of the anterior spinal or vertebral artery (M47.0), with myelopathy (M47.1), with radiculopathy (M47.2), without myelopathy and radiculopathy (M47.8) are distinguished. The diagnosis is established using radiation diagnostics. In Fig. Figure 6 shows the most characteristic changes on a spondylogram with spondylosis.
A more precise nature of the changes can be determined by X-ray computed tomography (Fig. 7). With exacerbation of the disease, patients develop dorsalgic syndromes of various localizations. Compression of the vertebral artery in the spinal canal is accompanied by signs of vertebrobasilar ischemia with dizziness, ataxia, cochlear, visual and oculomotor disturbances. With ischemic-compressive myelopathy, various syndromes develop depending on the level of damage, characteristics and degree of ischemia. The most common option is cervical myelopathy with amyotrophic lateral sclerosis syndrome, the signs of which can be segmental hypotrophy in the hands and at the same time symptoms of pyramidal insufficiency with hyperreflexia, pathological pyramidal reflexes and spastic increase in muscle tone in the lower extremities. In Fig. Figure 8 shows a diagram of the passage of the vertebral artery in its canal in the transverse processes of the cervical vertebrae and a spondylogram of compression of the vertebral artery in cervical spondylosis.
With compression of the spinal roots, segmental hypotrophy and hyposthesia, hyporeflexia of individual deep reflexes are determined. In Fig. Figure 9 shows the topography of stenosis of the intervertebral foramen with compression of the root by the hypertrophied articular surface.
Rice. 7. X-ray computed tomography (CT) for lumbar dorsopathy, arthrosis of the left facet (facet) joint of the L5-S1 spine.
Rice. 8.
Rice. 9. Intervertebral foramen stenosis with L5 root compression
Other dorsopathies (M50-M54)
The section “other dorsopathies” presents degeneration of intervertebral discs, often encountered in clinical practice, with their protrusion in the form of protrusion or displacement (hernia), accompanied by pain:
When formulating diagnoses, you should avoid such terms that frighten patients as “disc herniation” (it can be replaced with the term “disc displacement”, “disc damage” (synonymous with “disc degeneration”)). This is especially important in patients with a hypochondriacal personality and anxiety-depressive conditions In these cases, a carelessly spoken word by a doctor can be the cause of long-term iatrogenicity.
In Fig. Figure 10 shows the topography of the spinal canal, morphology and MRI for intervertebral disc protrusion. With displacements (herniations) of the intervertebral disc, various clinical options are possible depending on the location of the displacement, the presence of compression of the dural sac or spinal root. In Fig. 11 shows options for displacement of intervertebral discs and the topography of various options for compression of the dural sac or root. In Fig. Figure 12 shows the morphology of disc displacement, CT and MRI for various types of pathology. A variant of displacement of disc fragments into the spongy substance of the vertebral body is Schmorl's hernia, which, as a rule, is not clinically manifested by pain syndromes (Fig. 13).
Rice. 10. Topography of the spinal canal and protrusion of the intervertebral disc.
Rice. 11. Options for intervertebral disc displacement.
Rice. 12. Morphology and radiation diagnostic methods for intervertebral disc displacement.
The section “other dorsopathies” in heading M53 includes sympathalgic syndromes associated with irritation of the afferent sympathetic nerve due to posterolateral displacement of the cervical disc or spondylosis. In Fig. Figure 14 shows the peripheral cervical nervous system (plexus of the somatic nervous system, cervical ganglia of the sympathetic nervous system and its postganglionic fibers, located in the soft tissues of the neck and along the carotid and vertebral arteries. In Fig. 14a
the exit of the spinal roots and spinal nerves from the spinal cord, the formation of the cervical and brachial peripheral plexuses, which contain postganglionic sympathetic fibers, are visible. The topography in the area of the C1 vertebra, the exit of the vertebral artery from the spinal canal, where it is covered by the inferior oblique muscle and other suboccipital muscles, are highlighted. In Fig. 14b, 14c the main nerves in the neck area are visible, the exit of spinal nerves from the intervertebral foramina, the formation of the border sympathetic trunk by sympathetic fibers. In Fig. 14d shows the common and internal carotid arteries, the ganglia of the borderline sympathetic trunk and its postganglionic fibers, which “braid” the carotid and vertebral arteries.
Rice. 13. MRI for Schmorl's hernia.
Rice. 14.Cervical sympathetic nerves.
Cervicocranial syndrome (M53.0) corresponds to the widely used term “posterior cervical sympathetic syndrome” in our country, the main clinical manifestations of which are repercussive (widespread) sympathalgia with cervicocranialgia, orbital pain and cardialgia. With spasm of the vertebral artery there may be signs of vertebrobasilar ischemia. With anterior cervical sympathetic syndrome, patients experience a violation of the sympathetic innervation of the eyeball with Horner's syndrome, often partial.
