A person's lower back, even if he is not overweight, always bears a very large load. After all, upright walking is the only way for a person to move. Most often, acute pain in the lumbar spine and the problems of its treatment are associated with pathology of the deep muscles of the back and with hernias and protrusions of discs.
However, when acute back pain first occurs, it is unclear what caused it. Back pain can occur due to:
- osteochondrosis and its complications, that is, with protrusions and hernias of the lumbar spine;
- spinal canal stenosis;
- inflammation of the nerve roots, or radiculitis;
- spondylolisthesis and scoliosis, when the vertebrae are connected to each other at abnormal angles;
- inflammatory conditions such as rheumatoid arthritis, tuberculosis, brucellosis.
Finally, the cause of acute lower back pain may be a paravertebral tumor or metastases to the spine. And if it is known that the cause is a hernia, then how does the lower back hurt?
Symptoms of pain with hernias
There are markers, or “special flags,” that suggest that pain is associated specifically with damage to the musculoskeletal system and is discogenic in nature. These are the following symptoms and signs:
- sharp and acute pain appears either at the time of severe physical activity or immediately after it;
- acute pain has the character of an electric current, it is sudden, shoots in the lower back, most often in the leg, right down to the ankle joint;
- pain leads to a sharp restriction of mobility in the lumbar spine, and the patient takes a specific anti-pain position. In this pose, the slightest movement is eliminated, and breathing becomes less deep;
- pain associated with damage to the intervertebral discs is of a so-called radicular nature. This means that the slightest shock to the lower back leads to a sharp increase in pain in the form of lumbago, which is called lumbago. This is laughing, coughing, sneezing, trying to change body position or pushing in the toilet due to great need;
- later a permanent, aching component is added, associated with the reaction of the deep muscles to the appearance of an inflammatory focus caused by a hernia.
All these symptoms clearly indicate that the cause of the pain was discogenic complications of osteochondrosis - protrusion or hernia in the lumbar spine, in which these defects occur most often. Why does pain occur? Why does it develop?
Causes of acute pain with a hernia in the lumbar region
First of all: an intervertebral disc that has lost its shape is not a source of pain. The disc may even rupture entirely. Its outer, circular fibrous layers cease to hold the internal nucleus pulposus, which is under high pressure, and the contents of the disc fall out of its limits. This is how a hernia is formed from the protrusion. But the disc itself, just like any cartilage tissue in the body, is not capable of feeling pain. The cartilage formations are not innervated, since otherwise the nerves would have to be in constant motion, with the risk of getting caught between the discs. For the same reason, cartilage, as the boundaries of the skeleton, which has mobility, is also devoid of blood vessels.
Therefore, the source of pain is other structures:
- the first of them is the deep ligaments, which are constantly touched by the hernial protrusion;
- the second component is the nerve roots that enter and exit the spinal cord at the level of each segment, which have sensory and motor portions.
The nerve roots themselves also cannot perceive pain. But if they experience intense compression by a protrusion, or, especially, a hernia, this will lead to the development of aseptic inflammation.
This inflammation will be of the same nature as a callus on the heel, which has formed as a result of constant rubbing from shoes. Constant mechanical irritation of the nerve roots leads to edema, swelling, they begin to be compressed by the surrounding bone canals and ligaments, and the pain increases sharply with every movement and shock (especially with intraforaminal hernias) of such a swollen nerve root. That is why the pain is shooting and sharp;
- this pain also has a constant, aching component, which is largely due to the reaction of the surrounding muscles.
A muscle can respond to pain in only one known way. This is a reduction. If the pain is constant, then the muscle is in a state of constant spasm, and excessive contraction makes it impossible for blood to flow and remove harmful substances from the muscle that are formed as a result of its vital activity. First of all, it is lactic acid.
Therefore, in the presence of an irritating factor, such as a protrusion or hernia, the muscle becomes denser and gradually falls into a state of constant, chronic spasm. Pain stimulates contraction, and constant contraction increases this pain. A vicious circle is formed.
