Back Health The "Classics": Sciatica, Lumbago, Pinched Nerves, Lower Back Pain — Expert Interview with Dr. Richter

Dr. Alexander Richter, M.D., is a highly qualified specialist in orthopedics and trauma surgery, with a focus on spinal surgery and pain management. He serves as a senior physician in the Department of Spinal Surgery and Neurosurgery at the Helios ENDO Clinic in Hamburg, where he performs both conservative and surgical treatments at the highest level. Dr. Richter specializes in the diagnosis and treatment of acute and chronic back pain, disc problems, and deformities such as scoliosis and kyphosis.

Over the course of his more than 20-year career, he has successfully performed more than 2,500 spinal procedures. This includes, among other things, microsurgical procedures for herniated discs and spinal stenosis, as well as complex procedures such as spinal stabilization and correction, and the treatment of vertebral fractures, tumors, and metastases of the spine. His expertise also extends to revision surgery—that is, the surgical correction of complications arising from previous procedures. In addition, he offers interventional pain therapies, including injections into the spine and nerve roots. He takes a holistic approach in which surgical measures are always considered as a last resort—before he works with his patients to develop customized conservative therapies.

In addition to his clinical work, Dr. Richter has an academic background and previously worked at the Technical University of Hamburg-Harburg in the field of spinal biomechanics. His scientific papers have been published in renowned journals. As a speaker and instructor for the German Spine Society and the German Society for Orthopedics and Orthopedic Surgery, Dr. Richter is a recognized expert and is actively involved in the training of young physicians. Dr. Richter treats a wide range of patients, including both adults and adolescents with spinal deformities.

The editorial team of the Leading Medicine Guide had the opportunity to speak with Dr. Richter about 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. In particular, the so-called “classic” conditions—such as sciatica, lumbago, pinched nerves, and lower back pain—are widespread and can significantly impair daily life. These conditions often arise from a variety of causes—ranging from overexertion and lack of exercise to poor posture and degenerative changes in the spine. Especially in cases of acute pain, many patients seek quick relief, while chronic conditions require long-term treatment and prevention. An accurate diagnosis and personalized treatment are crucial for relieving pain and stabilizing back health in the long term.

Back pain has a variety of causes that often interact with one another. 

“Back pain is a huge problem that affects about 80% of people at least once a year. When people experience pain, they always assume that something must be structurally damaged, but that is very rarely the case. It’s not for nothing that we distinguish between specific and nonspecific back pain—and there are national guidelines on this as well. And only about 10–15% of back pain cases fall under the category of specific back pain, where a specific structural issue can be identified as the cause. For example, a patient might complain of classic lower back pain and wonder if they may have strained something—but the cause cannot be clearly determined. This is functional pain resulting from overexertion, which usually subsides on its own after one to two days if the patient gets some rest. The situation is different with a classic herniated disc. In this case, for example, the annulus fibrosus tears, the gel-like nucleus pulposus protrudes 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 in this case, there is a specific structure that is responsible for the symptoms,” explains Dr. Richter regarding the differences between specific and nonspecific back pain. 

One of the most common causes of back pain is a lack of exercise, which leads to weakened back and core muscles—muscles that are essential for stabilizing the spine and protecting it from overexertion. Without sufficient exercise and strength, everyday stresses—such as lifting heavy objects or maintaining awkward positions—can overburden the back and trigger pain. Poor posture, which creeps in due to prolonged sitting—especially at work—further increases the risk. A poorly aligned sitting position places uneven stress on the intervertebral discs, which can lead to wear and tear over time. At the same time, being overweight plays a role, as it increases the strain on the spine and can impair the natural cushioning functions of the intervertebral discs. Traumatic events such as falls or accidents can also cause sudden back pain, which can sometimes develop into chronic symptoms if not treated appropriately. Dietary factors and overall lifestyle also play a role. A lack of essential nutrients that are crucial for bone health can negatively affect the condition of the spine. 