With cervical-brachial syndrome (M53.1), patients, along with sympathalgic pain, have degenerative-dystrophic changes in the area of the upper limb (humeral-scapular periarthrosis, shoulder-hand-fingers syndrome).
Coccydynia (M53.3) is manifested by sympathalgic pain in the coccyx area and degenerative-dystrophic changes in soft tissues in the pelvic area.
Dorsalgia
The section “dorsalgia” (M54) includes pain syndromes in the neck, trunk and limbs in cases where displacement of the intervertebral discs is excluded. Dorsalgic syndromes are not accompanied by symptoms of loss of function of the spinal roots or spinal cord. The section contains the following headings:
Rice. 15. Innervation of soft tissues of the spine.
Rice. 16. Fascia and muscles of the lumbar region.
Dorsalgia in the absence of displacement of the intervertebral discs may be associated with irritation of the nerve endings of the sinuvertebral nerve (branches of the spinal nerve), located in the soft tissues of the spine (Fig. 15).
The most common dorsalgia syndromes in clinical practice are lumbodynia and lumboischialgia, which is explained by the features of the functional anatomy of the lumbar region (Fig. 16). Functionally important is the thoracolumbar fascia of the back (Fig. 16b), which communicates between the girdle of the upper limbs (through the longissimus muscle) and the girdle of the lower limbs. The fascia stabilizes the vertebrae on the outside and is actively involved in the act of walking. Extension of the spine (Fig. 16c) is carried out by the iliocostalis, longissimus and multifidus muscles. Flexion of the spine (Fig. 16d) is performed by the rectus abdominis and oblique muscles, and partially by the iliopsoas muscle. The transverse abdominis muscle, attaching to the thoracolumbar fascia, ensures balanced function of the posterior and anterior muscles, closes the muscle corset and maintains posture. The iliopsoas and quadratus muscles maintain communication with the diaphragm and, through it, with the pericardium and abdominal cavity. Rotation is produced by the deepest and shortest muscles - the rotators, running in an oblique direction from the transverse process to the spinous process of the superior vertebra, and the multifidus muscles.
From a functional point of view, the anterior and posterior longitudinal, interspinous, supraspinous and yellow ligaments of the spine constitute a single ligamentous structure. These ligaments stabilize the vertebrae and facet joints on the outer and lateral surfaces. In the motor act and maintaining posture, there is a balance between fascia, muscles and ligaments.
The modern concept of lumbodynia (dorsalgia), in the absence of the above-described degenerative changes in the spine, assumes a violation of the biomechanics of the motor act and an imbalance of the musculofascial apparatus between the anterior and posterior muscle girdle, as well as in the sacroiliac joints and other structures of the pelvis.
In the pathogenesis of acute and chronic lumbodynia, great importance is attached to microtraumas of the soft tissues of the musculoskeletal system, during which there is an excessive release of chemical mediators (algogens), leading to local muscle spasm. Muscle spasms during ischemia of muscles and fascia become sites of painful nociceptive impulses, which enter the spinal cord and cause reflex muscle contraction. A vicious circle is formed when a primary local muscle spasm creates conditions for its maintenance. With chronic dorsalgia, central mechanisms are activated with the activation of suprasegmental structures, including the sympathetic nervous system, which creates additional conditions for the formation of more widespread muscle spasms and algic phenomena.
The most common syndromes of lumbodynia (dorsalgia) are thoracolumbar fascia syndrome, case syndrome of the multifidus muscle, rotator cuff syndrome and iliopsoas muscle syndrome. Diagnosis of these syndromes is possible based on manual diagnostic tests
In the vast majority of cases, vertebroneurological pathology is associated with degenerative-dystrophic changes in the spine. In these cases, in practice it is customary to diagnose “osteochondrosis of the spine,” which is based on primary dystrophic damage to the intervertebral discs, but in recent years, thanks to the introduction into practice of CT and MRI, myelography with water-soluble contrast, it has been shown that pain syndromes and neurological symptoms can be associated not only with pathology of intervertebral discs, but also with spondyloarthrosis. stenosis of the spinal canal and menovertebral foramina, spondylolisthesis, pathology of muscles and ligaments. which may not be directly related to osteochondrosis, but even with spinal osteochondrosis at various stages of the “degenerative cascade”, various factors play a leading role in the development of pain syndrome - bulging or herniated disc, instability or blockade of the spinal motion segment, arthrosis of the intervertebral joints. narrowing of the spinal or radicular canals, etc. In each of these cases, the pain syndrome and the accompanying neurological symptoms have clinical originality, different time dynamics, prognosis and require a special approach to treatment. Thus. When formulating a diagnosis and coding it in accordance with ICD-10, the features of both neurological and vertebral manifestations should be taken into account as much as possible.
In ICD-10 vertebrogenic neurological syndromes are presented mainly in the section “Diseases of the musculoskeletal system and connective tissue (M00-M99), subsection “Dorsopathies” (M40-M54). Some neurological complications of vertebral pathology are also indicated in the section “diseases of the nervous system” (G00-G99), but the corresponding codes are marked with an asterisk (for example, G55 * - compression of the roots of the spinal nerves and nerve plexuses in diseases classified in other sections) and, therefore , can only be used as additional codes in the case of double coding.
