Therapie des Rückenschmerzes: Was ist durch Studien belegt?

Zusammenfassung

Rückenschmerzen stellen ein großes Gesundheitsproblem dar, auch in Deutschland führen sie in erheblichem Ausmaß zu Arbeitsunfähigkeit und Berentungen. Rückenschmerzen müssen klassifiziert werden nach Lokalisation, Dauer und nach vorhandener oder nicht vorhandener neurologischer Ausfallssymptomatik, ggf. mit Angaben zum Schweregrad, wovon maßgeblich die weitere Therapie abhängt. Von Anfang an besteht ein gewisser Zeitdruck, um einen Chronifizierungsprozess zu vermeiden. Deswegen sollte initial (bis auf im Folgenden genannten Notfallsituationen) eine adäquate, konsequente und evidenzbasierte konservative Therapie erfolgen. Die Betroffenen sollten nicht immobilisiert werden (Bettruhe, im HWS-Bereich Halskrausen), da inzwischen klar ist, dass dies ein schlechteres outcome im Vergleich zu denen, die ihre Alltagsaktivitäten weiterführten, bedingt. Medikamentöse Basistherapeutika sind „non-steroidal-anti-inflammatory-drugs” (NSAID), eventuell kurzfristig Opioide und Muskelrelaxantien. Operative Maßnahmen werden nur in einem geringeren Prozentsatz der Patienten notwendig. Die Studienlage bezüglich weiterer therapeutischer Verfahren wie Akupunktur, Verabreichung von Orthesen und Chirotherapie ist noch unzureichend, über die Anwendung lokaler Injektionsbehandlungen sollte nur im Einzelfall entschieden werden. Bei chronischen Rückenschmerzen muss eine multimodale, interdisziplinäre Schmerzbehandlung erfolgen, mit konsequentem körperlichen Training und (kognitiv-)verhaltenstherapeutischen Maßnahmen zur Veränderung eines maladaptiven, auf Ruhe und Schonung ausgerichteten Krankheitsverhaltens. Zur Besserung einer Schmerzbewältigung kann auch der Einsatz von Antidepressiva gerechtfertigt sein.

Abstract

Back pain has to be classified by localisation, duration, and existence or absence of neurological deficits. Therapy mainly depends on the severity of neurological symptoms. The time period between the onset of symptoms and efficient therapy should be short in order to prevent the development of chronic pain. Therefore a sufficient, consistent and evidence-based conservative treatment should be initiated early on, with the only exception of special emergency situations as described further down in this article. Patients should not be immobilized, a better outcome is proven in patients who immediately continued practising their daily activities. First line medication consists of non-steroidal-anti-inflammatory-drugs (NSAID). If necessary, opioids and muscle-relaxants may be applied additionally. Surgical procedures are only indicated in a small number of patients. A sufficient data base with regard to the benefit of acupuncture, orthesis, and chiropractic medicine is lacking. Local injections should only be done in very special cases. Concerning chronic back pain a multimodal, multi-disciplinary pain treatment concept with physical training and behavioural therapy should be applied in order to teach the patient to avoid a passive and maladjusted attitude. Antidepressant drugs may also be indicated in chronic back pain.

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