The Lumbosacral Challenge
Lower back pain, either with or without pain sensations radiating down into the leg, are very common and can be called a "national affliction". Approximately 35% of people in Germany are currently estimated to suffer from back pain of varying intensity. The so-called lifetime prevalence is 100 percent. This means, that during their lifetime, everyone will experience lower back pain at least once, if not more often than that.
Nevertheless, according to the experience of GPs, only one in four patients consult their doctor, whilst orthopaedic doctors state similar observations, i.e. only half of those patients affected come to see them about their lower back pain, or, associated leg complaints. Most affected persons first try to manage their pain by self-applied home-thermotherapy or by taking prescription-free medicines, such as analgesics, e.g. acetylsalicylic acid. An orthopaedic issue, that turns out to be an issue for pharmacists, too.
A Wealth of Terminology
"Lower back pain" usually denominates pain in the so-called lumbosacral region between the upper lumbar spine and the sacrum. Doctors call this type of pain "lumbar spinal syndrome" or, to be more scientifically precise, the local lumbar syndrome and frequently includes complaints affecting the entire back. What is commonly called lumbago is called an acute lumbar syndrome (lumbago).
If the pain is not restricted to the lumbosacral region, and radiates out into the leg, this implies that the sciatic nerves are also affected. The diagnosis is then called lumbar sciatic pain, or lumbar root syndrome while stating the affected nerves, e.g. sciatic pain L5 / S1. 15% of all days missed in the workplace due to sickness can be accounted for by lower back pain, or such pain in combination with associated leg complaints. 21% of health-related early retirements are due to lumbar spinal syndromes.
There is a clear difference between complaints originating from the spinal column itself, i.e., vertebragenic lower back pain, and such that have their causes in urological, gynecological or abdominal diseases, which are, however, projected into the lumbosacral region. Vertebragenic lower back pain is predominant, whilst most of these are due to degenerative causes such as degeneration of the intervertebral discs, or, diseases of the vertebral joints, ligaments and muscles. Inflammatory, tumorous, injury- or deformity-related causes for lower back pain are less common. With a rate of 98%, static and degenerative changes in the lumbosacral region are the number one cause of lower back pain.
Degenerative changes on the lumbar spine that occur earlier in life, are usually caused by axial strains on the intervertebral discs, e.g. by bending down and lifting heavy weights whilst walking upright. A sedentary lifestyle and bad posture are accompanied by the formation of fissures and signs of wear and tear on the intervertebral disc substance, which is originally of gel-like consistency. This leads to a destabilisation of the entire structure, accompanied by a tendency in the intervertebral disc tissue to get dislodged. Our own autoradiographic investigations and diffusion assessments have shown, that the metabolic processes within the intervertebral discs - which have no blood vessels - are characterised by long distances and the penetration of semi-permeable membranes, and that these are reduced by persistent compressive stress. On the other hand, these processes are supported by a regular alternation between compression and decompression of the disc tissue, meaning: systematic physical exercise.
Simple lower back pain that is limited to the lumbosacral region is characterised by its sudden occurrence and how it relates to specific body positions. Specific movements and postures increase the pain or relieve it. Coughing, sneezing and squeezing of abdominal muscles may likewise increase the complaints. In such "minor" cases, the use of non-prescription analgesics (WHO class I) is the norm. The same applies to the application of heat, i.e. thermotherapy, and rest.
However, when the pain radiates out into the leg, it is urgently recommended to consult a doctor - particularly if the symptoms are accompanied by feelings of numbness, tingling sensations and, possibly, even a sensation of weakness in the respective limb. When lower back pain occurs in combination with symptoms such as voiding and evacuation dysfunctions (bladder and rectum), this is particularly alarming! According to the Pharmaceutical Council of the German Medical Professional Association [Arzneimittelkommission der Deutschen Ärzteschaft], such cases must be classified as emergencies and usually require immediate admission to hospital and respective surgery. The cause for such complaints is usually a mass prolapse of the intervertebral disc, which leads to a compression of the nerves in the pelvic region, and which requires immediate surgical action. Likewise, there is cause for immediate medical action in cases of acute failure of functionally important muscles, e.g. in cases of peroneal nerve impairment. Red Alert is indicated when lower back pain comes in combination with bouts of high temperature, which may imply an inflammation in the area of the spinal column. Lower back pain combined with weight loss also requires urgent attention and laboratory diagnostics to eliminate the possibility of tumours, or metastases.