Conditions such as sciatica, lumbago, herniated discs, and lower 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 stenosis, and causes pain that radiates down the leg. Lumbago occurs suddenly, often due to poor posture or sudden movements, and usually results from muscle tension or ligament injuries. Lower back pain is very common and is caused by tension, overexertion, or degenerative changes in the spine. It can occur on its own or exacerbate existing symptoms.

“With a herniated disc, it is typical for disc tissue to protrude from the disc and press on nerve structures, causing the classic nerve pain. This pain may begin as back pain, slowly shift within the back, or radiate to other areas of the body. If the lumbar spine is affected, pain may radiate to the buttocks and leg—extending into the back of the thigh, the side of the lower leg, or even the forefoot. In addition, the pain may intensify when lying down, especially when the leg is raised in a straight position. This puts additional tension on the nerve, which is a typical finding during a neurological examination when checking for nerve irritation. Furthermore, abnormal sensations may occur in the areas innervated by the affected nerve. In the worst-case scenario, muscle paralysis may occur. An example of a nerve involved would be the L5 nerve, which is responsible for lifting the foot and big toe. If it is impaired, the patient may feel as though they are tripping over their own foot because they cannot lift it properly,” explains Dr. Richter, adding:

“Patients usually seek medical attention quickly, as pain is often accompanied by anxiety and they want a diagnosis as soon as possible. It is then up to us to provide patients with comprehensive advice. That is why the medical history is particularly important: We ask how the pain began and how it has progressed. We then conduct a targeted examination to check for warning signs, in order to determine whether structural damage is the cause or whether the pain is nonspecific. Only then can we make initial recommendations. In cases of nonspecific pain, pain medication and gentle exercise can often help right away. Follow-up physical therapy can also be beneficial. An MRI isn’t always necessary right away—it’s only recommended if symptoms persist significantly after six weeks, as the guidelines also stipulate. This is difficult for many patients to understand, as they want to find a specific cause for their pain, ideally one that’s visible on an image.”

---

Imaging techniques are crucial when it comes to the precise localization and assessment of back problems. Magnetic resonance imaging (MRI) is the preferred method here, as it provides detailed images of soft tissues, nerves, and intervertebral discs. It can be used to visualize herniated discs, nerve compression, or inflammatory changes. Computed tomography (CT) is also used, particularly when assessing bony structures or complex fractures. An X-ray can also be useful for detecting structural changes such as spondylolisthesis, scoliosis, or osteoarthritis in the spine. Functional X-rays help identify instabilities or abnormal movements of the spine. If systemic causes such as inflammation or tumors are suspected, laboratory tests and positron emission tomography (PET) may be used.

---

A holistic approach is essential for preventing back pain. 

“In principle, it is important to encourage patients to be more active—a crucial factor. We are all subject to the aging process, and the intervertebral discs also wear out. For example, over 90% of all 80-year-olds show advanced degeneration of the intervertebral discs—but that does not necessarily mean they are ill or in pain. There is not much that can be done to counter this normal aging process of the spine, but we can try to support it as best as possible. This includes regular physical activity, maintaining a healthy weight, and avoiding smoking, since nicotine impairs microcirculation and thus the nourishment of the intervertebral discs. Strength training plays a crucial role, and a healthy diet is always recommended. All of this falls under the term “lifestyle,” which each person can influence individually. This has changed significantly in recent decades: In the 1950s, people in Germany still walked an average of ten kilometers per day; by 2016, that figure had dropped to just 0.7 kilometers. As a result, we now face both a lack of physical activity and an obesity problem. The decline in physical activity has significant implications for back health. Therefore, targeted exercise therapy plays a central role in the prevention and treatment of back pain,” states Dr. Richter.

Maintaining good posture in everyday life is just as important. For example, office chairs should be ergonomically adjusted and monitors positioned at eye level to prevent strain on the lumbar and cervical spine. Lifting heavy objects correctly—using strength from the legs rather than the back—is another key factor in preventing injuries such as lumbago. Daily physical activity, such as walking, swimming, or yoga, keeps the spine flexible and improves blood flow to the intervertebral discs, which helps prevent wear and tear in the long term. 

