Spinal origin

Syndromes

Lower back pain is a benign and auto limited process in most cases. If the pain radiates down the lower limb it is referred to as lumboscialtagia. If the pain persists after 4 weeks of treatment, the condition requires radiological assessment. If the pain is accompanied by a loss of strength in the limb or sensibility disturbances, the assessment should be carried out immediately. The most frequently established diagnoses are:

Disc hernia: A protrusion of the material normally enclosed inside the disc towards adjoining structures. The level at which it occurs and the existence or not of contact or compression of the adjoining roots determines the intensity and the localisation of the symptomatology (image 1) (image 2)

Degenerative disc pathology: The intervertebral disc becomes dehydrated with the possibility of fissures causing pain. (image 3)

Spondylolisthesis: The displacement of a vertebral body over another, generally due to alterations secondary to arthrosis of bone and ligament structures of the vertebral column. (image 4)

Foraminal stenosis – canal stenosis: A decrease in the space through which the root has to pass through (foraminal stenosis) or the set of roots that have not yet left the spinal canal (canal stenosis). This decreased space is due in the majority of cases to abnormal growth of the bone that takes place in the degenerative process we know as arthrosis. In many cases, other factors such as disc hernia or disc protrusions, or ligament hypertrophies are associated modifying bone structure and thus triggering the decrease in calibre. (image 5)

Arthrosis of posterior vertebral joints: Posterior vertebral joints are directly responsible or contribute towards a significant number of lumbalgias. Their anatomic function of these structures causes overloading with certain exercises, postural habits, or when the degenerative process initiated at the disc reduces the height of the intervertebral space. (image 6)

Post-laminectomy syndrome: This syndrome, also known as failed back surgery syndrome, refers to lumbar or radicular pain that persists or does not disappear after surgery of the vertebral column. There can be multiple causes (recurrent hernia, epidural fibrosis, secondary instability, etc. ) (image 7)

Radiculopathy: Any of the mentioned proceses can cause a persistent lesión despite treatment of the nerve root. The pain will affect the distribution territory of the affected root.

Other causes: Irradiated lumbar pain may or may not have its origin in inflammatory, infectious or cancerous processes, origins that need to be ruled out through the corresponding clinical assessment and additional explorations.

Pain in the neck and in the upper back. The term brachialgia indicates that the pain radiates into the arm reaching as far as the hand. Even though on many occasions the origin of the pain is muscular, the persistence of cervicalgia or the existence of irradiation into the arm make a radiological exploration advisable.

Loss of strength or sensibility calls for immediate medical exploration of the condition. (image 8)

Muscular origin

Regional syndromes

Muscle overload or traumatism can cause muscle bundles to contract, and if stress is present, the condition becomes chronic. These regional contractures are characterised by the so called “trigger points” that when palpated and pressed can set off the pain. The degree of pain will depend on the territory involved. On occasions this contracture affects muscles (piriform or psoas) that cause more specific clinical pictures, such as lumbosciatic pain secondary to contractures of a lumbar origin.

Fibromyalgia is a condition that causes generalised pain of unknown origin. Muscle pain is almost invariably accompanied by fatigue, sleep disorders, anxiety and depression. Diagnosis is established based on the criteria from American College of Rheumatology (1990) as follows:

History of generalised pain present for more than 3 months.

DEFINITION: The existence of generalised chronic pain is considered when:
*There is pain on both sides of the body.
*There is pain above and below the waist.

There is also pain in the axial skeleton (cervical, dorsal, lumbar areas and anterior thoracic wall).

Painful to touch in 11 of the 18 tender sites defined (when exerting a pressure equivalent to 4kg of weight; these sensitive sites are extremely painful).

Fig. 1.Painful sites in Fibromyalgia

For further information: www.fibromialgia-cat.org/

Nervous origin

Pain can originate in the nervous tissue under a number of conditions.
In diabetes and peripheral vasculopathy, vascularisation of the nerve is affected. The pain is usually distal and bilateral (ina glove or a stocking distribution).

In other cases, the nerve is trapped along its path through an anatomical passage narrowed by osteoligamentous or muscular modifications, as in carpal tunnel syndrome or paresthetic meralgia.
A minimal lesion during the course of a surgical procedure or a dental extraction can cause pain originating in the damaged nerve.

On occasions it is a viral infection such as herpes zoster that can damage the nerve endings and nerve fibers in the affected territory, with persistent pain after resolution of the acute episode. .(image 9)

Neuralgia of the trigeminus nerve (trigeminal neuralgia) is the best-known type of neuralgia and one of the processes that most severely restricts the quality of life of its sufferers. Nerve compression by the upper cerebellar artery at the point where it exits the cerebral trunk is the most frequent cause. (image 10)

Pain maintained by the sympathetic system

The IASP (www.iasp-pain.org ) agreed to group together a series of diagnoses characterised by pain, limited mobility and disorders of adjoining tissues that occur in patients without a previous lesion or that occur in a disproportionate manner in relation to the lesion. These diagnoses: Algodystrophy, Sudek, Reflex sympathetic dystrophy are all grouped together under Complex Regional syndrome Type II. Complex regional syndrome Type II substitutes the diagnosis of causalgia and is defined based on the same symptoms and signs but with a previous history of an important nerve lesion. Even though this is a controversial issue, this pathology is considered to involve the sympathetic nervous system. The involvement of the sympathetic system is also suspected in the chronic pelvic pain syndrome. (image 11)

Cephalea

Cephalea or headache is another universally known symptom. In the majority of cases, these headaches are benign and are often associated to viral infections, diet transgressions, lack of sep, etc. If there is persistence or high intensity of the pain, medical advice should be sought. Individuals suffering from chronic cephalea should seek medical advice if any changes in the characteristics of the pain occur. Even though there are no definitive treatments for chronic cephalea, in most cases it is possible to minimise the impact of the condition on the life of its sufferers.

www.achenet.org

Oncologic pain

During its progression, cancer or the sequelae from cancer treatments can cause pain. Symptoms and their location can vary depending on the location of the tumour. The existence of sustained release opioid analgesic drugs makes the treatment of these patients easier; however, on occasions the intensity or the high number of side effects from these drugs make the use of other means more advisable (neurolytic blocks, radiofrequency thermocoagulation, implantable systems of continuous epidural or intrathecal administration). The Pain Medicine Clinic can offer these alternatives to those patients requiring a different approach to pain.