Thus, in the pathogenesis of acute pain in the lower back with protrusion or hernia, several components can be distinguished: ligaments, swelling of the roots and muscle reaction, which forms aching pain that persists for a long time. How can we cope with this complex and multifaceted pain?
First aid for pain syndrome without drugs
Let's consider the principles of first aid, which can be carried out without taking medications and try to get rid of pain, and then - medications used in the first days, and even in the first hours after the onset of such acute pain.
Attention! You should be careful about one very common mistake. On the first day, and especially in the first hours, any warming up is strictly prohibited, and especially with the use of heating pads and physiotherapeutic devices that create excess heat. In the first day, swelling of the nerve roots and muscle tissue only increases, and an attempt to relieve pain by adding heat, according to the laws of physiology, only increases the blood flow to the area of inflammation, complementing and increasing the volume of hyperemia. Treatment of acute lower back pain in the first day with heat will only lead to increased pain.
Therefore, instead of intensive heating, you can, on the contrary, use cooling. If the patient does not have chronic inflammatory diseases of the kidneys or female genital organs, then an ice pack or some cold object can be applied to the lower back for a short time (5-10 minutes) several times a day through dense tissue. This will reduce swelling and relieve pain.
The second thing to do is to try to immobilize the patient by putting a semi-rigid corset on him. It will maintain the necessary distance between the lumbar vertebrae and reduce the risk of acute pain.
The third non-medicinal first aid method is the use of home physiotherapeutic devices, which do not heat, but distract and irritate. These are Lyapko and Kuznetsov applicators. The needles and thorns on which the patient lies, on the contrary, allow the volume of blood to flow from the area of inflammation into the subcutaneous tissue and deep layers of the skin. Thus, the pain syndrome is reduced, and the patient, at least while he lies still, experiences less discomfort. These simple remedies make it possible to alleviate the patient’s condition before using medications.
All other methods of treating acute lower back pain when protrusion and hernia occur or worsen are associated with the use of appropriate medications. Let's take a closer look at them.
Risks associated with epidural block
A physician may advise a patient not to have epidural injections if they have abnormalities in the epidural space of the spine. Such anomalies can be congenital or the result of spinal surgery, after which scarring has formed.
The presence of infection is also a contraindication for an epidural injection. Injecting steroids such as cortisone can reduce the body's ability to fight infections. Cortisone should not be used if there is any serious infection in the body.
The presence of diabetes or congestive heart failure is a contraindication for the blockade.
Medicines for the relief of acute back pain
These are medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), used intramuscularly for acute pain, centrally acting muscle relaxants, also used by injection, and local medications: gels, creams and ointments.
Narcotic analgesics are not used in our country for osteochondrosis. Such drugs are prescribed for oncological pathology, for example, with the development of metastases in the vertebrae. Even then, sometimes the patient cannot receive state-guaranteed care. If a doctor, seeing very severe pain, tries to help a patient in Russia by prescribing, for example, Durogesic in the form of a patch, then, unlike a doctor in the USA or Israel, what awaits him is not gratitude, but prison.
As a last resort, when the diagnosis is clear, confirmed by MRI, and the patient really has pain associated with a protrusion or hernia, a therapeutic blockade can be performed. But this manipulation is not performed at home, but in a hospital or treatment room. Let's look at the main groups of medications that help relieve pain in the first days of the onset or exacerbation of a protrusion or hernia.
NSAIDs: relieve pain and inflammation
Drugs from the group of NSAIDs, or nonsteroidal anti-inflammatory drugs, represent the “three pillars of the treatment of inflammation.” This is a decrease in body temperature, or an antipyretic effect, an analgesic effect, as well as an anti-inflammatory effect. We are not interested in the antipyretic effect, because with protrusions and hernias the body temperature does not rise, and paracetamol (Panadol) and other medications like ibuprofen (Nurofen) are not needed.
But the fight against pain and inflammation is what you need. The strongest analgesic effect of NSAIDs is the drug ketorolac (Ketanov), and in its strength it approaches the effect of narcotic analgesics. The anti-inflammatory effect, which consists in reducing edema, is expressed in drugs such as ketoprofen (Ketonal) and meloxicam (Oalis). The old drug diclofenac (Voltaren, Ortofen) has a very good anti-inflammatory effect. It can be used as a one-time injection, or in a very short course, no longer than 3 days.
