Back pain

Back pain is widespread. According to a study by the Robert Koch Institute, more than 60% of Germans have suffered from back pain in the last 12 months (BURDEN 2020 disease burden study). Back pain is not only a challenge for society as a whole due to the high costs involved in diagnosis and therapy, but also a challenge for the sufferers themselves due to the sometimes severe restriction of quality of life.

The spine consists of a total of 24 vertebral bodies and can be divided into the cervical, thoracic and lumbar spine. Between the vertebral bodies are the intervertebral discs (disci intervertebralis), which play an important role in relieving the spinal column through their shock-absorbing function. The intervertebral joints of the vertebral arches (facet joints) provide a further connection between the individual vertebral bodies. Together with the vertebral arches, the vertebral bodies form the spinal canal, in which the spinal cord runs. Like the brain, the spinal cord is part of the human central nervous system. The spinal nerves arise from the spinal cord and emerge from the spinal canal through the intervertebral foramina. They contain sensory and motor nerves which, on the one hand, transmit sensory information from far away from the body to the brain and, on the other hand, are responsible for controlling muscle functions.

In old age, almost everyone experiences age-related wear and tear of the spine, e.g. loss of height and bulging of the intervertebral discs. Such changes can even be observed in 20-year-olds in magnetic resonance imaging (MRI). In the absence of concomitant symptoms, they have no pathological value and do not require therapy.

Other symptoms of back pain may include:

• Sudden pain on exertion
• Restricted movement of the spine
• Gentle posture
• Warning signs: Disturbances in sensation, paralysis, disturbances in bladder and bowel emptying, fever.

Due to the multiple causes of back pain, back pain also differs in terms of symptoms. The back pain can be permanent or occur repeatedly during certain movements. Radiation of the pain into the buttocks or legs is possible. In the majority of cases, the lumbar spine is affected.

Those affected often adopt a protective posture, but this leads to a vicious circle: Physical inactivity leads to increased muscle tension and shortening, which in turn aggravates the pain.

In addition to the symptoms listed above, which initially do not require further diagnosis, the existence of warning signs (so-called "red flags") should be excluded. These include sensory disturbances, such as tingling or numbness, as these indicate nerve irritation. Another warning sign is signs of paralysis, where individual muscles can only be moved in a weakened manner or not at all. For example, the big toe or the entire foot can no longer be lifted in such a case. Sudden inability to empty the bladder or bowel, or sudden onset of incontinence should also be followed up with further diagnostics.

Causes of back pain include:

• Muscle tension
• Herniated disc (prolapse)
• Spinal stenosis
• ISG syndrome

Back pain can be divided into specific and non-specific back pain. In the majority of cases, it is non-specific back pain where no cause can be found. Specific back pain, on the other hand, is based on a specific disease, e.g. a herniated disc (prolapse).

Even if no exact cause can be found for the development of non-specific back pain, some factors that make its occurrence more likely can be identified. Lifestyle factors are particularly decisive here, especially prolonged sitting and a lack of exercise in everyday life . On average, Germans sit for more than seven hours a day, depending on their age. The result is muscle shortening and painful muscle tension in the lower back, hips and thighs. Smoking, psychological stress and being overweight also increase the likelihood of the occurrence of non-specific back pain.

With regard to the causes of specific back pain, some are exemplified below:

One of the most common causes is herniated discs, which cause disc tissue to leak into the spinal canal. This can lead to painful constriction of nerves.
Spinal stenosis, which occurs due to a narrowing in the spinal canal (spinal canal), can also trigger specific back pain. Typical here are pains that occur when walking and can radiate into the legs. In most cases, the affected person stops after walking a certain distance because of the pain, waits for the pain to disappear, and only then continues walking.
Furthermore, lower back pain can be caused by ISG syndrome. This collective term covers pain of the sacroiliac joint (ISG), which can be caused by a variety of reasons. As a rule, unilateral pain occurs in the lower back, radiating into the buttocks and/or leg.

