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I. Classification of Causes
(A) Acute and Chronic Injuries
1. Acute Injury Such as spinal fractures, tears in ligaments, muscles, joint capsules, acute herniated discs, etc.
2. Chronic Injury Such as ligamentitis, muscle strain, hyperplasia and degeneration of the spine bones and joints, spondylolisthesis, etc.
(B) Inflammatory Diseases
Inflammatory diseases are divided into bacterial and non-bacterial inflammation.
1. Bacterial Inflammation Can be further classified into suppurative and specific infections such as spinal tuberculosis. Suppurative infections often occur in intervertebral space infections, epidural abscesses, vertebral osteomyelitis.
2. Non-bacterial Inflammation Rheumatic myofascial fibrosis, rheumatoid arthritis, 3rd lumbar transverse process syndrome, ankylosing spondylitis, dense bone inflammation of the sacroiliac joint.
(C) Degenerative Changes in the Spine
Such as disc degeneration, small joint degenerative osteoarthritis, secondary spinal stenosis, senile osteoporosis, pseudo-spondylolisthesis, and spinal instability.
(D) Abnormal Bone Development
Scoliosis deformities, hemivertebrae, isthmic spondylolisthesis, kyphosis, sacralization or lumbarization of iliac, spina bifida, hooked spinous processes, horizontal sacrum, unequal leg lengths, flat feet.
(E) Poor Posture
Long-term desk work or bending over, pregnancy, obesity leading to a protruding belly.
(F) Tumors
Bone and soft tissue tumors, bone marrow or nerve tumors, etc.
(G) Referred Pain Caused by Internal Organs
Gynecological pelvic diseases, prostate diseases can cause lower back pain. Kidney diseases such as stones, tumors, nephroptosis, pyelonephritis, and retroperitoneal diseases like abscesses, hematomas can cause back pain. Liver and heart disease can also cause back pain.
(H) Psychological Factors
With the progress and acceleration of society, these types of diseases are gradually increasing, such as chronic fatigue syndrome, psychogenic spinal inflammation, neurasthenia, hysteria, depression.
Mechanism
I. Acute Injury
Acute injuries can cause small blood vessels in tissues to rupture and bleed, causing tissue swelling and exudation. Hematomas can trigger aseptic inflammatory responses. H, K, prostaglandins, histamine, osmotic pressure are considered the main factors that cause pain. In the hematoma of a fracture, the pH value can reach below juvenile levels, being acidic with a high concentration of H, thus causing pain. Tissue swelling and exudation can increase tissue osmotic pressure, and the rupture of tissue cells releases acidic lysozyme enzymes, thereby causing pain. Acute injuries can cause tears in ligaments and muscles, damage to the joint capsule, leading to pain near the damaged area. Fractures and dislocations, hematomas can compress the spinal cord or nerves, causing compression symptoms and resulting in distal pain or numbness; severe cases may lead to paralysis.
II. Chronic Strain and Degenerative Changes
Chronic strain and degeneration can cause a series of changes in the intervertebral discs, small joint facets, ligaments, and muscles, leading to pain.
1. Intervertebral Disc Changes In adults, the blood supply to the intervertebral disc is only slightly present on the surface layer of the annulus fibrosus, its nutrition mainly relies on lymphatic penetration. Due to more wear and tear in the lower lumbar intervertebral discs, heavier loads, and their location at the junction between the active segment and the fixed segment, degeneration can occur around the age of 20. Nachemson's research shows that if the pressure within the lumbar intervertebral disc while standing is 100%, it increases to 150% while sitting, and further tilting forward increases it to 180%. Standing slightly tilted forward results in 150%. This indicates that people who work for long periods in a seated or slightly forward-tilted position are more prone to intervertebral disc degeneration. Since the posterior side of the annulus fibrosus shows the most obvious signs of degeneration, it is prone to rupture, leading to herniation of the intervertebral disc. This can first stimulate the branches of the sinuvertebral nerve behind the intervertebral disc, causing lower back pain. If it compresses and stimulates the nerve roots, it can cause venous return obstruction, nerve root edema, and aseptic inflammation. Some believe that glycoproteins and histamine within the nucleus pulposus can cause chemical inflammation of the nerve roots. All these increase pain sensitivity, leading to radiating sciatica.
2. Degeneration of the Facet Joints These joints are typical synovial joints. Due to the degeneration of the intervertebral discs, the water content decreases, the intervertebral space narrows, and the pressure on the spine shifts to the facet joints. The excessive physiological stress causes the cartilage to gradually turn yellow and opaque, followed by roughness, wear, and shedding. This compresses the branches of the sinuvertebral nerve surrounding them, causing lower back pain. Synovitis of the facet joints can also cause lower back pain.
III. Lumbar Back Pain Caused by Inflammation
Substances in inflammation such as H+, prostaglandins, histamine, bradykinin, etc., can act on the pain receptors of nerves causing pain. An increase in tissue osmotic pressure can also cause pain. Ischemia in tissues can lead to the accumulation of acidic metabolic products, raising the H+ concentration in tissues and causing pain. Rheumatism and trauma can both cause cell damage and cell lysis, releasing acidic lysosomal enzymes that produce pain. The pus from bacterial infections is acidic, whereas tuberculous abscesses without pain are neutral. Inflammation can also cause tissue congestion, edema, and increased tissue pressure, leading to pain.
IV. Pain Caused by Tumors
The expansive growth of tumors can compress or stimulate peripheral nerve endings or nerve trunks, causing pain. The internal environment of tumors being acidic can also cause pain. Spinal tumors can compress nerve roots, causing radiating pain along the nerve pathways. Compression of the spinal cord can lead to spinal cord compression syndrome, causing sensory and motor dysfunction below the level of compression.
V. Lower Back Pain Caused by Osteoporosis
The relationship between osteoporosis and pain is not yet fully understood. Osteoporosis may cause vertebral compression fractures, leading to lower back pain.
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