Back pain: from pathophysiological mechanisms and clinical features to modern approaches to therapy

Background. Back pain is a clinically heterogeneous syndrome that requires a differentiated approach to therapy. The main origines of nonspecific back pain are the outer parts of the anulus fibrosus (fibrous ring) of intervertebral disks, facet joints, sacroiliac joints, as well as ligamentous and fascial formations.

Results. Modern elaborated approaches of neuro-orthopedic examination enable to determine the cause of back pain due to сomprehensive clinical evaluation of biomechanical and neurological impairments. Significant differences in clinical manifestations in patients are due to the variability of pathophysiological mechanisms of pain and the possibility of combining different pain phenotypes. The key aspect is pain phenotyping with the allocation of mechanical, inflammatory, neuropathic components, muscle spasm and signs of central sensitization. Signs of inflammatory pain may be detected in patients with nonspecific low back pain due to the development of osteoarthritis in facet joints, sacroiliac joints, as well as vertebral osteitis. When inflammatory pain patterns are present in the sacroiliac joints region, it is mandatory to rule out sacroiliitis within the spectrum of seronegative spondyloarthritis (including ankylosing spondylitis and others) using a specialized diagnostic algorithm. Muscle-tonic syndrome requires differentiation from myofascial pain syndrome, another common form of musculoskeletal pain, as they have fundamental differences in pathogenesis, clinical presentation and treatment approaches. Resistance to standard analgesic therapy warrants investigation for neuropathic pain and central sensitization features, which require the addition of anticonvulsants (gabapentin, pregabalin) and antidepressants (duloxetine, amitriptyline) to the treatment regimen.

Conclusion. Determination of the pain profile and accurate analysis of markers determining the leading pathogenetic component allows personalizing back pain therapy. A promising direction in the complex therapy of back pain is vitamin B combinations (B₁, B₆, B₁₂) due to their ability to affect key pathogenetic mechanisms: reduce peripheral and central sensitization, suppress inflammation and stimulate the regeneration of nerve fibers. Clinical studies demonstrate their coanalgesic effect in combination with nonsteroidal anti-inflammatory drugs and anticonvulsants, which allows reducing the doses of the main drugs and minimizing side effects.

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