We will not dwell in detail on dosages and administration regimens, since this is a matter for the attending physician. However, if the patient has a gastric ulcer or erosive gastritis, then drugs from the NSAID group are contraindicated for him. As a last resort, in the presence of gastritis and ulcers, you can simultaneously take these drugs along with proton pump blockers, such as Nolpaza, Omeprazole, Pariet. They protect the gastric mucosa from the destructive effects of NSAIDs.
After two to three days of intramuscular injections, they usually switch to tablet forms, which are also taken for several days. At the same time, from the very first day they begin rubbing ointments, creams and gels containing NSAIDs into the lumbar area. These are Fastum gel, Nurofen-gel, Dolgit-cream.
Attention! Warming ointments with capsaicin, for example, Capsicam, or Finalgon, can be used on the second or third day, when the pain has already begun to subside and the inflammatory edema has begun to resolve. On the first day, it is recommended to use ointments and gels with cooling, Deep Relief (ibuprofen + menthol), Ben-gay (methyl salicylate + menthol), or apply cooling and distracting essential oils to the lumbar area, for example, peppermint oil in a ratio of 1/10 s base oil.
Muscle relaxants: muscle relaxation
Unlike the relief of sharp and shooting pain, these medications are designed to relieve the persistent and aching pain component caused by excess muscle spasm. They cannot numb the very first, shooting pain. They were called centrally acting muscle relaxants because they regulate the functioning of spinal cord neurons and do not directly affect the muscle. They deceive her and allow her to relax. And this improves blood flow and allows you to eliminate the products of muscle metabolism. The most popular medications are Mydocalm, or tolperisone, and Sirdalud, or tizanidine. The first of them does not cause drowsiness, but the second is better taken at night or in the evening.
While taking muscle relaxants, it is better not to drive a car or work with moving machinery, since these drugs slightly increase the muscle reaction time. Muscle relaxants are also given intramuscularly during the first days of the disease, but they do not affect the gastric mucosa and can be prescribed as a course of therapy. As a result, chronic muscle spasm caused by protrusion and hernia is resolved, and persistent back pain also decreases or disappears.
Vitamins
The administration of B vitamins, or neurotropic vitamins, from the point of view of evidence-based medicine, does not affect the length of days of disability or the relief of pain. However, in the Russian Federation, doctors often use them for prophylactic purposes. Neurotropic vitamins are vitamins B1, B12 and B6, which take part in the functioning of the central and peripheral nervous system. Therefore, when there is swelling of the nerve roots, they are prescribed to create an excess depot, so to speak, just in case.
The most popular drug prescribed intramuscularly is Milgamma, which contains all these vitamin concentrates along with the local anesthetic lidocaine. He makes the injection painless. After a course of intramuscular injections, you can move on to the drug Milgamma compositum, this is a tablet drug.
Physiotherapy, exercise therapy and massage
All physiotherapeutic procedures associated with heat, mud therapy, balneological effects must be used outside the acute phase. Only then will physiotherapy, physical therapy and massage sessions have a beneficial effect. If you try to carry out a massage on the first or second day of acute back pain, it will only cause worsening, since the muscle is in a state of persistent spasm, and any shaking of the back will cause severe attacks of radicular pain. And standard massage techniques are not only relaxing, but also tonic. It is simply not appropriate to carry out one relaxing massage against the background of acute pain. Acute pain is a contraindication to any type of physiotherapy.
Material and methods
In order to study the therapeutic potential of the original drug meloxicam (movalis) for acute LBP, the CARAMBOL study (Clinical Analysis of the Results of Analgesia with Meloxicam and its Safety in Acute Lumbargia) was conducted. The work was observational in nature and did not involve interference with the usual treatment process or the prescription of new medications or therapeutic methods. The duration of use of NSAIDs to relieve NBS was determined by the attending physician, based on clinical recommendations and personal experience. The prescription of other drugs was not limited: muscle relaxants, B vitamins and proton pump inhibitors (PPIs).
