Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 7, pp 901–909 | Cite as

Efficiency and predictive parameters of outcome of a multimodal pain management concept with spinal injections in patients with low back pain: a retrospective study of 445 patients

  • Melanie Brunner
  • Timo Schwarz
  • Florian Zeman
  • Matthias König
  • Joachim Grifka
  • Achim Benditz
Orthopaedic Surgery


Low back pain is one of the most common diseases of modern civilization. Multimodal pain management (MPM) represents a central approach to avoiding surgery. Short-term results are published rarely and often incomparable because of different treatment concepts. This study compared the subjective and objective parameters as well as the anamnestic and clinical parameters of 445 patients with low back pain before and after inpatient MPM to investigate the influence of this type of therapy on short-term outcome. The majority of patients were very satisfied (39%) or satisfied (58%) with the treatment outcome. The median pain reduction for back pain was 3.0 (IQR 2.88) (numeric rating scale, NRS), thus 66% and 2.75 (IQR 3.38, 62%) for leg pain. The main pain reduction occurred within the first 10 days of treatment and was clinically significant from day 5 onwards. The outcome for patients with hospitalization of more than 10 days was significantly worse. The parameters female sex, BMI of > 30, local pain, and pain duration of 3–24 months had a significantly better outcome. In contrast, age, treatment cause, depression, anxiety, and other diseases had no statistically significant influence on outcome. MPM therapy for more than 5 days seems to be an efficient short-term approach to treating low back pain. Knowledge of some of the outcome predictors helps to early identify patients who require more intensive individual care. In the case of no clear indication for surgery, MPM can be an appropriate treatment option.


Lumbar spinal stenosis Multimodal therapeutic treatment Spinal injection Injection therapy Conservative treatment 



We are grateful to Monika C. Schoell for medical editing.

Author contributions

MB, TS, MK, JG and AB made substantial contributions to the conception and design of the study. MB, FZ, MK and AB participated in the acquisition of data, analysis and statistics. All authors made contributions to the interpretation of data and have been involved in drafting the manuscript. All authors read and approved the final manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing financial interests.

Ethical approval

The study was approved by the Ethics Commission of the University of Regensburg and carried out in accordance with the approved guidelines. Registration in Deutsche Register Klinischer Studien (DRKS), German Clinical Trials Register DRKS00011788.


