Pathologies and treatments

Back pain is one of the most widespread problems in the world population, 75-85% of Italians have suffered or suffer from some form of back pain during their life. Back pain is the second reason for requesting a medical examination and, after the flu, it is the main cause of loss of working days in people under 45 years of age. It affects the lumbar and sacral region; if it radiates to the lower limb it is commonly referred to as lombosciatalgia. Pain that originates from the lumbar region can be produced by several causes, excessive exertion or a fall that produces trauma; or chronic degenerative diseases (e.g. osteoarthritis or discopathies). The body’s response to pain is often associated with a contracture of the lumbar muscles, which increases the painful sensation, accompanying it with a marked difficulty in the movement of the trunk. Pain is commonly divided into: – acute, when it lasts 2/3 months and at the end of treatment it fully heals quickly – if it persists after 3 months and must be treated with specific remedies Most episodes of acute lumbar pain are due to excessive stretching of muscles or ligaments.

It is a condition due to the gradual narrowing of the vertebral canal,which occurs asa consequence of the degeneration of both intervertebral discs and joint veneers. Bone spurs are formed, called osteophytes,as a result of excessive loadon the intervertebral disc and for the progress of osteoarthritis of the spine (spondylosis). These osteophytes tend to reduce the diameter of the vertebral canal. The joint veneers widen and deform, further reducing the space available to the nerve roots and spinal cord. As stenosis progresses, this process can lead to contact and compression of nerve roots and spinal cord. The reason why this causes pain and weakness in the legs is still not known exactly, it can be associated with compression of the vascular vessels that carry blood to the nerve roots, which innervated the muscles.

It is a pathology of the intervertebral disc in which the inner part, called the “pulpy nucleus “, comes out of its seat makingits way through the lamellae of the fibrous anulus. Theanulus is the structure responsible for containing the nucleus and constitutes the outer contour of the disk. If the spillage of the nucleus compresses a nerveroot, the pain can spread into the territory innervated by that root. In fact, between two vertebrae there is always a pair of spinal nerves that then go to innervate a specific area of the body. In turn, compression of one of these spinal nerves causes pain in the part of the body that they innervate. The two positions in which the vast majority occur (about 98%) of the painful disc hernias are the last two intervertebral spaces, namely L4-L5 and L5-S1. Most episodes of discanulus rupture occur between the age of 30 and 40, when the consistency of the nucleus is still essentially gelatinous.

The most common type of vertebral fracture is compression fracture, usually caused by a fall in a subject that has osteoporosis. The burst ones are due to a violent load that causes the rear and front wall to collapse, thus reducing the height of the vertebra. It is a type of unstable fracture that immediately needs stabilisation. Bending/Compression fractures typically occur between T1 and L1 and have a wedge shape. It’s a more stable type of fracture, but it could get worse quickly.

It is a clinical condition typical of people over 65 years of age, when bone tissue is reduced (about 30%) and is less compact and more fragile than its standard. The peak of our skeletal structure is reached, in fact, around 20 years. Precisely because of this data, the loss of bone tissue is, to some extent, a physiological phenomenon rather than a disease. However, if a person has less bone tissue than the average amount for età and sex, osteoporosis is described as a pathology. The most frequent complication of osteoporosis is a fracture. When this concerns a vertebra we talk about collapse or fracture of the spine.

It is a pain that begins at the level of the joints or buttocks and spreads the entire length of the leg up to the foot. This condition often goes hand in hand with lumbar pain that can be more or less intense than pain in the lower limb. The term “sciatica” indicates that the sciatic nerve, which extends from the lower back through the buttocks and along the leg, is believed to be the cause of pain in this condition. True sciatica is a condition that occurs when a herniated lumbar disc compresses one of the roots that form the sciatic nerve. This type of lumbar pain mechanism is less common than other causes of low back pain. For example, sportsactivities or heavy work can cause lumbar pain and lower limb which is often mistaken for sciatica. The challenge for the doctor is to distinguish between root pain that is caused by an inflamed root and reported pain that is the result of muscle stretching or distortion. The most common symptom of real sciatica is a pain in the back of the thigh, lower leg or foot that can be of higher intensity than back pain. Usually, the patient reports that the pain of moderate to severe intensity, begins at the level of the buttock and runs the leg towards the foot. It is important to know that real sciatica produces a pain that radiates beyond the knee. Often the patient reports having had an episode of lumbar pain, started a few days or weeks before the pain in the leg appeared, then the pain in the leg became more intense than lumbar pain, and in some cases the lumbar pain completely disappears. However, in the case of long-lasting sciatica, pain can gradually locate in the buttocks and back of the leg. In this situation, the patient may have a vague sense of soreness that does not reach the lower part of the leg or foot, as instead in the early stages of the appearance of pain. Often there is no specific traumatic event or movement associated with the onset of sciatica. Standing, lifting weights, sneezing or going to the bathroom can aggravate the pain. Lying down is usually the most convenient location. Occasionally sciatica is accompanied by paresthesia, weakness and deficit of the function of the sphincters.