The study included 2078 patients with NBS, mean age 46.3±13.4 years, 56.6% women. In 34.8% of patients, a real episode of LBP occurred for the first time, in 65.2% it occurred repeatedly. Over the previous year, patients experienced from 2 to 12 (on average 2.61±1.35) cases of NBS: 2 episodes - in 59.3%, 3 - in 27.5%, 4 - in 10.5%, 5 or more - in 2.7% of patients.
Inclusion criteria
into the study: age 18 years and older, the fact of visiting a doctor in connection with acute severe pain in the lower back (duration no more than 2 weeks, severity of 4 points or more on a numerical rating scale - NRS), presence of indications for prescribing meloxicam, according to in the opinion of the attending physician, the patient’s consent to participate.
Non-inclusion criteria:
contraindications for the use of NSAIDs, the presence of symptoms of severe threatening pathology (“red flags”), as well as severe functional impairment, which makes it difficult to re-observe patients.
Data obtained during 2 visits of patients were analyzed: at the 1st visit, a standard clinical examination and survey were carried out before prescribing therapy; at the 2nd visit, the result of therapy was assessed after 14 days.
The severity of LBP was assessed using a 10-point NRS according to the following criteria: 0 points—no pain, 10—maximum severe pain. General health was also assessed using the NRS, where: 0 points - no deterioration, 10 - the most pronounced deterioration in health. On average, the severity of pain at the time of treatment was 6.69±1.65 points, deterioration in health was 5.68±2.09 points. Severe pain (7 points or more) was recorded in 57.0% of patients.
When interviewing patients who had previously had episodes of NBS, they found out the fact of using NSAIDs and an assessment of their effect. As it turned out, the vast majority (70.2%) of patients had already received drugs from this group. The effectiveness of NSAIDs in history was rated by patients as good in 28.0% of cases, as moderate in 54.6% and low in 17.4%.
Many patients had a history of adverse reactions (ARs) when using NSAIDs: dyspepsia (gastralgia, nausea, feeling of heaviness in the epigastrium, etc.) - in 44.7% of patients, development of stomach and/or duodenal ulcers - in 2.7% %, bleeding from the gastrointestinal tract (GIT) - in 0.4%, increased blood pressure (BP) - in 14.1%, edema - in 6.2%, allergic reactions - in 3.4%.
In addition, a number of features of the clinical manifestations of acute NBS were analyzed. When surveying patients, the following symptoms were identified: persistence of pain at rest - in 37.2% of patients, pain at night - in 19.0%, feeling of stiffness in the morning or after being at rest - in 60.7%, pain radiating to the leg - in 28.2%, signs of lumbar ischialgia (intense pain in the leg, accompanied by sensory disturbances) - in 9.6%.
All patients were prescribed original meloxicam (Movalis) at a dose of 15 mg/day. In the majority of patients (86.1%), it was used in a stepwise manner: the first 3-5 days in the form of intramuscular (IM) injections, with a further transition to the oral form. In 13.9% of patients, only oral meloxicam was used. By decision of the attending physicians, 52.3% of patients also received muscle relaxants (tolperisone - 31.7%, tizanidine - 18.7%, baclofen - 1.7%), 17.4% - B vitamins (mainly for i.m. introduction). To prevent the development of NSAID gastropathy, 21.6% of patients were prescribed PPIs, mainly omeprazole.
The result of treatment was determined by the frequency of complete cessation of pain and the dynamics of its severity (if it did not go away completely), as well as the general well-being of patients over 2 weeks of observation. In addition to this, patients were asked to rate the result of therapy on a 5-point scale, where: 1 point meant deterioration of the condition, 5 - excellent result. The frequency and nature of ADRs recorded during the observation period were also studied.
The obtained quantitative data are presented as the mean value and standard error of the mean value ( M± m
).
Statistical differences in quantitative parameters were determined using t
-test; the distribution of rank variables was determined using the odds ratio (OR) and Fisher's exact test. Indicator O.Sh. is given in the paper along with the corresponding 95% confidence interval (CI).
How to prevent pain?