  1. 1.
    Kent PM, Keating JL (2005) The epidemiology of low back pain in primary care. Chiropr Osteopat 13:13CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Benyamin RM, Manchikanti L, Parr AT, Diwan S, Singh V, Falco FJ, Datta S, Abdi S, Hirsch JA (2012) The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Phys 4:E363–E404Google Scholar
  3. 3.
    GBD 2015 Disease and Injury Incidence and Prevalence Collaborators (2016) Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the global burden of disease study 2015. Lancet 10053:1545–1602Google Scholar
  4. 4.
    Donath C, Dorscht L, Graessel E, Sittl R, Schoen C (2015) Searching for success: development of a combined patient-reported-outcome (“PRO”) criterion for operationalizing success in multi-modal pain therapy. BMC Health Serv Res 15:272CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Borys C, Lutz J, Strauss B, Altmann U (2015) Effectiveness of a multimodal therapy for patients with chronic low back pain regarding pre-admission healthcare utilization. PLoS One 11:e0143139CrossRefGoogle Scholar
  6. 6.
    Giesche F, Streicher H, Maiwald M, Wagner P (2017) Inpatient multimodal pain therapy: additive value of neuromuscular core stability exercises for chronic back pain. Schmerz 2:115–122Google Scholar
  7. 7.
    Benditz A, Loher M, Boluki D, Grifka J, Völlner F, Renkawitz T, Maderbacher G, Götz J (2017) Positive medium-term influence of multimodal pain management on socioeconomic factors and health care utilization in patients with lumbar radiculopathy: a prospective study. J Pain Res 10:389–395CrossRefGoogle Scholar
  8. 8.
    Benditz A, Madl M, Loher M, Grifka J, Boluki D, Linhardt O (2016) Prospective medium-term results of multimodal pain management in patients with lumbar radiculopathy. Sci Rep 6:28187CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW (2014) Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev (9):CD000963.
  10. 10.
    Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW (2015) Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane systematic review and meta-analysis. BMJ 350:h444CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Benditz A, Brunner M, Zeman F, Greimel F, Florian V, Boluki D, Grifka J, Weber M, Renkawitz T (2017) Effectiveness of a multimodal pain management concept for patients with cervical radiculopathy with focus on cervical epidural injections. Sci Rep 1:7866CrossRefGoogle Scholar
  12. 12.
    Schröder G, Knauerhase A, Willenberg HS, Kundt G, Wendig D, Schober HC (2017) Biomechanics of the osteoporotic spine, pain, and principles of training. Arch Orthop Trauma Surg 5:617 – 24CrossRefGoogle Scholar
  13. 13.
    En’Wezoh DC, Leonard DA, Schoenfeld AJ, Harris MB, Zampini JM, Bono CM (2017) Relationship between size of disc and early postoperative outcomes after lumbar discectomy. Arch Orthop Trauma Surg 6:805–811CrossRefGoogle Scholar
  14. 14.
    Collados-Maestre I, Lizaur-Utrilla A, Martinez-Mendez D, Marco-Gomez L, Lopez-Prats FA (2016) Concomitant low back pain impairs outcomes after primary total knee arthroplasty in patients over 65 years: a prospective, matched cohort study. Arch Orthop Trauma Surg 12:1767–1771CrossRefGoogle Scholar
  15. 15.
    Yang AJ, Coronado RA, Hoffecker L, Gao C, Saurwein K, Shoreman D, Hoffberg AS, Akuthota V (2017) Conservative care in lumbar spine surgery trials: a descriptive literature review. Arch Phys Med Rehabil 1:165–172CrossRefGoogle Scholar
  16. 16.
    Kraemer J, Ludwig J, Bickert U, Owczarek V, Traupe M (1997) Lumbar epidural perineural injection: a new technique. Eur Spine J 5:357–361CrossRefGoogle Scholar
  17. 17.
    Grifka J, Benditz A, Boluki D (2017) Injection therapy for cervical and lumbar syndromes. Orthop Feb 46(2):195–214CrossRefGoogle Scholar
  18. 18.
    Theodoridis T, Mamarvar R, Krämer J, Wiese M, Teske W (2009) Angle of needle position for the epidural–perineural injection at the lumbar spine. Z Orthop Unfall 1:65–68Google Scholar
  19. 19.
    Teske W, Zirke S, Trippe C, Krämer J, Willburger RE, Schott C, Theodoridis T, Beer AM, Molsberger A (2009) Epidural injection therapy with local anaesthetics versus cortisone in the lumbar spine syndrome: a prospective study. Z Orthop Unfall 2:199–204CrossRefGoogle Scholar
