Initial Situation

Almost everyone struggles with back or low back pain at some point in their lives. The pain often arises suddenly and then disappears again within a few days or weeks. However, at least 8% of Swiss adults suffer from severe and/or prolonged chronic back pain due to a specific cause.

Various causes - difficult diagnosis

The cause of back pain is often difficult to determine. Typically, age- and load-related (degenerative) mechanical wear of certain anatomical structures of the spine are responsible for the plaguing complaints in adults. Despite careful anamnesis and examination, it is often difficult to identify the cause of the pain. Even the most modern radiological procedures such as MRI and CT are not always helpful. This is due to the fact that different anatomical structures of the spine can be responsible for the pain. Degenerative changes in intervertebral joints (facet joints) and/or intervertebral discs (discus) are often the cause of the complaints. In addition, there are various other causes of pain, which can be traced back to the irritation of a nerve root (sciatica) or to an overload of the back muscles, for example.

Symptoms

The pain symptoms depend on the cause. Shooting, stabbing or burning pain is typical of lumbago, but can for example also be a sign of a degenerative change in the area of the facet joints. If radiating pain is accompanied by reduced sensation and/or strength in the legs, irritation of a nerve root is likely.

Diagnosis

For diagnosis purposes, a detailed anamnesis and a thorough physical examination are of primary importance. Imaging procedures (MRI, CT, X-ray) help in certain cases, but are not compulsory in every case.

Targeted test injections are a very important part of back diagnostics. Under ultrasound or X-ray control, targeted injections with local anaesthetics can be carried out. If for example such a test injection is made in the area of a questionably painful facet joint, it can be checked whether or not the pain temporarily subsides after the injection. If the complained pain subsides, it can be assumed that the complained pain originates from the structure in question.

Therapeutic options

The treatment of chronic back pain is often complex. Good therapy planning is important and helps to coordinate different measures effectively.

1. Physiotherapy / Manual Medicine / Chiropractic
2. Medication
   • Basic analgesics
     • NSAIDS
     • Paracetamol -> no benefit
     • Metamizol -> no benefit
3. Interventional treatments (intervention = targeted injection under X-ray or ultrasound control)

• Radiofrequency treatment of the medial branches of the facet joints
• Steroid injection around facet joints 
• Steroid injection in facet joints
• Steroid injection at nerve root
• Pulsed radiofrequency treatment of the DRG
• Neuromodulation
• Surgical measures

References

NICE Guidelines on Managing Low Back Pain