Alexander Richter is a highly qualified specialist in orthopaedics and trauma surgery, specializing in spinal surgery and pain medicine. He is a senior physician in the Department of Spinal Surgery and Neurosurgery at Helios ENDO-Klinik Hamburg, where he performs both conservative and surgical therapies at the highest level. Dr Richter specializes in the diagnosis and treatment of acute and chronic back pain, intervertebral disc problems and deformities such as scoliosis and kyphosis.
In his career spanning over 20 years, he has successfully performed more than 2,500 spinal procedures. This includes microsurgery and procedures for herniated discs and spinal canal stenosis, as well as complex procedures such as spinal stabilization and correction and the treatment of spinal fractures, tumours and metastases of the spine. His expertise also extends to revision surgery, i.e. the surgical correction of abnormal developments following previous interventions. In addition, he offers interventional pain therapies, including injections to the spine and nerve roots. He pursues a holistic approach in which surgical measures are always considered as the last option - before he develops customized conservative therapies with his patients.
In addition to his clinical work, Dr. Richter also has an academic background and worked at the Technical University of Hamburg-Harburg in the field of spinal biomechanics. His scientific contributions have been published in renowned specialist journals. Dr. Richter is also a recognized expert as a speaker and trainer for the German Spine Society and the German Society for Orthopaedics and Orthopaedic Surgery and is actively involved in the training of young doctors. Dr. Richter treats a wide range of patients, including both adults and adolescents with spinal deformities.
The editors of the Leading Medicine Guide were able to talk to Dr. Richter about the topic of back health and learn some interesting details.
Back pain is one of the most common health problems worldwide and affects a large number of people of all ages. Especially the so-called “classics” such as sciatica, lumbago, pinched nerves and low back pain are widespread and can have a significant impact on daily life. These complaints often arise from a variety of causes - from overloading and lack of exercise to poor posture and degenerative changes in the spine. Particularly in the case of acute pain, many sufferers seek quick relief, while chronic complaints require long-term treatment and prevention. The right diagnosis and individual therapy are crucial to alleviating pain and stabilizing back health in the long term.
Back pain has a variety of causes that often interact with each other.
“Back pain is a huge problem that affects around 80% of people once a year. When people have pain, they always assume that a structure must be broken, but this is very rarely the case. It is not for nothing that we differentiate between specific and non-specific back pain, for which there are also national guidelines. And only around 10-15% of back pain is specific back pain for which a structure can be blamed. It may be that a patient complains of classic low back pain and wonders whether something may have lifted - but the cause cannot be clearly determined. This is functional pain due to overloading, which usually subsides on its own after one or two days if you allow yourself some rest. The situation is different with a classic slipped disc. Here, for example, the disc ring ruptures, the gelatinous nucleus emerges from the disc into the spinal canal and presses on a nerve there, which can cause pain such as the typical sciatic nerve pain, but can also lead to paralysis of various muscle groups. And here you have a structure that is responsible for the symptoms,” explains Dr. Richter on the differences between specific and non-specific back pain.
One of the most common causes of back pain is a lack of exercise, which leads to weakened back and core muscles that stabilize the spine and protect it from overloading. Without sufficient movement and strength, everyday strains, such as lifting heavy objects or remaining in awkward positions, can overstrain the back and cause pain. Poor posture caused by sitting for long periods of time, especially at work, further increases the risk. A poorly aligned sitting position puts uneven strain on the intervertebral discs, which can lead to wear and tear in the long term. Excess weight also plays a role, as it increases the strain on the spine and can impair the natural buffering functions of the intervertebral discs. Traumatic events such as falls or accidents can also cause sudden back pain, which can sometimes develop into chronic complaints if not treated appropriately. Nutritional factors and general lifestyle also play a role. A lack of essential nutrients, which are crucial for bone health, can affect the condition of the spine.
The complaints of sciatica, lumbago, slipped discs and low back pain are often interrelated, as they all result from problems in the spine and surrounding structures.