  20. 20.
    Hamel M, Maier A, Weh L, Klein A, Lucan S, Marnitz U (2009) “Work hardening” bei chronischen rückenschmerzen. Orthopade 10:928–936Google Scholar
  21. 21.
    Fairbank J (2007) Use and abuse of Oswestry Disability Index. Spine 25:2787–2789CrossRefGoogle Scholar
  22. 22.
    Gaul C, Mette E, Schmidt T, Grond S (2008) Praxistauglichkeit einer deutschen version des “Oswestry low back pain disability questionnaire”. Der Schmerz 1:51–58Google Scholar
  23. 23.
    Mannion A, Junge A, Fairbank J, Dvorak J, Grob D (2006) Development of a German version of the Oswestry Disability Index. Part 1. Eur Spine J 1:55–65CrossRefGoogle Scholar
  24. 24.
    Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC, Carreon LY (2008) Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, medical outcomes study questionnaire short form 36, and pain scales. Spine J 6:968 – 74CrossRefGoogle Scholar
  25. 25.
    Lee JS, Hobden E, Stiell IG, Wells GA (2003) Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med 10:1128–1130CrossRefPubMedGoogle Scholar
  26. 26.
    Childs JD, Piva SR, Fritz JM (2005) Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976) 11:1331–1334CrossRefGoogle Scholar
  27. 27.
    Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD, Manning DC, Martin S, McCormick CG, McDermott MP, McGrath P, Quessy S, Rappaport BA, Robbins W, Robinson JP, Rothman M, Royal MA, Simon L, Stauffer JW, Stein W, Tollett J, Wernicke J, Witter J, IMMPACT (2005) Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 1–2:9–19CrossRefGoogle Scholar
  28. 28.
    Mannion A, Junge A, Grob D, Dvorak J, Fairbank J (2006) Development of a German version of the Oswestry Disability Index. Part 2. Eur Spine J 1:66–73CrossRefGoogle Scholar
  29. 29.
    Osthus H, Cziske R, Jacobi E (2006) Cross-cultural adaptation of a German version of the Oswestry Disability Index and evaluation of its measurement properties. Spine (Phila Pa 1976) 14:E448–E53CrossRefGoogle Scholar
  30. 30.
    Herrmann C (1997) International experiences with the hospital anxiety and depression scale—a review of validation data and clinical results. J Psychosom Res 1:17–41CrossRefGoogle Scholar
  31. 31.
    Herrmann C, Buss U, Lingen R, Kreuzer H (1994) The screening for anxiety and depression in routine medical care. Dtsch Med Wochenschr 38:1283–1286Google Scholar
  32. 32.
    Shakir A, Ma V, Mehta B (2013) Comparison of pain score reduction using triamcinolone vs. dexamethasone in cervical transforaminal epidural steroid injections. Am J Phys Med Rehabil 9:768–775CrossRefGoogle Scholar
  33. 33.
    Grifka J, Broll-Zeitvogel E, Anders S (1999) Injection therapy in lumbar syndromes. Orthopade 11:922–931Google Scholar
  34. 34.
    Broll-Zeitvogel E, Grifka J, Bauer J, Roths PH, Degryse P (1999) Medical training therapy in lumbar syndromes. Orthopade 11:932–938Google Scholar
  35. 35.
    Brodke DS, Ritter SM (2005) Nonsurgical management of low back pain and lumbar disk degeneration. Instr Course Lect 279–286Google Scholar
  36. 36.
    Casser HR, Arnold B, Brinkschmidt T, Gralow I, Irnich D, Klimczyk K, Nagel B, Pfingsten M, Sabatowski R, Schiltenwolf M, Sittl R, Söllner W (2013) Multidisciplinary assessment for multimodal pain therapy. Indications and range of performance. Schmerz 4:363–370Google Scholar
  37. 37.
    Arnold B, Brinkschmidt T, Casser HR, Diezemann A, Gralow I, Irnich D, Kaiser U, Klasen B, Klimczyk K, Lutz J, Nagel B, Pfingsten M, Sabatowski R, Schesser R, Schiltenwolf M, Seeger D, Söllner W (2014) Multimodal pain therapy for treatment of chronic pain syndrome. Consensus paper of the ad hoc commission on multimodal interdisciplinary pain management of the German pain society on treatment contents. Schmerz 5:459–472Google Scholar
  38. 38.
    Rodrigues CP, da Silva RA, Nasrala E, Andraus RAC, Fernandes MTP, Fernandes KBP (2017) Analysis of functional capacity in individuals with and without chronic lower back pain. Acta Ortop Bras 4:143–146CrossRefGoogle Scholar
  39. 39.
    Layne EI, Roffey DM, Coyle MJ, Phan P, Kingwell SP, Wai EK (2017) Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines? Spine J. PubMedCrossRefGoogle Scholar
  40. 40.