The term " dorsopathy» (from the Latin dorsum - back) includes not only all possible variants of spinal pathology (spondylopathy), but also the pathology of the soft tissues of the back - paravertebral muscles. ligaments, etc. The most important manifestation of dorsopathies is dorsalgia - pain in the back. (cm.. )
According to origin they are distinguished:
vertebrogenic (spondylogenic) dorsalgia associated with the pathology of pozonochnieka (degenerative, traumatic, inflammatory, neoplastic and other nature);
nonvertebrogenic dorsalgia caused by sprained ligaments and muscles, myofascial syndrome, fibromyalgia, somatic diseases, psychogenic factors, etc.
Depending on the location of the pain, the following types of dorsalgia are distinguished::
cervicalgia – neck pain;
cervicobrachialgia– pain in the neck, spreading to the arm;
Thoracalgia – pain in the thoracic back and chest;
lumbodynia – pain in the lower back or lumbosacral region;
lumboischialgia – lower back pain spreading to the leg;
sacralgia – pain in the sacral region;
coccydynia - pain in the tailbone.
For acute intense pain, the terms “cervical lumbago” or “lumbago” are also used.
According to severity, acute and chronic dorsalgia are distinguished. The latter continue without remission for more than 3 months, that is, beyond the normal period of soft tissue healing.
However, the clinical picture of spinal lesions is not limited to pain; it may include:
local vertebral syndrome
, often accompanied by local pain syndrome (cervicalgia, thoracalgia, lumbodynia), tension and soreness of adjacent muscles. pain, deformity, limited mobility or instability of one or more adjacent segments of the spine;
vertebral syndrome at a distance
; the spine is a single kinmatic chain, and dysfunction of one segment can, through a change in the motor stereotype, lead to deformation, pathological fixation, instability or other change in the state of the upper or lower sections;
reflex (irritative) syndromes
: referred pain (for example, cervicobrachialgia, cervicocranialgia, lumboischialgia, etc.), musculotonic syndromes, neurodystrophic manifestations, repercussion autonomic (vasomotor, sudomotor) disorders with a wide range of secondary manifestations (enthesiopathy, periarthropathy, myofascial syndrome, tunnel syndromes and etc.);
compression (compression-ischemic) radicular syndromes
: mono-, bi-, multi-radicular, including cauda equina compression syndrome (due to herniated intervertebral discs, stenosis of the spinal canal or intervertebral foramen or other factors);
syndromes of compression (ischemia) of the spinal cord
(due to herniated discs, stenosis of the spinal canal or intervertebral foramen, or other factors).
It is important to identify each of these syndromes, requiring special treatment tactics, and reflect them in the formulated diagnosis; differentiation of reflex or compression syndromes is of important prognostic and therapeutic importance.
According to the classification of I.P. Antonova, when formulating a diagnosis neurological syndrome should be put first, since it is he who decisively determines the specifics of the patient’s condition. However, given that the coding in accordance with ICD-10goes according to the primary disease, then a different sequence of formulating the diagnosis is allowed, in which vertebral pathology is indicated first(disc herniation, spondylosis, spondylolisthesis, spinal stenosis, etc.). Compression of the spinal nerve roots can be coded as G55.1* (for compression by a herniated intervertebral disc), G55.2* (for spondylosis) or G55.3* (for other dorsopathies coded in categories M45-M46, 48, 53-54 ). In practice, clinical and paraclinical data (CT, MRI, etc.) often do not allow one to unambiguously decide whether the neurological syndrome is caused by a herniated disc or a sprain of muscles and ligaments - in this case, coding should be carried out according to the neurological syndrome.
The diagnosis must necessarily reflect secondary neurodystrophic and autonomic changes, local muscular-tonic syndromes with compression of the plexuses and peripheral nerves. However, in these cases, proving a cause-and-effect relationship with spinal lesions is extremely difficult. Convincing criteria for the differential diagnosis of vertebrogenic and non-vertebrogenic variants of glenohumeral periarthropathy, epicondylosis and other enthesiopathy have not been developed. In some cases, vertebrogenic pathology acts as a background process, being only one of the factors in the development of perarthropathy or enthesiopathy (along with limb overload, non-adaptive motor sitereotype, etc.). In this regard, it seems advisable to resort to multiple coding, indicating the code for enthesiopathy and dorsopathy.
When formulating a diagnosis, it should be reflected:
course of the disease: acute, subacute, chronic (remitting, progressive, stationary, regressive);
phase: exacerbation (acute), regression, remission (complete, partial);
exacerbation frequency: frequent (4-5 times a year), medium frequency (2-3 times a year), rare (no more than 1 time a year);
severity of pain syndrome: mild (not interfering with the patient’s daily activities), moderately expressed (limiting the patient’s daily activities), severe (severely complicating the patient’s daily activities), pronounced (making the patient’s daily activities impossible);
state of spine mobility(mild, moderate, severe limitation of mobility);
localization and severity motor, sensory, pelvic and other neurological disorders.
