11 Multimodal Spinal Therapy
The spectrum of treatment for back and neck pain ranges from the simple application of heat and administration of analgesics at one extreme to open surgery at the other. Multimodal spinal therapy is in the center of this range. It deals primarily with nerve root compression, treating it with a combination of local injections, physical therapy, pain treatment, and behavioral training. The severity of the presenting symptoms determines whether the multimodal program is conducted on an outpatient basis in a day clinic or in an inpatient setting. A multimodal intensive program should be followed when there is no compelling reason for immediate surgery. This program aims to improve symptoms quickly and permanently, preventing chronification and the need for possible surgery later on as a result of ineffective conservative treatment.
11.1 Outpatient Minimally Invasive Spinal Therapy
Multimodal spinal therapy, including spinal injections, can in principle be carried out on an outpatient or day hospital basis. Apart from the few interventions that require 24-hour monitoring, such as cervical epidural injections, all the special interventions conducted by physicians can be administered in an outpatient setting. The limiting factors for outpatient treatment, which are also the indications for inpatient treatment, are presented below.
Indications for inpatient minimally invasive spinal therapy (IMIST) in the event of serious findings and pain rated > 5 on the Numeric Rating Scale (NRS) are as follows:
Intervertebral disk prolapse.
Decompensated spinal canal stenosis.
Postsurgical: scarring, instability (postdiscotomy and postfusion syndromes).
Spondylolisthesis (degenerative and isthmic).
Osteoporotic fracture.
Synovial cysts.
Patients who are admitted to the hospital usually present with severe pain, a considerable maladaptive posture, and paralyses that are in the gray area of becoming indications for surgical intervention. They usually arrive at the hospital by ambulance as they are otherwise unable to travel. Inpatient observation is also necessary in cases where large prolapses are present, as there is a risk of further paralysis. The indication for the outpatient treatment of a nerve root compression syndrome is therefore “diagnosis by exclusion.”
The first day of outpatient treatment consists of the usual detailed examinations and determining the diagnosis. Once the further diagnostics with radiography and, in some cases, laboratory findings are completed and the patient has received a sufficient amount of information, adequate pain therapy should be administered on the first day in the form of spinal nerve analgesia or epidural injection. In acute cases with severe pain, the cervical spinal nerve analgesia (CSPA) or lumbar spinal nerve analgesia (LSPA) is conducted daily over the following days. This is followed in each case by physical therapy, thermotherapy, Glisson traction, Fowler position or side-lying for the lumbar spine, and electrotherapy.
Cervicobrachial syndromes and lumboischialgia have a strong tendency to become chronic. For this reason, pain-coping strategies are introduced right from the start. Progressive muscle relaxation follows during the consecutive sessions. The invasive interventions are reduced, with intervals of 2 to 3 days depending on how the symptoms develop.
Epidural perineural injections and other types of epidural injection therapy are administered a maximum of three times over the entire treatment cycle, with a break of several days between injections. Depending on which is the most prominent primary and secondary pain as time goes on, trigger point and facet infiltration, sacroiliac joint infiltrations, acupuncture, or other interventions drawn from the wide spectrum of treatment possibilities can be administered. In some cases, concomitant therapy with medication is necessary right from the start (see Chapter 4, “Multimodal Medication Concomitant Therapy”; Table 11‑1 , Table 11‑2).
The patient should also see the physician again sometime after the third week, e.g., after a further 3 to 6 weeks, depending on the amount of irritation in the cervical or lumbar nerve root. The physician uses this opportunity to assess the patient’s orthopedic and neurological status and check the diagnosis. When necessary, local infiltrations are conducted to desensitize the nerve root at this point in time and later at increasingly longer intervals.
The remaining components of the multimodal program are carried out by patients themselves. This applies especially to exercises commencing in the pain-relieving position, and sports that are gentle on the spine.
11.2 Inpatient Minimally Invasive Spinal Therapy
Intensive IMIST should be conducted over a period of 4 to 8 days before operating on spinal symptoms that are extremely resistant to treatment. This does not apply if a serious acute paralysis requires immediate surgery. Most cases involve a nerve root compression syndrome arising from an intervertebral disk prolapse, spinal canal stenosis, or postsurgical scarring. In terms of invasiveness, IMIST is intermediate between outpatient specialist orthopedic treatment and open surgery (Theodoridis and Krämer 2003) (Table 11‑3).
Outpatient | Inpatient | Inpatient |
General practitioner | IMIST | Open surgery |
Specialist physician |
In most cases, symptoms improve in the long term, so that open surgery need no longer be considered as a treatment option. The improvement of symptoms is achieved by giving daily injections of analgesics to the spinal nerve and epidural perineural infiltrations, and at the same time implementing a special physical therapy program that continues after the patient is discharged. In most cases, the symptoms can already be reduced so effectively in the first days of therapy that the patients can be discharged to outpatient therapy after 3 or 4 days. In some cases, however, the patient needs to spend more days in inpatient treatment before being able to be discharged.
The IMIST concept is multimodal, containing medical therapy, physical therapy, and psychotherapy components. The concept has proved itself over the last 25 years with more than 20,000 patients at the Orthopedic University Clinic at St. Josef-Hospital Bochum in Germany. It is continually being improved on the basis of experience and scientific studies. The essential components of the multimodal program—spinal injections, movement therapy, and behavioral training (back school)—are evidence based and specifically recommended by the Drug Commission of the German Medical Association (Table 11‑4).
11.2.1 Medical Interventions
The medical interventions are supervised by specially trained orthopedists/trauma surgeons and pain therapists. These include injections close to the spine as LSPA or epidural and perineural infiltration as the key daily intervention.
Following the minimally invasive interventions (injections), the patient is placed in a special pain-relieving position or in Glisson traction. This is individually adjusted and checked by the physician. Further daily medical interventions, e.g., peripheral infiltrations, manual therapy, and acupuncture, are performed at other times and depend on the findings.
The patient’s self-assessment of pain and the clinical neurological findings are assessed regularly, and pain medication is adjusted individually during the inpatient stay. In special cases, changes in medication are decided upon in an interdisciplinary pain conference involving medical pain specialists, psychotherapists, and internal medicine physicians. The pain medication is also assessed after discharge, in consultation with the patient’s general practitioner.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