The aim of diagnostics is primarily to distinguish between specific and non-specific back pain.

Our spine specialist Priv.-Doz. Dr. Pestka will ask you about your complaints in a personal consultation. Among other things, you will be asked questions regarding the trigger, the progression over time and the severity of the pain.

A physical examination is then performed. The spine is examined for malpositions, palpated and tapped. Often, a so-called hard tension, a hardening of the muscles, can be palpated in the area of pain. In addition, the mobility of the spine is checked.

In addition, other tests, for example the Lasègue test, can be performed: The person to be examined lies on his or her back and the examiner raises the stretched leg. If the person being examined now feels a shooting pain, this indicates irritation of a nerve, as occurs, for example, in the case of a herniated disc.

If there are no warning signs and there is no indication of a specific cause of the pain, the patient has nonspecific back pain for which imaging does not need to be performed according to current recommendations. Occasionally, however, imaging, usually magnetic resonance imaging (MRI), is still performed. This overdiagnosis may not be entirely without consequences, since after a certain age almost everyone is affected by symptomless age-related wear and tear of the spine. In many cases, a supposedly pathological finding is discovered in the MRI, which is then treated at great expense. Thus, overdiagnosis results in overtherapy. Let Priv.-Doz. Dr. med. Pestka whether further diagnostics are necessary and medically reasonable.

Overall, therefore, any imaging that is to be obtained of the spine should be critically evaluated.

Conservative therapy:

The following treatment options refer to nonspecific back pain, i.e., that no evidence of a specific disease has emerged during diagnostics. In the case of specific back pain where a cause has been found, a targeted therapy must be initiated, which is described in the respective chapters.

The following conservative therapies are available:

• Regular physical activity
• Educating patients about good prognosis and back-friendly behavior in everyday life
• Drug therapy: analgesics
• Physical therapy: heat
• Physiotherapy, back school
• Relaxation techniques, acupuncture

Exercise is one of the most important therapies for relieving back pain. The aim is to break the vicious cycle of back pain, physical rest and further muscle tension. Therefore, the first back school rule is "Thou shalt move!" All types of exercise are appropriate as long as they do not provoke back pain. The exercise program for chronic back pain focuses on spine-friendly sports such as swimming, running and cycling. However, other movement patterns that involve rotational movements without creating a hollow or rounded back also help strengthen and mobilize the spine.

Providing patients with detailed information about their condition is also very important. This includes, on the one hand, the good prognosis of back pain: 90% disappear within the first week. In addition, it is important for those affected to know the risk factors for the development of back pain in order to eliminate them as far as possible and thus prevent a recurrence. This includes avoiding prolonged sitting, e.g. with the help of standing tables, and setting up an ergonomic workstation. Weight normalization and smoking cessation can also have a positive influence on the complaints.

For acute pain relief and inhibition of inflammatory processes, analgesics from the group of non-steroidal anti-inflammatory drugs (NSAIDs) can be used. If this does not provide sufficient pain relief, weakly or strongly acting opioids can also be used. In addition, the application of heat, e.g., by means of heat patches or a warm bath, can be helpful.

In a physiotherapy session, muscle tension can be relieved and the trunk muscles strengthened, thus relieving the spine. Participation in a back school should, among other things, additionally provide knowledge on how everyday life can be designed in a way that is easy on the back. This includes, for example, lifting a heavy object while squatting and with a straight back.

As part of the treatment of back pain that persists for more than 12 weeks and is thus considered chronic, other therapeutic methods can be used. These include relaxation techniques, e.g. progressive muscle relaxation (PMR), or acupuncture.

Operation:

Surgery should not be used for non-specific back pain. In Germany, numerous operations are performed on the spine that would not be necessary. A not insignificant proportion of patients continue to be plagued by pain even after the operation.

Accordingly, obtaining a second opinion is highly recommended before performing spine surgery.