It should be emphasized that the course and phase of the disease are determined by its clinical manifestations, and not by x-ray or neuroimaging changes.
Neurological syndromes with intervertebral disc herniation, see..
examples of formulations and diagnoses
Cervical myelopathy due to a median disc herniation C5-C6 grade III with moderate flaccid paresis of the upper extremities and severe spastic paresis of the lower extremities, stationary phase.
Cervical radiculopathy C6 due to lateral disc herniation C5-C6 of the second degree, chronic relapsing course, acute stage with severe pain and severe limitation of spinal mobility.
Chronic cervicalgia against the background of cervical osteochondrosis, stationary course, with moderate pain syndrome, without limitation of spine mobility.
Myelopathy of the thoracic region due to a median disc herniation Th9-Th10 with moderately severe lower spastic paraparesis, pelvic disorders.
Radiculopathy L5 due to disc herniation L4-L5 with severe pain, acute phase.
Radiculoischemia L5 (paralyzing sciatica syndrome) on the left due to a lateral disc herniation L4-L5 of the third degree, regression stage, moderate paresis and hypoesthesia of the left foot.
Chronic lumbodynia against the background of osteochondrosis of the lumbar spine (L3-L4), recurrent course, incomplete remission phase, mild pain syndrome.
Chronic lumbodynia due to multiple Schmorl's hernias, stationary course, moderate pain syndrome.
!!! PLEASE NOTE
In the absence of reliable clinical and paraclinical data that clearly indicate the leading type of degenerative-dystrophic lesion of the spine that determines the symptoms in this patient, the formulation of the diagnosis may only include an indication of vertebrogenic lesions, A coding should be carried out according to the leading neurological syndrome, reflex or compression. In this case, all specific spondylopathies, as well as non-vertebral syndromes, should be excluded. ICD-10 provides the opportunity to code according to the leading neurological syndrome in categories M53(“Other dorsopathies”) and M54(“Dorsalgia”). This is how cases of “osteochondrosis of the spine” should be coded in the absence of an indication of the leading role of disc herniation, spondylosis or spondyloarthrosis.
Examples of diagnosis statements:
M54.2 Chronic vertebrogenic cervicalgia with pronounced muscular-tonic and neurodystrophic manifestations, recurrent course, exacerbation phase, severe pain, moderately severe limitation of cervical mobility.
M 54.6 Chronic thoracalgia due to damage to the spinal-costal joints THh11-Th12 on the right (posterior costal syndrome), recurrent course, exacerbation phase, severe pain syndrome.
M 54.4 Chronic vertebrogenic bilateral lumbar ischialgia with pronounced muscular-tonic and neurodystrophic manifestations, recurrent course, exacerbation phase. severe pain syndrome, moderately severe limitation of mobility of the lumbar spine.
M 54.5 Acute lumbodynia with severe tension of the pravertebral muscles and antalgic scoliosis, severe pain syndrome, limited mobility of the lumbar region.
Spinal pain is a clinical syndrome with many causes.
The most common cause of pain in the spine is dystrophic lesions of the spine:
- osteochondrosis with damage to the intervertebral discs and adjacent surfaces of the vertebral bodies;
- spondylosis, manifested by arthrosis of the facet and/or facet joints;
- spondylitis.
- Osteochondrosis. The term "osteochondrosis" means a degenerative process of articular cartilage and underlying bone tissue. All parts of the spine are susceptible to osteochondrosis, but the pathological process is more pronounced, as a rule, in the lower cervical, upper thoracic and lower lumbar spine. A feature of osteochondrosis is the breadth of its distribution - degenerative-dystrophic lesions of the spine by the age of 40 are found in almost all people.
The initial manifestation of osteochondrosis is pain in the affected part of the spine. The pain can be either relatively constant, like lumbodynia (prolonged pain in the lumbosacral region), or have the character of a lumbago - lumbago. Subsequently, as the pathological process progresses, a predominance of pain in one or another part of the spine is observed. Characteristically, the pain intensifies during physical activity, prolonged immobile or sedentary positions, being in an uncomfortable position, or a feeling of discomfort. Further development of osteochondrosis can lead to severe deformation of the spine such as kyphosis, lordosis or scoliosis.
Osteochondrosis is characterized by numerous and varied neurological disorders, the severity of which depends on the stage of the disease (exacerbation or remission). In the uncomplicated course of osteochondrosis, periods of rather long remission are observed when the symptoms of the disease are not pronounced. The acute stage is characterized by the appearance of acute pain in the corresponding part of the spine, followed by radiation to the arm, lower back or leg.
