Back problems are one of the most important causes of inability to work in Germany. Almost every third adult has back problems more often or continuously. Back illnesses are part of the overarching diagnostic chapter of the "diseases of the spine and back", which is responsible for around a quarter of all days of incapacity to work.
The statistics show the proportion of people with work-related back, shoulder and neck pain in the countries of Europe. In the year indicated, the proportion of people with work-related back pain in Belgium was 19.4 percent.
Back pain is a subjective experience that others only have indirect access to. Epidemiology and medical practice are therefore dependent on spontaneous or question-triggered reports from those affected. There is no laboratory test and no technically supported examination, which in case of doubt could prove or rule out back pain.
Neither in the medical nor in the beautiful literature of the late 19th and early 20th centuries did back pain or other back problems play a particularly important role. Nowadays, back pain and diseases of the spine (so-called dorsopathies; synonymous: back pain) are health disorders of outstanding epidemiological, medical and health economic importance in Germany and comparable countries. Back pain is a particularly common reason for using the medical care system, inability to work and pensions due to partial or total disability.
But where is "the back" and what is "pain"? The second question is difficult to answer because the understanding of pain varies; from person to person; and depending on the social or ethnic group, there are different pain ideas and pain thresholds. This is especially true for reports of minor pain. It is particularly difficult to differentiate between not-yet-pain, feelings of stiffness or other discomfort in the back region. The question of the exact location of the "back" is easier to answer. Anatomically speaking, it extends from the occiput to the buttock fold. In everyday language, a distinction is usually made between the neck (back of the head to the last tangible protruding cervical vertebra) and the back. In the German-speaking countries there is no uniform "back" concept, as the English-speaking world has in the "low back" (lower back).
Diseases of the back (spine pain)
Back pain (here in the sense of low back pain) is pain in the region below the costal arch and above the buttock fold. The five lumbar vertebrae and their articulated connections, the sacrum, the coccyx and the intervertebral discs are surrounded by numerous ligaments, tendons and muscles. The posterior extensions of the lumbar vertebrae form a channel; it includes the lower part of the spinal cord. Any of these structures can be the source of pain.
Back pain can be classified based on the different causes, the duration, the severity (pain intensity and functional impairment) and the chronification stage. A further distinction must be made regarding the causes: One speaks of non-specific back pain if simple causes cannot be used to find a cause that can convincingly explain the present symptoms (see section Risk Factors).
Given the frequency of back pain and the ratio of specific to non-specific back pain (1:> 4), a more or less serious illness cannot be assumed behind every back pain. Only in the case of atypical, persistent or increasing pain, or in certain risk constellations, should one consider it to be a disease sign (symptom) which, among other things, can refer to:
- diseases of the spine (e.g. Bechterew's disease),
- Diseases of internal organs (e.g. inflammation of the kidney),
- specific pathological processes (e.g. vertebral body breakdown in osteoporosis or after an accident, inflammation, malignant tumor),
- certain places of origin (e.g. muscles, intervertebral disc, nerve root).
Also called as “vertebroplasty”, back surgery in Germany often implies using minimally invasive methods. The operation implies injection of bone cement in the space between the fractured or damaged vertebrae, or in vertebrae themselves to restore normal mobility and functionality.
Therapy for back pain
If there are no indications of specific causes of back pain, symptom-related treatment should first be started taking into account.
Treatment includes non-drug and drug measures. The following key points should always be taken into account:
- Motivate people to actively participate in treatment and to assume responsibility for treatment;
- Long-term multi- and interdisciplinary treatment plans (only) for chronically handicapped courses;
- Joint decision-making in the development of treatment goals and treatment plans;
- Medicinal therapy to support non-medicinal measures in the acute phase in order to be able to resume everyday activities;
- avoid prolonged bed rest, physical inactivity and protection; it is important to continue as far as pain and disability allow;
- With everyday back pain you can see yourself as "conditionally healthy": your health is limited, but not in such a way that you cannot continue your everyday life, leisure time and work with your own and outside help. Trophizing Katas is almost always inappropriate.
Scientific evidence suggests that patients who are included in very different treatment studies surprisingly experience similar improvements. The extent and course of the improvement are similar and are often indistinguishable from what would have been observed without specific treatment. Therefore studies are needed that compare the effects of new procedures with the spontaneous course of back pain without any specific treatment. This would make it possible to assess the benefits of the procedure for those affected by (non-specific) back pain.