“In our practice, we try to motivate patients to be more active and convince them of the benefits. This means we have to invest time in advising them accordingly. If an MRI is available, we can use the images to explain to the patient which changes are part of the normal aging 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 alleviate the pain, provided that structural damage is not the cause. They themselves must take active steps to care for their body so that they feel better,” emphasizes Dr. Richter.

The treatment of back pain varies considerably depending on its course and cause, as acute and chronic pain require different approaches.

“In cases of structural causes of back pain, such as a herniated disc—which occurs acutely and may be accompanied by nerve pain, weakness, or paralysis—it makes sense to confirm the diagnosis using imaging techniques. This is usually done via an MRI or CT scan to identify the exact cause of the symptoms. If there is no severe paralysis, conservative treatment with anti-inflammatory and decongestant medications may be considered. This option must be discussed with the patient, as it requires patience. During the acute phase, a targeted cortisone injection into the affected nerve area—known as PRT treatment—may also be considered. This has a strong anti-inflammatory effect, as pain is often caused by swelling and chemical reactions. Injecting cortisone directly into the affected area can produce a positive effect. Physical therapy is recommended as a complementary treatment. Patients with a herniated disc often notice for themselves that movement is better than sitting for long periods or lying in bed. However, this conservative approach takes time to achieve pain relief. A herniated disc cannot be “dissolved” by injections or medication—the body must break it down using its own repair mechanisms. “As this happens, the protruding tissue dries out, which reduces pressure on the surrounding structures, allows the nerves to decongest, and eases the pain,” explains Dr. Richter.

Regarding the possibility of surgery, he adds: “The number of spinal surgeries has increased—on the one hand, because spinal surgery has advanced significantly, and on the other, because people are living longer and still have high expectations for their physical performance even in old age. A common reason for surgery is narrowing of the spinal canal (spinal stenosis). However, when it comes to herniated discs, we now know that surgery is not necessary in 80 to 90% of cases. The symptoms usually improve on their own over time. Our role as physicians is to support this healing process—recovery occurs regardless of the chosen treatment. Surgery is generally performed only in cases of severe paralysis or when bladder or bowel functions are impaired. Even if severe pain persists for many weeks despite comprehensive conservative measures, surgical treatment may be considered.”

Surgically, microsurgical or minimally invasive procedures are used to remove the herniated disc material and relieve pressure on the nerve root. Techniques such as microdiscectomy or endoscopic disc surgery allow for precise treatment with minimal tissue trauma. In more complex cases, such as spinal instability, spinal fusion may be necessary. Modern procedures such as intervertebral disc prostheses may be considered for younger patients with specific indications.

---

At the Helios Clinic in Hamburg, Europe’s largest specialized clinic for bone, joint, and spinal surgery, approximately 500 spinal surgeries are performed each year.

---

Multimodal treatment approaches for chronic back pain: Collaboration and patient involvement as the keys to success.

“Patients with chronic back pain represent a challenging patient group. They require intensive care. A multimodal treatment approach is necessary because many different factors must be taken into account. The physician must work with the patient to develop a structured treatment plan involving physicians, physical therapists, sports scientists, and psychologists. The goal is to support the patient in managing their chronic pain and to try to reduce it—provided that no clear cause explaining the pain is found. It must be determined whether psychosocial stressors, anxiety, or even weak muscles are contributing factors. “Unfortunately, such a multimodal approach is not available everywhere, and insurance providers do not always cover the costs, since this form of therapy is designed for the long term,” states Dr. Richter.

At the end of our conversation, he adds: “Patients should generally be given a greater sense of responsibility when it comes to prevention, pain management, and treatment. Closer collaboration with primary care physicians, as well as physical therapists and psychologists who treat patients with back pain, would be desirable as part of a multimodal assessment. This would allow for better knowledge sharing, though it is often difficult to implement in practice.”

Thank you very much, Dr. Richter, for this insightful conversation on the topic of back health!