- Lumbago occurs with awkward or sudden movement, lifting heavy objects and is accompanied by a sudden “lumbago” type pain that lasts for several minutes or seconds, or “tearing” and throbbing pain in the spine, aggravated by coughing and sneezing. Lumbago causes limited mobility in the lumbar spine, “pain-relieving” posture, flattening of lordosis or kyphosis. Tendon reflexes are preserved, sensitivity is not impaired. Pain in the spine lasts from several hours to several days.
- Lumbodynia occurs after significant physical exertion, prolonged uncomfortable posture, shaking ride, hypothermia. Clinically, it is accompanied by a dull aching pain in the spine, which intensifies with changes in body position (bending, sitting, walking). The pain may spread to the buttock and leg. Static changes are less pronounced than with lumbago. Movement in the lumbar region is difficult, but the restriction is minor. Pain is detected when palpating the spinous processes and interspinous ligaments at the level of the lesion. When bending back, the pain disappears; when bending forward, there is a sharp tension in the back muscles. Knee reflexes and reflexes from the heel tendons are preserved. The process often has a subacute or chronic form.
- Intervertebral disc herniation is a rupture of a spinal disc due to overload, malnutrition or injury. As a result of rupture of the outer fibrous ring of the intervertebral disc, its internal contents (nucleus pulposus, which is a gelatinous mass with a diameter of 2 - 2.5 cm, surrounded by a dense cartilaginous ring) protrudes into the spinal canal. A bulging part of the disc can impinge on the nerves and vessels of the spinal cord, which results in pain in the spine and other disorders.
- Spinal instability is pathological mobility in the spinal segment. This can be either an increase in the amplitude of normal movements, or the emergence of new degrees of freedom of movement that are uncharacteristic for the norm.
The main symptom of spinal instability is spinal pain or neck discomfort. In the cervical spine in patients with instability in the atlanto-occipital joint, irritating pain can be periodic and intensify after physical activity. Pain is the cause of chronic reflex tension of the neck muscles. In children, instability is the cause of the development of acute torticollis. At the onset of the disease, there is increased tone of the paravertebral muscles, which leads to their overwork. Microcirculation disorders occur in the muscles, the development of malnutrition and decreased tone. There is a feeling of uncertainty when moving in the neck. The ability to withstand normal load is impaired. There is a need for means of additional immobilization of the neck, including supporting the head with the hands.
More rare causes of spinal pain include:
- congenital defects of the spine, manifested in a different number of vertebrae, most often in the lumbar region.
We can talk about either extra lumbar vertebrae (the 1st sacral vertebra turns into the 6th lumbar vertebra, the so-called lumbarization of the sacral spine) or their deficiency (the 5th lumbar vertebra turns into the 1st sacral vertebra - sacralization);
- spondylolysis and spondylolisthesis - we are talking about a defect in the interarticular part of the vertebral arch, which, in the case of complete separation of the arches (spondylolysis) and bilateral localization, can lead to a shift of the damaged vertebral body forward (spondylolisthesis);
- ankylosing spondylitis (ankylosing spondylitis) - painful inflammation of the spine, starting in the sacro-lumbar joints;
- osteoporosis can cause pain in the spine in women (during menstruation) and in older people. The vertebral bodies in this disease have a reduced bone density, and therefore, in the presence of pressure, they deform to a wedge-shaped shape or to the shape of the so-called fish vertebra (enlarged pits on the upper and lower surfaces of the vertebral bodies);
- pain in the spine can also be caused by tumor processes. Most often they are metastases of tumors of the chest organs, including the lungs, prostate and thyroid glands, and kidneys;
- infectious lesion of the spine (most often of staphylococcal nature), associated with entry into the blood and transfer of an infectious agent from a focus in the lungs or genitourinary organs. Another infection that affects the spine, especially in earlier years, is tuberculosis;
- pain in the spine caused by diseases of the internal organs. In women, these are most often gynecological diseases - changes in the position of the uterus, cysts, inflammation and tumors of the ovaries.
Prostate disease, urethral infections and bladder stones can also cause back pain;
- in some cases, back pain is a consequence of a psychosomatic reaction, which means that some patients transfer their depression, nervous stress, neuroses to the spine and feel them there in the form of pain. In these cases, pain in the spine may be the result of psychological defensive reactions associated with increased muscle load. The pain felt, in turn, intensifies the depressive and neurotic state, and the overall situation worsens even more, difficulties are consolidated and become chronic.
In modern medicine, the term “lumbodynia” is increasingly used. But the concept does not provide an unambiguous definition of what kind of disease this is. The diagnosis “lumbodynia” means a collective term that refers to all diseases accompanied by pain in the lower back. Based on this principle, pathology has its own ICD 10 code – M54.5. This is how any back disease is coded, which is accompanied by symptoms associated with.
However, the formulation of the diagnosis implies this ICD 10 code only as a preliminary opinion of the doctor. In the final conclusion, after the examination results, the main cause of lumbodynia is recorded in first place under a different code, and the term itself is used to indicate a complication.
