Assessment of risk factors

Lack of regular physical activity, sports and a sedentary lifestyle are very important risk factors for spine pathologies, including frequently diagnosed discopathy. Already in the early years of life, atrophy of blood vessels in the intervertebral discs occurs and the region is nourished by the diffusion of surrounding tissues. The more physically active the child is, the better is the process of nourishing the intervertebral discs. If children do not exercise or play sports, they spend many hours at school and then using the computer. In consequence, these factors provide a basis for the development of discosis – i.e. the formation of degenerative lesions within the intervertebral discs. Subsequently, degenerative changes in the spine may occur due to discopathy [4]. We can influence many risk factors, known as modifiable factors. These include, among others: physical activity, sedentary and overloading lifestyle, smoking, a non-ergonomic workstation where we spend many hours during the day or throughout our lives. Fixing the monitor at an incorrect height, or incorrect use of a mobile phone at flexion, causes overload of the cervical spine [5, 6]. The overload level vs. flexion angle is presented in Table II.

Unfortunately, nowadays, when the use of electronic devices is so common, it is practically impossible to eliminate these factors, but it is possible to modify them to some extent. For example, if a doctor recommends an accountant to quit the use of a computer, it is practically impossible. Therefore, this stage should be based on the adjustment of modifiable factors. Table III presents examples of modifications of risk factors for back pain syndromes.

The case is a bit more difficult for non-modifiable factors. We cannot significantly influence these factors, so any adjustments of modifiable factors may partially support this stage. The non-modifiable factors include mainly: age, patient’s predispositions (e.g. immune disorders – higher risk of infection, hematological disorders – higher risk of bleeding, hematoma) and genetic factors.

Pharmacotherapy

Medical therapy in the broad sense is an almost fixed element of SD treatment. Very often, analgesics, anti-inflammatory drugs, myorelaxants and vitamin pharmacotherapy are used. However, it should be clearly stated that the use of analgesia alone, i.e. only symptomatic treatment, is insufficient. In consequence, it may have a negative impact on the patient by pain attenuation and delay diagnosis and targeted treatment implementation. According to the latest literature, rest and pharmacotherapy do not play a key role in the treatment of back pain syndromes. Physical activity and multidirectional treatment are recommended [9]. During exacerbations, it is difficult to talk about exercise therapy or kinesiotherapy in the broad sense. In such circumstances, the patient reports severe pain and limited spine mobility, which prevents them from working or performing basic everyday activities. Due to the fact that myofascial pain syndrome (MPS) is frequently diagnosed, one of the newer minimally invasive therapy alternatives that can interrupt this pathological process is the use of a microinjection technique, a peri-spinal therapy called local intradermal therapy, or more commonly, spinal mesotherapy. This method can be used with drugs to relieve pain and inflammation (e.g. ketoprofen), anesthetics (e.g. lignocaine, bupivacaine), myorelaxants (e.g. diazepam), and regenerative drugs (e.g. tropocollagen I) [10, 11]. Due to its safety and low risk of complications, this therapy is used more and more often as one of the treatment stages with the aim, among others, of interrupting the process of chronic disease exacerbation, reducing pain, improving mobility and creating conditions for the effective use of the third stage – rehabilitation.

Surgical treatment

In some patients, despite the implementation of conservative treatment, spinal surgical treatment should be considered, which is used primarily in the case of neurological symptoms, such as paresis or sphincter disorders. Obviously it is targeted at its cause. Unfortunately, very often the surgical treatment is delayed for various reasons. Then, the pathological lesion progresses, the patient gets older, and new diseases develop with age. All this may have a significant impact on the final effect of surgical treatment.

Unfortunately, some patients still report pain despite spinal surgery. In such cases failed back surgery syndrome is diagnosed [12]. Failed back surgery syndrome is a generalized medical term that is often used to describe the condition where back pain persists or appears after spine surgery. Important risk factors include instability after surgery, tissue scarring after surgery, and the patient’s predispositions [12, 13].

However, a very important aspect is a thorough assessment of whether the symptoms originate from the spine or whether they are caused by paraspinal pathologies, such as greater trochanteric pain syndrome, which require different treatment [14]. In consequence, it turns out that the patient, apart from SD, may also suffer from other disorders of organs of the musculoskeletal system, which, e.g., develop as a result of SD or constitute their complications.

Rehabilitation

Spinal rehabilitation plays an essential role in treatment of musculoskeletal disorders. Eagerly used are movement therapy and kinesiotherapy, both allowing one, among other benefits, to relax tense tissues, stretch them and, as a result, strengthen the entire musculoskeletal system. This has a significant impact on the stabilization of the spinal motor unit [15, 16]. Additionally, physical therapy is used, having local anti-inflammatory, anti-swelling and analgesic effects, improving circulation and, consequently, promoting regeneration of pathologically changed tissues [15–17]. Many studies have reported the effectiveness and safety of various therapies. However, attention is not always paid to the time needed to implement a specific physiotherapeutic procedure for a specific spine pathology. Therefore, for this purpose, various studies are carried out to determine at what stage, after medical therapy, to implement the specialized rehabilitation: whether to use it simultaneously or immediately after the second stage – medical therapy – or sometimes after the discontinuation of medical therapy. This is important for the effective maintenance of previously administered medical therapy [18].

Soon after introducing conservative therapy (pharmacotherapy) as well as after surgical therapy the use of exercise therapy is recommended after a short time but under some conditions especially after surgical procedures.

However, starting exercise therapy too quickly in patients after spinal surgery may lead to health deterioration and expose the patient to complications requiring reoperations. This applies to both less and more invasive surgical techniques. After the endoscopic removal of an intervertebral disc herniation, i.e. a minimally invasive surgical technique that should cause little tissue trauma, the healing period of the annulus fibrosus is consistent with the biological process of soft tissue healing, i.e. a standard period of 6 weeks. Spinal rehabilitation introduced too soon may lead to the development of recurrent hernia [19].

The same applies to patients with spinal stenosis after extensive open spine surgery with spinal canal decompression and posterior lumbar interbody fusion, i.e. screw implantation. Typically, rehabilitation aimed at the spine is not implemented earlier than after 2–3 months due to the risk of implant loosening and exposing the patient to another surgical procedure [20, 21]. In some patients, the rehabilitation process can be started earlier; therefore the treatment in this matter should be individualized. Table IV shows the implementation time of targeted rehabilitation for the operated basic pathology for selected spine surgery methods.

Therefore, each spinal pathology has its own different treatment regimen. Early postoperative physiotherapeutic treatment is justified, but it should first concern other issues, e.g. anticoagulation, breathing improvement, learning and controlling walking with the use of orthopedic equipment. Attention should also be paid to the patient’s education, especially regarding spinal load reduction in everyday life.