If it is impossible to obtain relief for persistent lower back pain with accompanying pain in the leg and persistent impaired mobility by way of conservative, i.e. non-surgical action, so-called minimal-invasive intervention is available before resorting to open surgery. These methods are gaining more and more significance and are important to mention during a consultation with a pharmacist. Such minimal-invasive action includes evidence-based, tried and tested epidural injections near the spine, and lumbar spinal nerve analgesia, and intradisc procedures such as chemonucleolysis (enzymatic dissolution of the dislodged intervertebral disc tissue with Chymopapaine), the application of laser therapy, or, percutaneous vacuum extraction of the shifted intervertebral disc tissue. Recently developed methods include intradisc thermotherapy and catheter treatment with various active substances. Chemonucleolysis is efficient, however, its application remains restricted due to numerous side effects such as allergies and toxic effects on the nerve tissue.
Prospective randomised studies have shown, that the intradisc application of laser therapy and percutaneous nucleotomy, i.e., vapourising or vacuum extraction of the dislodged intervertebral disc tissue, are not effective. This type of treatment has little more than placebo effect.
Epidural steroid injections with various cortisol-based medicines, however, have proven efficient in particular with chronic root compression syndromes. This is not only confirmed by meta-analyses, but also by two of our own prospective randomised studies. Within these studies, steroids and local anaesthetics were injected into the lumbar vertebral canal in various ways. A newly developed double needle technique seems to be particularly suitable for this method: cortisone (e.g. 10 mg Triamcinolon) and a local anaesthetic (e.g. 1 cm3 1% Lidocaine solution) are inserted via a particularly thin needle directly into the vertebral canal and into the anterolateral epidural space - this means that these substances are applied to the area immediately surrounding the mechanically irritated nerve roots. One prime advantage of this method is that minute amounts of the active substances suffice to numb the affected nerve section.
Lumbar spinal posterolateral analgesia (LSPA) involves the paravertebral application of a local anaesthetic via a 12 cm needle into the foramino-articular region, i.e. into the area immediately adjacent to the affected motor segment. This injection technique allows to reach the exiting nerve root on the Foramen intervertebrale (intervertebral opening to allow the passage of the spinal cord nerves) and thereby the Ramus ventralis, the main front branch of a spinal nerve, which is responsible for the pain in the leg when stimulated. At the same time, it is possible to reach the Ramus dorsalis, which is the key to obliterating the lower back pain. With ten to twelve of these injections, in combination with two to three epidural-perineural injections, it is possible to manage the acute pain phase of lumbar sciatic pain syndromes and to break the vicious cycle "pain-cramp-pain". Recent neuro-physiological investigations show, that it is possible to desensitise irritated nerve roots with repeated administration of local anaesthestics. In other words: the frequency and intensity of the pain is reduced, even when the effect of the injection as such has worn off.
The reduction of the pain and tension gives the patient the opportunity to address the cause of the pain, i.e., to reposition the dislodged intervertebral disc tissue, e.g. by ensuring to always lie down with flexed hip and knee joints ("bent-knee-position"), either on the back or on the side, by way of physiotherapy following this bent-knee position, and by way of physical therapy with thermotherapy and electrotherapy.