What kind of disease underlies this pathological syndrome? The reasons leading to the patient's pain may have different origins. Most often, pathology occurs due to, but the problem also develops due to tumors, injuries, and autoimmune conditions. Therefore, the prognosis and treatment will be individual, depending on the root cause of the pain syndrome. Every patient suffering from lumbodynia needs a thorough diagnosis, as well as etiological therapy, which is prescribed by a specialized specialist in the main pathology.
More about the disease
The main one is the degenerative-dystrophic process in the spine. Therefore, any pathology of the intervertebral discs, leading to compression of the spinal roots and accompanied by characteristic symptoms, is called vertebrogenic lumbodynia. The disease according to ICD 10 has code M51, reflecting structural changes in bone tissue as a result of osteochondrosis. The diagnosis implies bringing to the fore the degenerative-dystrophic process itself, leading to pain.
The main symptoms of vertebrogenic lumbodynia are similar to those of local dorsopathy. They can be represented like this:
- pain in the lumbar region;
- irradiation and;
- limited mobility in the lumbar segment of the spine;
- local muscle tension in the affected area;
- gait disturbance in the form of lameness;
- changes in sensitivity and innervation of the lower extremities up to paresis or paralysis.
The main difference between vertebrogenic lumbodynia is the presence of constant irradiation, the absence of general intoxication and temperature reaction, even with significant pain.
The pain can be either chronic, unilateral or symmetrical, and in severity - mild, moderate or severe. It always decreases at rest or when taking a comfortable position, and increases with movement. Unilateral lumbodynia - or left-sided - occurs with a local degenerative-dystrophic process with compression of the corresponding nerve root.
Acute vertebrogenic lumbodynia is characterized by the following features:
- sudden onset, often after intense physical effort;
- pronounced pain syndrome;
- the impossibility of active movements in the lower back or their serious limitation;
- pronounced irradiation into the leg, leading to the patient having to lie down;
- Despite the severity of the symptoms, the general condition remains completely satisfactory.
Acute pain is always combined with muscular-tonic syndrome. The latter is characterized by a sharp limitation of active movements in the lower back and limbs. The essence of the syndrome lies in the tension of the muscle fibers innervated by the damaged spinal root. As a result, their tone increases, which complicates the normal function of the limbs. The problem occurs more often on the right or left, but can be bilateral.
Chronic vertebrogenic lumbodynia lasts for years and decades, periodically reminding itself of painful sensations. Typical symptoms:
- aching or dull moderate pain in the lower back;
- weak irradiation into the leg, increasing during exacerbation after hypothermia or physical stress;
- muscle-tonic syndrome is slightly expressed;
- the patient remains able to work, but the degenerative-dystrophic process is steadily progressing;
- an appointment is required, but the unpleasant sensations only subside and do not go away completely.
The diagnosis of chronic lumbodynia is easily confirmed by magnetic resonance or computed tomography, where specific osteochondral changes, including herniation, are clearly visible. Treatment of the disease takes a long period of time, but the main task is to quickly relieve pain. For this purpose (NSAIDs), analgesics, muscle relaxants and anxiolytics are used.
They complement the therapeutic complex with physical. exercise and physical therapy. How to treat vertebrogenic lumbodynia with persistent pain syndrome? Typically, this situation occurs when it is organic, which is associated with hernial protrusions. Therefore, when persistent pain persists, surgical approaches to treatment are used - from local anesthetic blockades to surgical assistance in the form of laminectomy.
Lumbar pain
There are several causes of pain in the lower spine. Lumbodynia is associated with the following pathological conditions:
- degenerative-dystrophic process – spinal osteochondrosis (the most common cause);
- tumors of bone and nervous tissue localized in the lumbar region;
- cancer metastases to the spine;
- autoimmune processes – , ;
- congenital anomalies of skeletal structure;
- pathology of muscle tissue - or autoimmune lesions.
Since the main cause of lumbodynia is spinal osteochondrosis, the main symptoms are associated with it. Typical manifestations include:
- classic symptoms of tension associated with muscle hypertonicity (Lasègue, Bonnet, Wasserman);
- difficulty walking;
- limited mobility in the lower back;
- pronounced emotional discomfort.
When the spine is damaged due to tumors, the pain is persistent and pronounced. They do not go away under the influence of conventional NSAIDs, and removal requires the use of narcotic analgesics. There is a clear intoxication with loss of appetite, pale skin and weight loss. In the lumbar region, especially against the background of weight loss, it is easy to notice a neoplasm that does not move during palpation and is dense to the touch.
With chronic damage to the spine, the symptoms are not too pronounced if the process is in remission. However, it progresses steadily, which, against the background of cooling or intense exercise, leads to exacerbation. Chronic lumbodynia during this period differs little from an acute pain attack. But due to the fact that the disease lasts a long time, treatment is delayed and sometimes requires surgical correction. Lumbodynia is common, which is due to the increased load on the spine. However, due to the negative impact of many medications on the fetus, treatment has its own nuances and difficulties.