Degenerative Discopathy is a natural process due to the aging of theorganism. In fact, as they age, the intervertebral discs gradually loseflexibility, elasticityand abilityto absorb trauma. The layers of fibrous tissue surrounding the discs(fibrous anulus ) becomebrittle and therefore more likely to tear and yield. At the same time, the central part of the disc, which is soft and gelatinous, dehydrates and shrinks. It has been shown that in Degenerative Discopathy the discs become more sensitive to external stimuli (positions, movements, pressure increases…), due to increased sensory innervation compared to healthy discs. The diagnosis begins with a full medical examination: the doctor examines the back focusing on local palpationpain, flexibility, range of movement and the presence of some more common signs of root suffering, due to degenerative changes in the spine. The visit includes the evaluation of: muscle strength, reflexes, sensitivityto the skin.

Discale protrusion is a particular type of intervertebral disc pathology in which, the inner part (called the pulpy nucleus),due to pressure exerted on the disc by certain factors (such as bodyweight, work activities, sports activities, movements and positions of the body…), tries toget out of the disc by making its way through the slats that form the outer shell of the disc(anulus). Generally,anulus is able to prevent this from happening. In some cases, however, the slats that make up this outer coating of the disc, can break, making the protective layer thinner and less resistant to the increase in internal pressures, caused precisely by the tendency of the pulpy nucleus to push outwards. In this case, you create a bulge on the outer surface of the disk. This bulge is called “protrusion” Protrusions are generally almost completely asymptomatic. If, however, they are formed in the postero-lateral area of the disc, that is, in the passage area of the root of the nerve, pressure can be created on the nerve itself, which will be felt as irradiated pain to the lower limb (in the case of a lumbar disc) or higher (in the case of a cervical disc). The symptomatology can therefore be very similar to that of an expelled hernia, even in the absence of a real hernia (which instead is determined by the leakage of part of the internal material of the disk, that is, the pulpy nucleus). The pain is related: • the pressure that the disc exerts on the nerve • the inflammation that this phenomenon entails • the release of certain substances capable of giving rise to pain, which are released in the contact area between disk and nerve.

Tensive headache is the most frequent primary headache, with a population prevalence of 46%. It is characterized by bilateral pain, localization and intensityvarying from mild to strong. Pain is gravative-constrictive, i.e. described as “a weight” or “a tightening vice”, which does notworsenwith physical activity and generally does not prevent normaldaily activities. The duration of an attack ranges from 30 minutes to 7 days, and it is not yet clear what mechanisms are behind it. The most accredited hypothesis is that of a multifactorial origin, in which soreness of the muscles of the skull and neck contribute, along with a deregulation of the structures involved in the brain control of pain. This type of headache can also affect those who already sufferfrom headache or chronic migraine. In fact, the recommended therapies involve taking analgesic drugs and anti-inflammatories from self-medication to block and reduce theintensity of the episode, and a pharmacological or non-pharmacological prophylaxis in some patients. In common language cervical headache is a pain that is located or onset in the cervical region and is a symptom that can have longer duration than tensive headache and migraine. It should be pointed out, however, that pain localised at the cervical level is often the expression of certain forms of primary headache, such as tensive headache andmigraine. Cervical sprain headache (known as “whiplash”) is attributed to a head and/or cervical trauma. In the acute form the headache is resolved within 3 months of trauma, and may occur as an isolated symptom or in the context of a constellation of symptoms that include dizziness, pain in the neck, shoulders and/or arm, stunning, fatigue, mood disorders, insomnia, difficulty concentrating and attention. Features that tend to distinguish headaches caused by pathologies of the cervical column from migraine or tensive headache include: fixed lateral pain, reproduction of headache through pressure on the neck muscles or movement of the head and irradiation of pain in the shoulder or arm. The diagnosis is therefore based on a detailed collection of the patient’s history, on a complete objective examination and, in case of trauma or suspected pathology of the cervical column, on the execution of appropriate instrumental and laboratory investigations. The therapy depends on the underlying pathology and includes pharmacological and rehabilitation therapies. Given the long duration of the symptom, a drug with a prolonged analgesic action allows you to intervene to promptly block the onse of episodes with continuous pain and that can worsen in intensity. Migraine is a primary headache that affects 14% of the world’s population. It is characterized by the presence of recurrent headache attacks lasting between 4 hours and 3 days, which is located unilaterally, that is, on only one side of the head. Pain generally has a pulsating character and worsenswith physicalactivity and movement (climbing stairs, lowering the head) making it difficult to perform the usualdaily activities. Headaches are associated with symptoms such as nausea, vomiting and hypersensitivityto lights, noises and smells (photo-phono-osmophobia),often forcing sufferers toseek psycho-sensoryrest in a dark and silent environment during theattack. The confirmed migraine phase can be preceded by focal neurological symptoms, usually visual and completely reversible, which are called aura and which distinguish migraines in its two forms, with and without aura. The numerous studies carried out to date have not clarified the mechanisms behind migraines. Currently, it is considered a multifactorial pathology whose origin contributes both environmental and genetic factors. Triggers, internal or external to the body (some foods, anxiety, depression, stress, relaxation after stress, alteration of the sleep-wake cycle, modifications of female sex hormones, some drugs, etc.), act on a “special brain”, a brain that produces less energy and consumes more, leading to the migraine attack.  Since this is therefore a primary headache, the routine use of examinations (computer tomography, MRI, electroencephalogram or others) is not justified, whereas it is important to act promptly, even at the appearance of the first symptoms, with attack drug therapy. To stop the incoming crisis, reducingthe intensityof pain and associated symptoms can be used analgesics and anti-inflammatories from self-medication. For those who suffer from frequent migraines or particularly disabling and/or resistant attacks to attack therapy, the therapy of more specific prophylaxis or drugs to be agreed with the specialist is indicated.