Non-drug therapy for back pain is an important part of the treatment of non-specific back pain. The following are considered beneficial therapies:
- Patient information and consultations: They are the basis of every treatment and have to take into account the reality of life and the psychological situation of patients in the home as well as in the world of work and leisure activities;
- Exercise and sports therapy: primarily for subacute / chronic non-specific back pain; not for acute back pain;
- Relaxation procedures (progressive muscle relaxation, autogenic training): can be used if there is an increased risk of chronification of acute / subacute back pain, they are recommended for chronic non-specific back pain;
- Occupational therapy: for chronic non-specific back pain as part of multimodal treatment programs;
- Manual therapy: manipulation / (chirotherapy) / mobilization in combination with movement therapy;
- Massage: especially in combination with exercise therapy;
- Back school: only conditionally recommended, prerequisite is a biopsychosocial approach; suitable for non-specific back pain lasting / recurring for more than six weeks, especially for chronic non-specific back pain;
- Heat therapy: can be used for acute non-specific back pain;
- Cognitive behavioral therapy (CBT): if there are psychosocial risk factors for subacute / chronic non-specific back pain.
Drug therapy for back pain
Drug therapy for nonspecific back pain is symptomatic and serves to support non-drug therapy. In this way, those affected should be able to resume their daily activities that are avoided due to pain. The following drug groups are generally recommended for use:
- opioid analgesics
- muscle relaxants
- Antidepressants: non-selective monoamine reuptake inhibitors (NSMRIs), especially for chronic non-specific back pain.
The use of medication should be discussed with a doctor or pharmacist in the area of simple over-the-counter pain relievers (paracetamol, ibuprofen, acetylsalicylic acid).
With regard to herbal active substances, the so-called phytotherapeutics, there are indications that extracts of willow bark and devil's claw have a pain-relieving effect. However, there is no recommendation for acute or chronic non-specific back pain.
Operative and other intervening procedures
In the case of non-specific back pain, invasive therapies, percutaneous procedures (injections) and surgical procedures according to the National Care Guideline cannot be recommended based on current knowledge. Operative procedures for back pain can be used if there are specific causes of back pain. Patients can fall back on national and international guidelines.
In summary, it can be stated that around 60% to 80% of adults complain of back pain, but doctors can identify no illnesses, no pathological process (central pathomechanism) and no reliable anatomical source for the complaints in the majority of those affected. In primary care, it is therefore important to carry out a thorough medical history and only a basic diagnosis in order to distinguish non-specific from specific back pain. The need for specific training and experience is particularly evident when clarifying persistent and increasing back pain. Depending on the examination results, further medical and other disciplines are to be consulted. In the case of persistent back pain with a high risk of chronification, this may also apply to psychological psychotherapists, medical psychotherapists and psychosomaticians.
Sick people with specific back problems (e.g. ankylosing spondylitis, scoliosis or osteoporosis) should be made aware of the help and self-help communities relevant to them.
Care for back pain
Back pain is a frequent reason for visits to the doctor among Germans. As part of the Robert Koch Institute's 2003 health survey, a quarter of all those surveyed stated that they had seen a doctor for back pain in the past 12 months. For the most part, these were outpatient visits to the doctor. Of those surveyed, 3% reported at least one acute inpatient treatment within the past 12 months and 5% stated that they had participated in a back pain rehabilitation measure at least once in their life. For people with back pain in the previous 12 months, the corresponding proportions were 40% for visits to the doctor, 5% for hospital stays and 8% for rehabilitation. The frequency of rehabilitation services appears to be comparatively low, presumably because no differentiation was made according to the severity of the complaints. In the Lübeck study of severely affected insured persons by a statutory insurance company, around two thirds reported earlier inpatient rehabilitation because of their back pain.
Use of outpatient and inpatient medical care and participation in rehabilitation measures due to back pain
||Proportions of those with back pain in the previous 12 months
|back pain in the previous 12 months
|Consultation with the doctor back pain *
|Reha because of back pain **
When do I need a vertebroplasty?
This procedure is made in the following cases:
- Disintegration and fracture of vertebrae caused by inuries and traumas;
- Tumor formation;
- Prolapse or misplacement of intervertebral discs;
- Serious symptoms of spondylolysis – considerable fracture of one or several vertebrae;
- Hernias between discs;
- Spinal traumas;
- Instability of vertebrae.
If a person has one of these conditions, backbone stabilization is required: it allows fixing vertebrae so that to eliminate pain. The surgery can also be complemented with conservative treatment options and lifestyle changes. For example, bed rest or physical therapeutic techniques can help to restore health and improve strength of vertebrae. Muscle relaxants and anesthetics may also relieve pain and unpleasant symptoms. Please note that the doctor makes decision concerning treatment after organizing all necessary analyses.
How back surgery in Germany is performed?
Visual examination only is not enough to state a precise diagnosis. Even the most skilled and experienced doctors require fully-fledged clinical examination. Before spinal surgery, several examinations are performed.
First, magnetic resonance imaging (MRI) with contrast agents is made. It is preferable to X-ray imaging, because such method of visualization shows the minutest details and zones (conditions of the spinal tissues, nerves, the spinal cord and intervertebral discs). X-ray imaging is useful at initial stages of examination only.