The table below presents treatment options for back pain in various clinical situations.
| Condition/treatment | NSAIDs | Surgical assistance | Ancillary drugs | Non-drug correction |
| Classic vertebrogenic lumbodynia | Ortofen, Ibuklin, Ketorol, Nise and others | Laminectomy, stabilizing operations, novocaine blockades | Anxiolytics – Alprazolam, Rexetine, antidepressants (Amitriptyline, Phenibut) | Physiotherapy – DDT, electrophoresis, amplipulse, exercise therapy, massage |
| Tumors of the spine or spinal cord | Ineffective, narcotic analgesics are used | Tumor removal, spinal cord decompression | Psychocorrectors (the entire arsenal if necessary) | Exercise therapy only |
| Autoimmune diseases | The whole arsenal | Joint replacement as an auxiliary surgical aid | Cytostatics (cyclophosphamide, leflunomide, methotrexate) | Physiotherapy – quartz, DDT, amplipulse, electrophoresis, exercise therapy, massage |
| Lumbodynia during pregnancy | Only simple analgesics for acute pain - Paracetamol, Analgin | Novocaine blockades for life-saving indications for unbearable pain syndrome | Local distracting ointments or rubbing | Gentle exercise therapy in the absence of a threat to the fetus |
The spondylogenic nature of spinal lesions is associated with autoimmune diseases. Most often it is ankylosing spondylitis, less often - dermatomyositis or rheumatoid arthritis. Treatment is usually conservative, and pain can be relieved using the combined effects of NSAIDs and cytostatics. With maintenance use of immunosuppressants, the disease progresses in a stable manner with steady progression, but with long-term disability. gives only a temporary effect associated with the irritating effect of plant materials. However, such therapy is not capable of affecting osteochondral tissue. Therefore, the passion for folk remedies is destructive, especially with autoimmune or malignant lesions of the spine.
They give a good effect for relieving pain and quickly restoring movements. Their effect is most pronounced during the degenerative-dystrophic process, as well as during recovery after. Exercises used for vertebrogenic lumbodynia:
- arm and leg lunges. Starting position - standing on all fours. The essence of the exercise is to simultaneously straighten the leg and arm on the opposite side. The duration of the lesson is at least 15 minutes;
- circular movements. Starting position - lying on your back, feet shoulder-width apart, and hands pressed to the body. The essence of the training: alternately raising the lower limbs to a height of up to 15 cm and performing rotational movements. The exercise is done at a slow pace. The duration of the lesson is at least 10 minutes;
- bridge. Classic exercise for osteochondrosis. Its essence is to lift the pelvis using the strength of the muscles of the limbs, with emphasis on the feet and elbows. Duration of training - at least 10 minutes;
- leg girth. Starting position - lying on your back, legs straightened in all joints, arms along the body. The essence of the exercise: you need to bend both lower limbs at the knee and hip joints, and lift your body to reach with your arms and clasp your hips. Number of repetitions – at least 15 per day;
- tilts. The exercise is useful for strengthening the muscular corset of the back during a subsiding exacerbation or remission. During periods of severe pain, it is better to refuse to perform it. The essence of the training is to bend your torso from a standing position and try to reach your feet or the floor with your hands. The number of repetitions is at least 15 times a day.
Physical exercise cannot be the only alternative to treating a patient. They are effective only in combination with medication support or surgical correction.
Chronic type
Although acute back pain is common, the basis of vertebrogenic lumbodynia is made up of chronic degenerative-dystrophic processes. The disease takes a protracted course with an autoimmune lesion, in the presence of unoperated diseases. The main signs of chronic lumbodynia:
- prolonged aching pain;
- duration of incapacity for work – at least 3 months per year;
- weak effect of NSAIDs;
- significant improvement with the use of cytostatics and antidepressants;
- persistent signs of spinal damage on.
The pain is often unilateral, less often bilateral, which is associated with asymmetrical compression of the spinal roots. If the symptoms spread to both parts of the back and lower extremities, then we are talking about a tumor or autoimmune process. In this case, the prognosis is always serious; a thorough detailed examination using magnetic resonance or computed tomography is required. Right-sided lumbodynia is somewhat more common, since the force of the load is distributed unequally. People who are right-handed, and these are the majority in nature, tend to load this half of the body with physical effort. As a result, the muscle corset sags, and the degenerative-dystrophic process progresses, which inevitably leads to right-sided pain syndrome.
One of the types of chronic spinal lesions is post-traumatic lumbodynia. There is always a history of trauma, usually in the form of a compression fracture or surgical correction. Clinical remission is difficult to achieve, since the organic nature of osteoarticular changes prevents effective therapy with conservative means. Such patients are assisted by a neurologist together with a neurosurgeon, since it is often necessary to switch to surgical treatment tactics.