Trigeminal neuralgia is a rare disease, also known as “painful tic”, caused by pressure exerted by a blood vessel on the trigeminal nerve which, hyperecided by this pressure, sends inappropriate pain signals in response to otherwise harmless stimuli. It is the most common of facial pain and affects the female sex most frequently, mainly after the age of 50. It is characterized by attacks of sudden and extremely intense and lancinating pain, often described as an electric shock, which is located on one side of the face at the trigeminal nerve – at the level of the cheek-side of the nose or in the lower lip-chin. Attacks last from a few seconds up to a maximum of 2 minutes and can be spontaneous or triggered by harmless stimuli such as eating, talking, yawning, brushing teeth, shaving or taking a current of air. The course of the disease is very often intermittent: long periods of frequent attacks are followed by weeks, months or years free from pain although in most subjects the frequency tends to worsen over time with periods free from increasingly short attacks. The treatment of trigeminal neuralgia is aimed at preventing attacks with drugs that must be agreed with the neurologist and taken in doses and with therecommended modalities.

Posterpetic neuralgia is a painful symptomatology that can arise as a consequence of a herpes zoster. Usually neuropathic pain is located in the same skin region where the herpatic rash developed, and typically appears when skin lesions are healing. It is rarely possible for neuralgia to occur in the absence of obvious skin signs. In this case we speak of zoster sine herpete. Annoying symptomatology can be configured as simple itching, tingling or real pain and derives from damage to the nerve pathways caused by the varicella-zoster virus (VZV) which is a neurotropic virus. Symptoms can persist for several months. After the initial infection, chickenpox virus could lie in the dorsal horn of the spinal cord for decades before its unwelcome presence becomes apparent the moment it activates to cause an acute attack of herpes zoster (known as St. Anthony’s Fire). It typically occurs as a burning, a tingling pain with occasional lancinating components that can precede the appearance of small skin vesicles distributed on the skin nerves or nerves in two to three days. In turn, this can lead to the unpleasant persistence of pain in the form of post-herpetic neuralgia (PHN).

The iliac sacred articulation is also known as the sacral ileum articulation. It connects the lumbar part of the spine with the pelvis by means of a ligament apparatus in tension. Due to the solid supporting structure present, the iliac sacred articulation does not have a high degree of mobility. However, it can be moved by applying high forces or taking incorrect postures. Even the smallest displacements in the iliac sacred joint can cause intense back pain. A blockage of the iliac sacred articulation, a so-called sacroiliac block, can be caused by the sudden application of a force during the execution of an exercise or following an accident. Pain in the iliac sacred joint can also arise as a result of wear and tear (osteoarthritis), loosening of the synphysis during pregnancy, instability of the pelvic cinule, or ankylosant spondylitis. The muscles and tendons of the iliac sacred joint can also cause pain in the iliac sacred joint itself as a result of excessive exertion, prolonged incorrect postures or incorrect loading. Typical pain in case of pathologies of the iliac sacred joint Affected people feel pain in the area of the iliac sacred articulation. Pain can also radiate to the lumbar spine and legs. A similar pain is generated by pathologies interesting the sciatic nerve. In case of sciatica, together with back pain, you can experience numbness and paralysis of the legs as well as urinary and intestinal problems. In case of pathologies related to the iliac sacred joint (sacroiliac syndrome), back pain increases in intensity during the day. Movements to straighten out and lift heavy objects are particularly painful, as are standing for extended periods. Osteoarthritis pain in the iliac sacred joint initially occurs only in the presence of high physical stresses. As the pathology evolves, people begin to feel pain even in the presence of normal stresses, and then even at rest. Ankylosant spondylitis is a rheumatic condition associated with chronic inflammatory processes of the iliac sacred joint commonly observed at a young age. The first symptom of this pathology is back pain at night.

Spondylolysesis is a pathological condition characterized by a slow and progressive displacement of a vertebra from the underlying one. There are several causes that can give rise to this disorder in the spine. Symptomatology is proportional to the extent of the vertebral displacement and is manifested by the pain typical of low back pain aggravated by physical exertion and lumbar-sacral disorders. The vertebrae most affected by this condition are the lower lumbarvertebrae, especially the fourth and fifth lumbar vertebrae(L4 and L5)and the first sacral vertebrae (S1).