Functional radiography of back can be useful: this is a bit different form of X-ray imaging that shows vertebrae location towards each other during unbending and bending. That helps doctors to define the degree of instability in the sections of the spinal cord. Computer-aided tomography with X-rays also shows different abnormalities of the spinal cord.
Vertebrae stabilization is another kind of spinal surgery in Germany that isn’t equally suitable for all patients with spinal fractures. Today, advanced surgeons use synthetic non-cement products that don’t require heating before being injected in vertebrae.
In fact, back surgery is used in the last case, when conservative treatment methods cannot make any difference, and treatment requires more serious approach. Pretty often, back surgery implies use of support constructions made of titan and its alloys. Such devices ensure back stability and maximal comfort. When the treated section is stabilized, transpedicular instrumentation includes screws that are fixed via vertebra pedicle.
Possible risks of spine operation
As any other surgery, spinal operation implies some risks, but is usually normally tolerated by most patients without side effects. Theoretically, in the same day a patient can move without assistance, and positive results are already noticeable. Only 1-3% of people have minor negative outcomes after vertebroplasty. Sometimes, fever, bleeding and nerve damage occur. Experienced German doctors take care of all postoperative complications.
Back surgery in German clinics
When conservative therapies don’t bring any considerable results, the spinal surgery is a must. German clinics offer the whole spectrum of surgical treatment methods starting from minimally invasive disc surgeries and finishing by open operations implying installation of stabilizing structures. Many German doctors perform such advanced procedures as vertebroplasty that serve to treat structural fractures of vertebrae.
Be sure: being a patient of German spinal centers means you’re in safe hands, and pain management will be efficient as never before. German centers help people with the different problems:
- Disc hernias;
- Fractures of vertebrae;
Operation for discal hernia
In case of disc hernias, inner tissues get damaged, or intervertebral fissure occurs: it makes vertebral pulp bulge into the spinal cord. It leads to constriction of the spinal cord and nervous roots and causes serious pain that can spread over the limbs. That leads to some sort of low sensibility, poor motor functioning and problems with reflexes. Blood flow to the nervous roots is restricted, and it may even cause partial paralysis.
Hernias can be successfully diagnosed with the help of computer tomography (CT) and magnetic resonance image (MRI). It should be noted that discal hernia excision is not obligatory in all cases: if a person does not experience serious neurological symptoms (there are no defects), conservative methods can be enough to treat the condition.
Traditional ways of treatment can be the following:
- pain killers and anti-inflammatory drugs;
- infiltration of joints;
- lumbar plexus analgesia.
All of these procedures are controlled with X-ray imaging or CAT. When periradicular treatment is performed, doctors inject cortisone in the nervous roots to reduce pain and relieve symptoms.
Traditional and micro-invasive spinal surgery
Today, German doctors prefer microsurgical discectomy to usual open operation. Besides, hernias between discs are eliminated with the help of minimally invasive methods, as well.
Another alternative option for discal hernia curing is endoscopic discectomy. In this case, a patient is administered local anesthesia, and a surgeon uses an endoscope with camera and HD video transmission to see the inside of the spinal cord. Miscroinstruments are used to perform all necessary manipulations: bulging zone of vertebral pulp is cut out with their help. But this technique is not suitable for all types of spine hernias. For instance, it’s inappropriate for torn pulp segments of the spine, and if hernia is located in sacral or lumbar sections of the spine.
German doctors widely use artificial disc implants that have a lot of benefits. First, they feature great biological design that allows fully restoring mobility and eliminating pain. Intervertebral discs are particularly useful in the area of the lumbar spine.
Surgical treatment for spinal stenosis
Operation for spinal stenosis is usually made when the person experiences degenerative alterations (wearing) of the spine conditioned by aging, heavy load and some other factors. However, these are not the only causes of this disease. Spinal stenosis can also be caused by:
- protrusion of discs;
- degenerative wearing;
- bone overgrowth of the spinal cord;
- arthrosis of facet joints.
When the mobility of the spinal cord should be preserved (for instance, dynamic stabilization of the spinal cord is required), a surgeon uses a dynamic implant that helps to stabilize vertebrae while maintaining its mobility.
What is Stenosis, or Narrowing of the Spinal Canal?
The human spinal cord has a complex structure. Outer vertebrae and intervertebral discs carry the main burden of the body, whilst facet joints located inside are responsible for the mobility of the spine.
The vertebrae, facet joints and spinous processes (that can be easily palpated)are connected all together with vertebra arches. Acanal formed insideis called thespinalcanal. It carries the spinal cord, protected by several layers of membranes (meninges), that ends with nerve bundles in the lumbar region. Between the adjacent vertebrae, two bundles of nerves comeoutthe spinal cord to the right and to the left through openings called neuroforamina. Narrowing of the spinal canal is called stenosis of the vertebral column. Similarly, there may be a narrowing of the openings, so-called foraminal stenosis.