Sciatica is caused by irritation of the sciatic nerve, usually due to a herniated disc or spinal canal stenosis, and causes radiating pain down the leg. Lumbago occurs suddenly, often due to incorrect posture or jerky movements, and usually results from muscle tension or ligament injuries. Low back pain is widespread and is caused by tension, overloading or degenerative changes in the spine. It can occur independently or exacerbate existing complaints.
“In the case of a slipped disc, it is typical for disc tissue to protrude from the disc and press on nerve structures, causing classic nerve pain. This can start as pain in the back, slowly shift there or radiate to other areas of the body. If the lumbar spine is affected, the pain can radiate to the buttocks and leg - to the back of the thigh, the side of the lower leg or even the forefoot. The pain can also intensify when lying down, especially when the leg is raised in an extended position. This puts additional tension on the nerve, which is a typical feature of the neurological examination when checking whether nerve irritation is present. In addition, there may be discomfort in the areas supplied by the affected nerve. In the worst case, muscle paralysis may occur. An example of nerve involvement would be the L5 nerve, which is responsible for lifting the foot and big toe. If it is impaired, the patient may feel like they are tripping over their foot as it cannot be lifted properly,” explains Dr. Richter and adds:
“Patients usually consult a doctor quickly, as pain is often associated with anxiety and they want clarification as quickly as possible. It is then up to us to provide patients with comprehensive advice. That's why the medical history is particularly important: we ask how the pain started and how it develops. We then examine specific alarm symptoms to determine whether structural damage is the cause or whether the pain is non-specific. Only then can we make initial recommendations. In the case of non-specific pain, pain medication and gentle exercise can often already help. Subsequent physiotherapy can also have a supportive effect. An MRI is not always necessary immediately - it is only recommended if the symptoms persist significantly after six weeks, as stipulated in the guidelines. This is difficult for many patients to understand, as they want to find a specific cause for their pain, ideally visible on an image."
Imaging procedures are crucial when it comes to the precise localization and assessment of back problems. Magnetic resonance imaging (MRI) is the preferred procedure here, as it provides detailed images of the soft tissue, nerves and intervertebral discs. It can be used to visualize herniated discs, nerve compression or inflammatory changes. Computed tomography (CT) is also used, especially when it comes to assessing bony structures or complicated fractures. An X-ray can also be useful to detect structural changes such as spondylolisthesis, scoliosis or arthrosis in the spine. Functional x-rays help to detect instabilities or incorrect movements of the spine. If systemic causes such as inflammation or tumors are suspected, laboratory tests and positron emission tomography (PET) can be used.
A holistic approach is essential to prevent back pain.
“In principle, it is important to motivate patients to exercise more - a crucial factor. We are all subject to ageing processes, and the intervertebral discs also wear out. For example, over 90% of all 80-year-olds have advanced degeneration of the intervertebral discs - but this does not necessarily mean that they are ill or in pain. There is not much we can do about this normal ageing process of the spine, but we can try to support it as much as possible. This includes regular physical activity, avoiding obesity and refraining from smoking, as nicotine impairs microcirculation and thus the nutrition of the intervertebral discs. Muscular training plays a decisive role, and a healthy diet is also always recommended. All of this falls under the term 'lifestyle', which each person can influence individually. This has changed considerably in recent decades: In the 1950s, people in Germany still walked an average of ten kilometers a day; in 2016, the figure was just 0.7 kilometers. As a result, we now have both a physical activity problem and an obesity problem. The decline in physical activity has a significant impact on back health. Targeted exercise therapy therefore plays a central role in the prevention and treatment of back pain,” states Dr. Richter.
An upright posture in everyday life is just as important. For example, desk chairs should be ergonomically adjusted and monitors should be positioned at eye level to prevent strain on the lumbar and cervical spine. Lifting heavy objects correctly, with the force coming from the legs and not the back, is another key factor in preventing injuries such as lumbago. Exercise in everyday life, such as walking, swimming or yoga, keeps the spine supple and improves blood flow to the intervertebral discs, which prevents wear and tear in the long term.
