Dorsalgia - Lumbar Pain (Back Pain) is one of the most common pain syndromes determined by vertebral pathologies. Lumbar pain affects 60-80% of adults and is one of the common cause of decreased working ability especially in patients below the age of 45. Number of such patients is quite big especially in neurology outpatient visits. It is considered that in most cases (up to 90%) pain doesn’t last more than 6 weeks while in the rest pain has chronic character.
Dorsalgia is multi-factorial clinical syndrome.
Causes of vertebrogenic lumbar and extremity pains are:
- Disc hernias
- Sacralization or lumbalization
- Arthrosis of intervertebral joints
- Ankylosing spondylities
- Vertebral canal stenosis
- Instability of vertebral segment by Spondilolysthesis
- Vertebral fractures
- Sine tumors
- Ankylosing Spondyloarthrosis
- Functional diseases of vertebral canal
Non-vertebral causes of lumbar pain are:
- Myo-fascial pain syndrome
- Psychogenic pain
- Somatic pain during diseases of internal organs
- Intra- and extramedullar tumors
- Metastatic lesions
- Retroperitoneal tumors
General cause of pain in any segment of vertebral column (cervical, thoracic, lumbar or sacral) is caused by compression of spinal meningies, dorsal columns or neural trunks. Compressions by itself can be caused by central or lateral stenosis of vertebral canal.
Reason of so common vertebral pain syndrome is explained by anatomic and functional complexities of vertebral column. Only in cervical region in addition to 7 cervical spines there are 25 synovial and 6 fibro-cartilaginous structures plus multiplicity of supporting ligaments. Vertebral strain, weak spinal muscles, various pathologic processes in inter-vertebral discs lead to degenerative and dystrophic changes. Initially it starts with synovitis in vertebral joints and then leads to sub-dislocations (Unstable Phase), in vertebral discs – it is expressed with functional derangements, loss of height, instability in the mobile segment. All such changes lead to dynamic stenosis of vertebral column i.e such stenosis that evolves during rotation, flexion and extension of the vertebrae. During such motions superior vertebral joint spine compresses neural trunks.
After unstable phase is stabilization phase characterized by solid organic stenosis of vertebral column. Its development in intervertebral joints is determined by increase in size of articular facets and osteophyte formation especially in inferior articular facets.
Disc hernia is also common reason; mostly it is prolapsed in posterior segment causing central or lateral stenosis anyway compressing the neural trunks located nearby.
Three main pathophysiologic mechanisms of dorsalgies are explained:
1) Peripheral sensitization of the pain receptors- caused by traumas or other pathologic processes. These receptors become more sensitized during muscle-skeletal traumas; traumatization increased release of pro-inflammatory and pain substances (Prostaglandins, Bradykinin), which switch on of peripheral sensitization mechanisms.
2) Neuropathic pain mechanism- injuries of any neural structures (nerves, neural trunks, neural ganglia) by trauma, inflammation, vascular insufficiency can cause the pain.
3) Central sensitization- initially this is the defense mechanism but during long standing pains it represents worsening factor.
No matter which structure of vertebral column is involved the clinical picture is dominated by compressive or reflexive signs.
Compressive syndromes develop if altered structures in vertebral column compresses or deforms neural trunks, spinal cord or spinal blood vessels. Reflexive vertebrogenic syndromes are seen when vertebral structures with rich sensory innervations are irritated or damaged. It is considered that only epidural vessels and bony structures lack nociceptive receptors.
According to localization vertebral pain syndromes can be classified as: cervical, thoracic and lumbo-sacral.
Diagnosis is made mainly by radiological studies. Vertebral column X-ray is initial studying method; it gives opportunity to determine configuration of the vertebral column and the nature of existing lesions to determine further studies with CT or MRI.
CT and MRI is the main mode to determine the nature of pain syndrome giving opportunity to estimate each vertebral component in detail: sizing of vertebral canal, deformation type and grade detection, calcified regions, ligament hypertrophy, cartilaginous hernias, vertebral joint arthrosies, tumor detection, and spinal cord general evaluation can all be managed by radiological studies.
Pain syndrome management during acute phase of spondylo-dorsopathies is pain control, regaining of normal locomotion functions of vertebral column and adequate sources and environment for rehabilitation process. Pain relief on time, from one point, gives opportunity to start “Movement Therapy” early and from another, it interferes with development of emotional disturbances. Analgesic medications used for vertebral pain syndromes are from NSAID (Non-Steroidal Anti-Inflammatory Drugs) group. Patients usually self-medicate their selves with NSAIDs in addition to other medications in case of pain recurrence or intensification. Long term use of analgesics increases the risk of drug side effects that’s why all the pain medications and especially NSAIDs should be taken under physician’s control. Early inclusion of NSAIDs is recommended.
A long list of NSAIDs is available for physicians today. According to mechanisms of action there are “non-selective” and ,,selective’’ inhibitors of the enzyme (COX) cyclooxigenase I and II and II respectively. They differ markedly in priorities and unwanted effects respectively having different clinical effects, duration of pain management and side effects. In case of vertebral pain, considering cost-effectiveness, efficiency and side effects priorities are given to Diclofecac, Ibuprofen and Ketoprofen from non-selective COX I and COX II inhibitors group and Meloxicam from selective COX II inhibitors group. One of the first drugs of choice is Diclofenac Sodium - Clodifen (WORLD MEDICINE, England). Injection solution 75mg/3ml of Clodifen has perfect pain-killing and anti-inflammatory actions, coupled with its easy tolerability.In addition to various pharmacologic effects of all NSAIDs Clodifen has additional complex action on analgesic mechanisms. By inhibiting synthesis of prostaglandins Clodifen decrease peripheral sensitization of pain receptors and halts neurogenic inflammatory processes.
Clodifen,s intrinsic pharmacologic pecularity is in its ability to maintain physiologic metabolism in cartilaginous tissue.
Dosing regimen and duration of therapy is determined by individual physician according to the severity and complexity of the disease course. Usually Clodifen is given as single 75 mg /24hr injection or 150 mg (2 ampoules) /24 hr as a loading dose for rapid effect. Duration of therapy is 5- 10 days and daily dose shouldn’t be above 150mg. Clodifen,s pharmacologic priority is in its short half-life (t 1/2) and no cumulating effect, and well penetration and concentration into inflammatory tissues. From all the above Clodifen has excellent drug benefit/risk ratio. Rapid pain relive is main reason for Clodifen prescription, it is first line drug of choice especially for managing acute pain syndromes with high intensity pains.