Back Pain

If you suffer from back pain...

...a variety of causes must be considered. Back pain is always very nasty but is mostly completely harmless! Within the age group of 30 to 60 about 60 to 80% suffer from back pain.

Basically it has to be differentiated between unspecific back pain, where no clear biological causes can be found (muscle tenderness) - and specific back pain with a clear physiological finding (slipped disk, arthrosis, stenosis etc.). Only about 3-5% of acute back pain is caused by a slipped disk. Also degenerative changes of the vertebral bodies or the facet joints can cause back pain once they lead to irritation or compression of spinal nerves. But especially tense and strained muscles can cuase back pain. This pain can radiate into the legs and shoulders. Also draught or cold can be responsible for an aching back.Rheumatic diseases or traumatic injuries and – quite seldom- also tumors may also lead to back pain.

An appropriate diagnosis and analysis of the contributing factors are hence often complicated and require the long-term experience of the specialized physician.

Not always back pain is caused by degenerative changes of the intervertebral disk. And not always a herniated disk causes back pain.

Mostly back pain manifests in the lumber spine (lower back pain, lumbagos). Quite rarely pain originates in the thoracic spine.

If pain is located in the neck (neck pain), their origin is usually in the cervical spine.

Frequent causes of low back pain:
  • Muscle tenderness (unspecific back pain)
  • Skeletal diseases (e.g. osteoporosis)
  • Degenerative changes (wear and tear) of vertebral bodies and spinal disks
  • Inflammatory diseases (e.g. rheumatism, gout, infections)
  • Misalignments like scoliosis, spina bifida and kyphosis (Bechterew and Scheuermann's disease)
  • Traumatic injuries like fractures or luxations of vertebral bodies
  • Disorders of viscera in the region of the cervical spine (liver, bile, stomach and heart)
  • Disorders of viscera in the region of the thoracic spine (trachea, esophagus, vascular disease, lung)
  • Disorders of viscera in the region of the lumbar spine (womb, vascular disease, kidneys)
  • Myofascial disorders Erkrankungen (musculature next to the spine or associated tendons)
Frequent symptoms
  • Severe lower back pain radiating into the buttocks, legs or feet and which may be aggravated by sneezing or coughing.
  • A feeling of numbness or even paresis in your leg
  • Eventually also from numbness of the inner thighs, the anal or genital region, bladder and/or bowel dysfunction

The clinical picture depends on to what extent adjacent nerves are compressed by the herniated disk. Hence, not all listed symptoms may prevail simultaneously.

Number one cause of pain - the spinal disk

The 23 intervertebral disks are elastic cartilaginous joints of about 5 to 20 mm thickness between adjacent vertebrae in the spine. They consist to more than 90% of water. Their main function is to dampen impacts of daily life activities – they work just like a shock absorber. Furthermore they are spacers between the vertebrae and make room for the nerves which exit to the left and right from the spinal canal. In their centre is the nucleus pulposus – a gel-like tissue which is surrounded by a firm fibrous ring (the anulus fibrosus). In children and adolescents up to about 16 years the disks are endowed with blood vessels and hence provided with nutrients.

Nutrient supply is crucial for the spinal disk

With increasing age unfortunately nutrient supply of the spinal disks gets worse until it is almost stopped during adulthood. This process starts in the fibre rings and then proceeds within the disk. In adults the disks are supplied with nutrients only by diffusion from the richly vascularized endplates of the vertebrae. Most important substances are oxygen, glucose and proteins. Important for this diffusion process into the disk is a continuous changing between pressure and relief - like in a pump.

Due to these mechanisms it is so important to keep moving a lot. Unfortunately our current life style with a lot of sitting in cars at work etc., leads to a suboptimal nutrition of our spinal disks. Hence - without wanting it - we positively starve our spinal disks ourselves. As a consequence they get weak - especially in the lumbar spine - and cannot fulfill their bumper function any longer.

The natural process of degeneration is then accelerated and little tears in the back area of the disk may occur (similar to brittle rubber tire) what might first be felt as local back pain - also called lumbago. In the worst case a undue stress of the spinal disk (e.g. when lifting a heavy object) there will be increased pressure of the disk nucleus against the weakened fibre ring. The ring might then rupture, the nucleus material can exit into the spinal canal and (disk herniation) pinch spinal nerves.

No successful therapy without precise diagnosis

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The success of a surgical intervention greatly depends on how well it really targets the structures that are responsible for your pain

Eventually back pain cannot be relieved with a surgical intervention. This may be the case if an underlying disease or other factors render a successful surgery questionable. In order to decide in individual patients if and what surgical intervention is really promising, vast experience of a spine specialist is indispensable. If the clinical picture suggests that no significant relieve of pain can be expected from spine surgery it is important that patients be offered a highly individualized therapeutic strategy. For an efficient relieve of symptoms this generally comprises much more than the conventional injections, analgesics and physiotherapy.

 

It is important to distinguish
Local back pain - that is solely in the back Doppelpfeil pain that originates in the back but radiates also into other regions of the body – for example into the legs.

 

Acute back pain

A common cause for acute (radiating) back pain are degenerative changes of the intervertebral disks.

It might be a fissure in the fibrous ring or positively a protrusion of the disk or actually a veritable disk prolapse.

 

 

Chronic back pain

If back pain lasts more than 6 weeks it is considered chronic. Every chronification of pain is a challenge for the treating physician. If conservative treatment options – like physiotherapy, electro- or thermal therapy, and analgesic pain management - do not relieve symptoms within 6 to 8 weeks, a differentiated analysis of the underlying causes of pain is necessary. Usually a blood analysis as well as imaging methods like x-ray, computed tomography (CT) or magnetic resonance tomography (MRI) will apply.

If with these techniques there is still no sufficiently precise diagnosis possible, a discography of the affected spinal disks might be indicated. With these methods, fissures in the outer fibrous ring (anulus fibrosus) of the disk may be detected. In some cases it might be required to combine discography and computed tomography. If a rupture of the spinal disk is diagnosed, a percutaneous nucleotomy might be an appropriate therapeutic option. In cases of significant degeneration of not more than one or two spinal disks, helpful interventions might be discoplasty (endoscopic decompression and refreshing of the disk), an artificial disk replacement or a spondylodesis. Which of these options applies has to be considered carefully.

 

Dr. Schubert in an interview on conservative and surgical therapy for back pain

 

 

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Reviews

I needed to tell just one sentence and diagnosis was established and then also confirmed by imaging techniques. Neither the orthopedic specialist nor the radiologist I had visited before, had identified the herniated disc. They told me to do some sports and that surgery would not help. Immediately after the surgery in the ATOS clinic, my symptoms disappeared and I was also pain free. Absolute number 1 address for spinal disc problems.

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