“In our practice, we try to motivate and persuade patients to exercise more. This means that we have to invest time in advising them accordingly. If an MRI is available, the images can be used to explain to the patient which changes are part of the normal ageing process and cannot be influenced, while other factors can be actively improved to reduce episodes of pain. The patient must understand that only their own initiative can change the pain, unless structural damage is the cause. They themselves must actively do something for their body so that they feel better,” emphasizes Dr. Richter.
The treatment of back pain differs considerably depending on the course and cause, as acute and chronic pain require different approaches.
“In the case of structural causes of back pain, such as a herniated disc, which occurs very acutely and can be accompanied by nerve pain, weakness or paralysis, it makes sense to confirm the diagnosis using imaging procedures. This is usually done with an MRI or CT scan to identify the exact cause of the symptoms. If there is no serious paralysis, conservative treatment with anti-inflammatory and decongestant medication can be considered. This option must be discussed with the patient, as it requires patience. In an acute phase, targeted cortisone infiltration into the affected nerve area - known as PRT treatment - can also be considered. This has a strong decongestant effect, as pain is often caused by swelling and chemical reactions. If cortisone is injected directly into the affected area, a positive effect can be achieved. Physiotherapy is also recommended. Patients with a slipped disc often realize for themselves that movement is better than sitting or lying in bed for long periods of time. However, this conservative approach takes time to achieve freedom from pain. A herniated disc cannot be “dissolved” by injections or medication - the body has to break it down using its own repair mechanisms. In the process, the protruding tissue dries out, reducing the pressure on the surrounding structures, causing the nerves to swell and the pain to subside,” explains Dr. Richter.
On the possibility of surgery, he adds: “The number of spinal operations has increased - on the one hand because spinal surgery has developed considerably, and on the other because people are getting older and older and still have high demands on their physical performance even in old age. A common reason for surgery is narrowing of the spinal canal (spinal canal stenosis). However, we now know that surgery is not necessary in 80 to 90 % of cases of slipped discs. The symptoms usually improve by themselves over time. Our job as doctors is to accompany this healing process - recovery takes place regardless of the treatment chosen. Surgery is generally only performed in cases of severe paralysis or if bladder or bowel functions are impaired. Surgical treatment can also be considered if severe pain persists for many weeks despite comprehensive conservative measures."
Microsurgical or minimally invasive procedures are used to remove the prolapsed disc substance in order to eliminate the pressure on the nerve root. Techniques such as microdiscectomy or endoscopic disc surgery enable precise treatment with minimal tissue trauma. In more complex cases, such as instability of the spine, fusion may be necessary. Modern procedures such as disc prostheses can be considered for younger patients with certain indications.
At the Helios Clinic in Hamburg, the largest specialist clinic for bone, joint and spinal surgery in Europe, around 500 back operations are performed every year.
Multimodal therapy approaches for chronic back pain: collaboration and patient participation as the key to success.
“Patients with chronic back pain are a difficult group of patients. They require intensive care. Multimodal therapy is necessary, as many different factors have to be taken into account. The doctor must work with the patient to develop a structured treatment concept involving doctors, physiotherapists, sports scientists and psychologists. The aim is to support the patient in dealing with their chronic pain and to try to reduce it - provided that no clear cause is found that explains the pain. It must be checked whether psychosocial stress factors, anxiety or weak muscles are the causes. Unfortunately, such a multimodal concept is not available everywhere, and the cost bearers do not always cover the costs, as this form of therapy is designed for the long term,” states Dr. Richter.
At the end of our conversation, he says: “The patient should always be given more responsibility when it comes to prevention, dealing with pain and its treatment. More intensive collaboration with doctors in private practice as well as physiotherapists and psychologists who treat back pain patients would be desirable as a multimodal assessment. This would make it easier to share knowledge, which is often difficult to implement in practice."
Thank you very much, Dr. Richter, for this informative interview on the subject of back health!