In order not only to remove, but to prevent the appearance of pain, you simply need to prevent the appearance of a hernia. Simple rules must be followed:
- move correctly and work on your posture, avoid flat feet;
- carry weights only evenly in a backpack on your back;
- when lifting weights, try to hold the load symmetrically, and in no case on one shoulder or in one hand;
- do not bend or turn while carrying a heavy load;
- monitor body weight, avoiding its excess;
- regularly try to hang on the horizontal bar or swim, unloading the spine, and do therapeutic exercises;
- after reaching a certain age, check the level of calcium in the blood, prevent osteoporosis;
- in winter, and especially in the presence of ice, you need to refrain from sudden movements, since falls and injuries are a risk factor for protrusion and hernia.
This way you can avoid severe back pain. If you already have a protrusion, or, moreover, a hernia, and they bother you regularly, then the best way is a modern minimally invasive surgical intervention.
Currently, they are being carried out with great success in Bulgaria, the Czech Republic, and including Russia. These are cold plasma and laser nucleoplasty, vaporization, endoscopic microdiscectomy. As a result, either the appearance of a hernia from the protrusion is prevented, or the cartilaginous protrusion itself is eliminated, and the nerve roots, muscles and ligaments no longer compress anything. Only surgery can lead to radical extraction and improve the quality of life.
results
After 2 weeks, complete or almost complete cessation of NBS was achieved in 75.2% of patients, while the required duration of NSAID use for pain relief averaged 8.61±5.53 days.
Patients who maintained NBS after 2 weeks of therapy noted a significant decrease in its intensity: on average from 6.69±1.65 to 2.38±1.61 points according to the NRS. There was a significant positive trend in patients’ assessment of their well-being: from 5.68±2.09 to 2.57±1.83 points according to the NRS. Compared to the baseline, the reduction in pain severity and improvement in general well-being reached 64.2±22.8 and 54.4±19.6%, respectively.
The treatment outcome was assessed as excellent by 30.6% of patients, good by 52.9%, satisfactory by 13.5%, and low or absent by 2.7%.
In 96 (4.6%) patients, adverse reactions were recorded during therapy: dyspepsia - in 82 (3.9%), increased blood pressure - in 22 (1.1%), allergies - in 2 (0.1%), heartburn - in 2 (0.1%) and constipation - in 2 (0.1%). All N.R. were mild or moderate in nature and did not require interruption of therapy.
The relationship between the achievement of the main treatment outcome (complete pain relief after 2 weeks of observation) and the presence of a number of clinical and anamnestic factors was investigated. The frequency of relief of NBS depending on the presence or absence of the studied factors is presented in the figure.
The influence of various factors on the effectiveness of treatment for NBS.
The x-axis shows the frequency of complete relief of back pain in the presence and absence of the studied factor (%). * — significant difference in the frequency of relief of NBS (p<0.05). The gender of the patients did not affect the treatment outcome (OR 0.967, 95% CI 0.795-1.177, p
= 0.763).
The effectiveness of treatment was significantly higher in patients under 65 years of age (OR 2.053, 95% CI 1.592-2.642, p
= 0.000), in patients who had a first episode of LBP (OR 1.415, 95% CI 1.09-1.836,
p
= 0.009) and a history of good response to NSAIDs (OR 1.937, 1.513–2.481,
p
= 0.000).
A lower treatment outcome was associated with the presence of initially severe pain (7 points or more according to the NRS) (OR 0.481, 95% CI 0.393–0.588, p
= 0.000), the presence of pain at rest and at night (OR 0.559, 95% CI 0.441–0.709 ,
p
= 0.000 and OR 0.511 95% CI 0.413–0.631,
p
= 0.000, respectively) and especially with the clinic of lumbar ischialgia (OR 0.346, 95% CI 0.256–0.466,
p
= 0.000).
Compared with meloxicam monotherapy, the combined use of this drug with muscle relaxants and B vitamins did not increase the effectiveness of treatment (OR 0.827, 95% CI 0.594-0.889, p
= 0.02 and OR 0.917, 95% CI 0.804-1.1201,
p
=0.452 respectively).