Vertebral type
A chronic or acute process is most often associated with degenerative-dystrophic changes in osteochondral tissue. This is how vertebral lumbodynia occurs against the background of spinal osteochondrosis. It has characteristic features:
- good effect from NSAIDs and muscle relaxants;
- regular exacerbations after physical activity;
- at least 2-3 acute attacks during the course of the disease;
- typical changes during X-ray or magnetic resonance examination;
- often leads to disc herniation, which requires surgical treatment.
The prognosis for vertebral lumbodynia is usually favorable. This is due to slow progression, successful use of NSAIDs, as well as rare serious complications such as paresis of the limbs. Many patients use periodic medications until old age, which stabilizes the quality of life at an acceptable level. When performing regular physical exercises, the muscle corset is strengthened, which helps prevent further progression of the disease. The main task of the specialist is supportive dynamic observation for the purpose of timely diagnosis of autoimmune or tumor processes. In their absence, the patient can be treated for life with supportive medications.
Spondylogenic type
Damage to the intervertebral joints and vertebral processes is the basis of spondylogenic lumbodynia. It is most often autoimmune in nature, as it is associated with systemic damage to osteochondral tissue. Discogenic lumbodynia is caused by changes in the intervertebral space due to joint deformation. This leads to damage to the spinal roots, and is subsequently involved in the process. Pain in the spine, radiating to the leg and buttock with damage to the sciatic nerve, is called “sciatica.” The typical pain syndrome is felt more in the leg, which makes even simple movements of the limb difficult.
Typical signs of spondylogenic lumbodynia of an autoimmune nature with sciatica can be presented as follows:
- severe pain in the buttock and leg;
- severe limitation of movements in the limb;
- slight low-grade fever;
- severe emotional lability of the patient;
- reaction of acute-phase blood parameters with the systemic nature of the disease;
- bilateral changes in the joints on CT or MRI examination.
The patient's vertical posture is especially difficult, but what is it? This means that the patient cannot stand in a standing position for even a few seconds due to severe pain in the leg. The problem disappears after drug stabilization of the patient's condition.
Treatment of lumbodynia
There are two periods in therapeutic measures for lumbodynia. Severe pain requires bed rest for several days, as well as intensive use of medications to alleviate the person's suffering. In the acute period, the following treatment is used:
- or NSAIDs (, Analgin, Ketorolac);
- intravenous infusions of vasodilators (Trental);
- parenteral or oral use of muscle relaxants (usually Tolperisone);
- local anesthetic blockades or narcotic analgesics for persistent pain;
- physiotherapy - quartz or electrophoresis.
For those patients who have suffered an attack of lumbodynia, acute pain remains in their memory forever. However, therapy does not end with pain relief. It is important to take drugs that stabilize cartilage tissue -. If a hernia is present, surgical correction is indicated. Of those patients who cured lumbodynia, many patients underwent laminectomy. This is a radical way to get rid of intervertebral hernia.
Recovery Exercises
Physical therapy is an important part of the treatment of the disease. However, before you start training, it is important to establish the causes of lumbodynia. If there is a compression fracture, then bed rest with gentle exercise is indicated. Novocaine blockade often helps with severe pain.
The full set of exercises can be viewed here:
Physical activity should be combined with other non-drug methods of assistance. Massage is especially effective for chronic pathologies. It is advisable to conduct his sessions no more than 2 times a year. Can there be a temperature with lumbodynia? This question cannot be answered unequivocally. There should not be a high temperature reaction, but a slight low-grade fever due to an autoimmune process or excessive emotional outbursts is possible.
To alleviate the condition, hormones, cytostatics and psychocorrectors are prescribed. But what antidepressants can be taken in combination with exercise? According to neurologists, there are no serious restrictions on taking these drugs. Modern antidepressants can be used long-term.
Types of syndromes
There are several conditions that are typical for vertebrogenic lumbodynia. These include:
- muscular-tonic syndrome – associated with damage to nerve fibers;
- radicular disorders - caused by compression of the spinal nerves;
- lesion at the border of the lumbar and sacral sections – L5-S1 (intervertebral hernia);
- irritation of the S1 root on the left is due to the weakness of the muscle frame and the close anatomical location of the nerve fibers.
Signs of lumbodynia always increase the patient’s pain, since the manifestations of the disease spread to the lower extremities.
Lumbodynia and the army
Many young men are concerned about serving in the army. The answer to this cannot be unambiguous, since different clinical forms of lumbodynia are interpreted differently by doctors at military registration and enlistment offices. Young men are not suitable for service in the following situations:
- widespread with persistent manifestations and repeated exacerbations throughout the year;
- dorsopathy of the lumbar segment with persistent impairment of leg function;
- disc herniation;
- spinal tumors;
- any systemic diseases.
With minor pain or rare exacerbations of chronic lumbodynia without changes on CT or MRI, young people are subject to military service with minor restrictions. Each individual case of spinal damage is interpreted individually depending on the severity of changes in osteochondral tissue.