    van Helvoirt H, Apeldoorn AT, Knol DL, Arts MP, Kamper SJ, van Tulder MW, Ostelo RW (2016) Transforaminal epidural steroid injections influence mechanical diagnosis and therapy (MDT) pain response classification in candidates for lumbar herniated disc surgery. J Back Musculoskelet Rehabil 2:351–359CrossRefGoogle Scholar
  41. 41.
    Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM (2013) A randomized, double-blind, active-controlled trial of fluoroscopic lumbar interlaminar epidural injections in chronic axial or discogenic low back pain: results of 2-year follow-up. Pain Phys 5:E491–E504Google Scholar
  42. 42.
    Manchikanti L, Pampati V, Benyamin RM, Boswell MV (2015) Analysis of efficacy differences between caudal and lumbar interlaminar epidural injections in chronic lumbar axial discogenic pain: local anesthetic alone vs. local combined with steroids. Int J Med Sci 3:214–322CrossRefGoogle Scholar
  43. 43.
    Parr AT, Manchikanti L, Hameed H, Conn A, Manchikanti KN, Benyamin RM, Diwan S, Singh V, Abdi S (2012) Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Phys 3:E159–E98Google Scholar
  44. 44.
    Kaur S, Gupta R, Singh S, Kumar R, Singh K (2017) Impact of different approaches of epidural steroid injection on outcome of patients treated for low backache. Anesth Essays Res 3:697–701CrossRefGoogle Scholar
  45. 45.
    Manchikanti L, Staats PS, Nampiaparampil DE, Hirsch JA (2015) What is the role of epidural injections in the treatment of lumbar discogenic pain: a systematic review of comparative analysis with fusion. Korean J Pain 2:75–87CrossRefGoogle Scholar
  46. 46.
    Kozera K, Ciszek B, Szaro P (2017) Posterior branches of lumbar spinal nerves—part II: lumbar facet syndrome—pathomechanism, symptomatology and diagnostic work-up. Ortop Traumatol Rehabil 2:101–109CrossRefGoogle Scholar
  47. 47.
    Kim HJ, Suh BG, Lee DB, Park JY, Kang KT, Chang BS, Lee CK, Yeom JS (2013) Gender difference of symptom severity in lumbar spinal stenosis: role of pain sensitivity. Pain Phys 6:E715–E23Google Scholar
  48. 48.
    Miller MM, Allison A, Trost Z, De Ruddere L, Wheelis T, Goubert L, Hirsh AT (2017) Differential impact of patient weight on pain-related judgments about male and female chronic low back pain patients. J Pain 19(1):57–66. CrossRefPubMedGoogle Scholar
  49. 49.
    Madl M, Linhardt O, Boluki D, Matussek J, Renkawitz T, Grifka J (2007) Minimalinvasive injektionstherapie beim radikulären lumbalsyndrom. Schmerz 5:445–452CrossRefGoogle Scholar
  50. 50.
    Musher-Eizenman D, Carels RA (2009) The impact of target weight and gender on perceptions of likeability, personality attributes, and functional impairment. Obes Facts 5:311–317CrossRefGoogle Scholar
  51. 51.
    von Heymann W (2015) Pseudo-radicular referred leg pain. Schmerz 6:667–676 (quiz 676–8) Google Scholar
  52. 52.
    Pyskło B, Styczyński T (1998) Influence of coexisting pseudo-radicular syndrome on the results of traction treatment in cases of lumbar intervertebral disk hernia. Neurol Neurochir Pol 6:1449–1460Google Scholar
  53. 53.
    Knutti O, Kaech DL (1998) Radicular and pseudo-radicular pain syndrome. Ther Umsch 10:601–612Google Scholar
  54. 54.
    Dworkin RH, Clark WC, Lipsitz JD (1995) Pain responsivity in major depression and bipolar disorder. Psychiatry Res 2:173 – 81CrossRefGoogle Scholar
  55. 55.
    Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B (2007) Depression, chronic diseases, and decrements in health: results from the world health surveys. Lancet 9590:851–858CrossRefGoogle Scholar
  56. 56.
    Catalano D, Chan F, Wilson L, Chiu CY, Muller VR (2011) The buffering effect of resilience on depression among individuals with spinal cord injury: a structural equation model. Rehabil Psychol 3:200–211CrossRefGoogle Scholar
  57. 57.
    Beutel ME, Glaesmer H, Wiltink J, Marian H, Brähler E (2010) Life satisfaction, anxiety, depression and resilience across the life span of men. Aging Male 1:32–39CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopedics, University Medical Center RegensburgAsklepios Klinikum Bad AbbachBad AbbachGermany
  2. 2.Centre for Clinical StudiesUniversity Medical Center RegensburgRegensburgGermany

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