Why is extreme pleasure actually intense pain?

: Hellish pain: In the worst case, only a disc operation will help

Sometimes the signs are unmistakable. A thoughtless movement, for example when buying a drink or working in the garden, and all of a sudden a sharp pain shoots into the lower back. If this then extends over the buttocks down to the calf, the diagnosis is almost clear: herniated disc.

During this unpleasant event, tissue emerges from the soft, gelatinous core inside the intervertebral disc and presses on the nerve roots of the sciatica - the large nerve that runs through the entire leg from the lower spinal cord.

However, herniated discs often occur gradually. Due to natural wear and tear, the outer fiber ring of the intervertebral disc becomes increasingly cracked and porous, so that here, too, intervertebral disc tissue can gradually penetrate to the outside and irritate the surrounding nerve roots.

An unequivocal diagnosis is usually only provided by an image of the lumbar vertebral area in the magnetic resonance tomograph, or MRI for short. On the images produced there, doctors can usually clearly see whether a herniated disc is present or not.

Once this has been diagnosed and identified as the most likely cause of the back pain, the patient needs one thing above all: patience. "As long as it is not an acute emergency that results in neurological deficits such as paralysis, sensory disturbances or even uncontrolled urination, we advise our patients to wait a few weeks before considering an operation," says Michael Putzier, who heads the cross-campus spine center of the Center for Musculoskeletal Surgery at the Berlin Charité.

Physiotherapy instead of bed rest

Other experts see it similarly. This is also the case with Christian Knop, who was President of the German Spine Society (DWG) last year and is the Medical Director of the Clinic for Trauma Surgery and Orthopedics at the Stuttgart Clinic. "A patient only has to undergo an operation if there are tangible symptoms of failure," says the back expert. However, there is also the possibility of an operation if the patient has extreme pain that cannot be controlled with painkillers.

Knop would initially advise against surgery for patients who have to take blood-thinning medication or who have already had several operations or a heart attack. "Then the risk of a surgical intervention is usually higher compared to its benefit, so that you have to weigh carefully," says the Stuttgart expert.

In the meantime, people have completely abandoned advising the patient to rest in bed and to take passive measures such as the stepped position, in which one lies flat on the back with the lower legs at right angles to the thighs on an armchair or the like. "It is important that the patient remains active and keeps moving as well as possible," says Charitémediziner Putzier. "Otherwise, the back muscles will break down quickly and there will be further complaints," he warns.

Rash operations

In order to take the pain away from the person affected and to prevent the pain memory from becoming active and the pain thus becoming chronic, treatment with painkillers is essential for severe complaints. “The agents of choice are initially active ingredients such as ibuprofen or diclofenac, combined with a stomach protection agent, or metamizole,” says Michael Putzier. If these do not help enough, opioids such as tramadol or tilidine are also used.

"In addition, the radiologically supported infiltration of the nerve root with a mixture of a local anesthetic and a glucocorticoid can in many cases lead to a significant reduction in symptoms," adds the Berlin doctor.

Physiotherapeutic exercises should first show the patient how best to move despite pain and how to help the back to relax. Once the acute phase is over, the exercises help to strengthen the back and abdominal muscles and thus relieve the damaged intervertebral disc.

"If the pain does not subside even after six to twelve weeks and has a strong impact on the patient's everyday life, one should think about an operation," says Michael Putzier. However, not all patients or their doctors seem to have that much patience: every third disc patient is operated on prematurely without previously exhausting conservative treatment methods such as physiotherapy, massages and pain therapies, according to a study published by the Hamburg Center for at the end of 2016 Health Economics.

Individual decision

A team led by Matthias Bäuml, a research assistant at the Chair for Management in Health Care at the University of Hamburg, interviewed more than 6,000 insured persons on behalf of the Barmer GEK health insurance company. As the study showed, middle-aged working men in particular often prematurely undergo intervertebral disc surgery because they fear that otherwise they will no longer be able to do their job.

However, this examination is highly controversial among medical professionals. "With such populist evaluations of patient surveys, the health insurances are only trying to dispute the right to intervertebral disc surgery from their insured in order to save costs," says Frank Kandziora, head of the spine section of the German Society for Orthopedics and Trauma Surgery . "Unfortunately, the assumption that many doctors rashly indicate the indication for surgery due to economic interests is still very widespread," says DWG expert Knop.

"The decision for or against a surgical procedure is always an individual one - which must also be based on how much the patient depends on a functioning body."

A quick decision rarely has to be made: “You don't worsen the herniated disc if you wait a few weeks,” says Christian Knop.

If the patient has decided to have an operation in consultation with their doctors, the next step is to choose the procedure. Private clinics in particular offer a variety of different methods. However, not all of them are recommendable in the opinion of the experts.

Avoid sitting or standing for long periods of time

“I would definitely advise against chemonucleolysis, intradiscal electrothermal therapy, IDET for short, and laser procedures,” says Charité expert Putzier. There is currently insufficient scientific evidence for the usefulness of these methods.

In chemonucleolysis, the inner spinal disc nucleus is liquefied with the help of an enzyme and then suctioned off. The outer fiber ring is to be stabilized by IDET using an electrical probe that is heated. The laser process tries to shrink the leaked disc material by means of high temperatures.

Even major open back operations are usually unnecessary in the case of a normal herniated disc. The experts agree that minimally invasive procedures - either microsurgical or endoscopic, in which the leaked disc material is accessed through a small incision on the side or on the back - have proven successful. “When choosing a suitable clinic, the patient can, for example, use the certificates from the German Spine Society for guidance,” says Knop. The DWG lists the relevant clinics on the Internet (see left).

If the intervertebral disc tissue is removed and the nerve is free again, the pain in the leg will usually disappear immediately after the operation. The lower back needs a little more time to recover, as the surgical wounds naturally also have to heal deeply here.

"In the first 14 days after the procedure, the patient should take it easy and, above all, avoid sitting or standing for long periods," says Putzier. Too many restrictions are otherwise rather counterproductive. "The person affected usually feels best what is possible and what is not."

Complaints pass

No matter how well the operation went, the patient has to be clear about one thing: the damaged intervertebral disc could not be repaired. There is always the possibility of a relapse. “At the moment, methods are being tested to fill cracks in the outer disc ring with a suitable filling material,” says Putzier.

However, none of these methods are yet practical. "It is not uncommon for the implants to slip and then the symptoms are worse than they would have been without the operation," warns the doctor.

In any case, nobody can avoid long-term development of the abdominal and back muscles that support the spine and relieve the intervertebral discs. If you pay a little attention to your body, you can still look to the future with optimism: Several studies have consistently shown that the symptoms of a herniated disc are usually a thing of the past after one or two years - regardless of whether the patient has been operated on or not.