What are the Symptoms of Spinal Stenosis?
Similarly tothe liquid in a narrowed pipe, the flow of nerve impulses is obstructedwith narrowing of the spinal canal. For a patient that means back and leg painand difficulties to endure prolongedloads,or, in other words, reduced physical activity. At the first place, it is limitation of walking distances. You need to stop again and again to have a rest. That is why in Germany stenosis of the spinal canal is called a “shopwindow disease” (Claudicatiospinalis): a person who suffersfrom the disorder can work only short distances as if he or she stops in front of shop windows every minute. In addition, there may be disturbances with limb sensitivity or even paralysis of the legs.
How is spinal stenosis diagnosed?
Along with a general checkup of the patient and listening to the complaints, a neurological examination is usually required. A number of tests, such as X-rays with a contrast medium (myelography), computed tomography (CT) and magnetic resonance imaging (MRT), allow diagnosing the disease accurately.
What are the Treatment Options for Spinal Stenosis?
In many cases, with mild and moderate stenosis, non-operative symptomatic treatment, including physical therapy,is applied. Along with this, minimally invasive treatment can be used for pain management. In this case, you need to stay in a hospital or clinic on the inpatient basis.
Surgery is performed if serious nervous disorders, such as paralysis, partial numbness and functional disorders limitinglife activities, for example, the ability to walk or work, are present. In these cases, the use of only conservative treatment methods for spinal stenosis is usually not sufficient. The purpose of surgery, first of all, is decompression of the spinal cord to reduce pressure to the nerve endings and, secondly, the widening the spinal canal. This, often extensive, surgery, sometimes involving stabilization (fixation) of the spinal column, relatively often does not give the desired result. Many patients still have back pain or it comes back later, after a few months or years.
Surgical treatment can be done with one of the following ways:
- Lumbar decompression together with fusion. This operation implies dilation of the back spinal and fixation of spine with the help of special constructions A damaged intervertebral disc is replaced by a titanium cage.
- Ventral nucleotomy added with fusion. In such case, a doctor performs microsurgical extraction of the disc, inserts implants and joins vertebrae to form the gaps between the joints.
- Ventral unco-foraminotomy complemented by fusion. Spherical cutter is used to make vertebra larger, and the damaged vertebra is stabilized.
- Intra-disc electrothermal treatment. The surgeon inserts a needle inside the damaged intervertebral disc and heats it gradually. That boosts strength of collagen treads in the intervertebral disc and destroys nerves inside.
- Decompression and substitution of intervertebral disc serves to enlarge the spine and substitute the damaged disc with a prosthesis.
- Corporectomy with spondylosyndesis implies removal of vertebrae together with the junction of the nearby vertebrae. Further on, the space is filled up with a titanium vertebrae.
- Straightening spondylosyndesis together with fusion is used when multiple vertebrae must be replaced.
Unfortunately, after the stabilizing operation, the possibilities of treatment for the patient are exhausted and he/ she remains imprisoned in thisstate with recurrent pain symptoms. That is whyin Germany we apply step-by-step treatment for spinal stenosis, with an individual decision on the type and extent of surgeryfor every patient, and it is always minimally invasive. Thanks to this, the treatment is sparing and leaves some opportunities for the use of other kinds of therapies.
The following procedures are applied for spinal stenosis:
- Invasive pain managment
- Interspinousspacers (X-Stop, Maxx-Spine, Coflex)
- Open microsurgical decompression
Postoperative treatment of spinal stenosis takes a long time and depends mostly on the stage of spinal stenosis and the degreeof the neurologic changes already occurred. Rehabilitationcan be both on the inpatient and outpatient basis and includes also some home physical procedures. In rare cases, the patient may need a supporting corset used for external stabilization for some time after surgery.
Spinal surgery for scoliosis treatment
Scoliosis operation in Germany has the following aims and approaches:
- Normalization of cord curvature
- Fixation of the spinal cord by implants.
- Elimination of rotation.
- Stabilization of the spine.
When a vertebral fracture occurs, surgeons can apply various methods.
Spondylosyndesis means that two or several vertebral bodies are blocked. This is a widespread way of spinal stabilization that implies usage of rods and screws. This approach is also practiced to cure slipping of vertebrae.
Kyphoplasty is a minimally invasive method. A specific surgical balloon is put into the damaged vertebrae and is filled with bone cement. Sometimes the fractured vertebraeis fixed with medical cement solely.
The way of treatment is chosen based on patient’s individual diagnosis. If you want to get rid of chronic serious pain, you should visit the doctor as soon as possible. In about 90% of cases, the spinal pain may be eliminated even without a spinal surgery. Many conservative ways of curing (or their combination) are efficient for eliminating the disease and pain.