When lying down on the back with the hip and knee joints bent at a 90° angle, the sciatic nerve is almost fully relaxed. The intervertebral openings of the lower lumbar spine are expanded, and the vertebral joints are in their relaxed middle position. The minimal-invasive programme can be carried out on an out-patient basis, and just as well on an in-patient basis in particularly therapy-resistant cases. Minimal-invasive injections and accompanying physiotherapy are complemented by psychotherapy with instructions on how to cope with pain and progressive muscle relaxation.
Within a prospective randomised study on the epidural injection therapy on patients, who originally came to our clinic for surgical treatment, we have been able to show, that this treatment is effective. Successful treatment was recorded in 90% of cases, only 10% of patients still required surgical intervention.
Open surgery is medically indicated in cases of paralysis of functionally important muscles, or a high degree of suffering despite minimal-invasive treatment, and where there is evidence of corresponding results obtained from imaging techniques, nowadays predominantly computer tomograpy (CT) and magnetic resonance tomography (MRT). In these cases, it is essential to remove the shifted intervertebral disc tissue. Lumbar intervertebral disc operations continue to be the most common and important surgery on the spinal column. Micro-surgical methods are currently on the increase: the intervertebral disc prolapse is removed via a 3 cm incision, or, the vertebral canal is expanded in cases of spinal canal stenosis. The advantages are reduced traumatisation of the tissue with accompanying post-operative scar tissue formation.
A compulsory indication for lumbar intervertebral disc operation is present in cases of Cauda equina compression syndrome, i.e., if the pressure on the bundle of nerve fibres situated at the end of the spinal cord leads to sphincter dysfunctions and sensory disturbances in the perianal region.
If failures of functionally important muscles occur early, i.e. even during the initial phase of the disease, surgery is still urgently indicated within 24 hours, even without further attempts at conservative, i.e. non-surgical therapy. Fortunately, these emergency situations are very rare. The medical indication requires revision in cases where pain in the leg has been persisting beyond the six-week period, and which has resisted conservative therapy, even if there is no indication of paralysis.
Restrictive conduct is desirable on the part of the physician, i.e.: restriction on surgical treatment in cases of sensory disorders, reflex failures, tolerable sciatic pain and functionally insignificant pareses such as weakness in the muscles controlling the toes. It is imperative to avoid iatrogenic "Failed Back Surgery" syndrome, i.e. a post-operative cicatrisation and instability syndrome, since there is little chance for therapeutic success, as is confirmed Pharmaceutical Council. When considering surgery, the psycho-social situation of the patient must be taken into account. In other words: It must be ensured, that the patient is ready to accept and tolerate the usually occurring post-operative complaints. Accordingly, there is a number of risk factors contributing to the chronification of back and leg pain, which have been noted by the Pharmaceutical Council under the synonym of "Yellow Flag".
Risk factors contributing to the Chronification of Back and Leg Pain
- feelings of frustration in combination with low professional qualifications
- psycho-social overtaxation with depression, anxiety,false ideas about the disease, morbid gain
- passive attitude, poor physical condition
- other un-defined pain existing besides the backache
Comprehensive epidemiological studies have shown, that the results of the treatment of lower back pain and associated leg pain is unsatisfactory, both following conservative therapy, and in particular following intervertebral disc operation, if one or more of the above risk factors for chronification is present.
Any therapy of vertebragenic lower back pain should investigate all conservative and minimal-invasive possibilities before resorting to surgery. However, "absolute, i.e. straightforward indications" such as Cauda and paralysis in muscles controlling the foot require immediate surgical action.
Whilst taking into consideration the side effect profile, only those methods should be employed, that have been tried and tested for conservative therapy. This includes, mainly, injections near the spinal column, e.g. local anaesthetics and steroids, as well as the application of non-steroidal analgesics. Any conservative action must take into consideration the risk factors for chronification. Accompanying psychotherapy should be initiated in a timely manner. If in doubt, surgical interventions should be avoided, since those patients who are not operated on, are under no threat of post-operative cicatrization and instability syndrome, i.e.: no post-discotomy problems, i.e. failed back surgery syndrome.