- Lower back pain (LBP) is very common, in the USA and globally. The lifetime prevalence in the US is by some estimate 65-80%, and a substantial 10-40% of patients develop symptoms lasting for greater than six weeks.
- Risk factors for lower back pain are varied: male gender, current smoking, obesity, poor general health, physically demanding lifestyle, depression, anxiety, and other psychological stressors.
- There is also a prevalence of back pain in high-income countries relative to middle- or low-income countries.
- Common etiologies are myofascial pain, facet-mediated pain, discogenic pain, lumbar spinal stenosis, and lumbar radiculopathy
Challenges
- LBP in less than 1% of cases is the result of grave, time-sensitive, systemic pathology. Review of red flags for these conditions is key in the assessment of patient with chronic LBP.
- Cancer: Is there a personal history of cancer, or has there been unintentional weight loss or worsening pain at night?
- Infection: Is there fever, history of IV drug use, immunosuppression? Has a spinal procedure recently been performed?
- Trauma: Has there been a recent accident? Is there midline tenderness?
- Neurologic compromise: Is there new bowel or bladder incontinence with or without new weakness or lack of sensation?
Treatment Recommendations
- Like all chronic pain conditions, there is not a “one size fits all” treatment. Cornerstones of therapy include some combination of acetaminophen, NSAIDs, and neuropathic agents; physical therapy engagement is also paramount.
- For patients with “yellow flag” symptoms, such as psychological and other risk factors listed above, referral to a multi-disciplinary pain specialist is indicated.
Special Considerations
- Whether to get imaging is a controversial issue, with many patients requesting imaging and providers feeling pressured, from various sources, to rule out serious pathology or move closer to a diagnosis. In general, imaging is not recommended if LBP is present for less than six weeks and without any red flag symptoms. If a patient has persistent pain despite conservative management, imaging may be considered, often starting with x-ray and moving onto CT and / or MRI.
- It is well established that a majority of patients with no back pain will have abnormalities noted on imaging studies. It may be more appropriate to call these changes “age-related” than “degenerative.”
Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial [published online ahead of print, 2021 Sep 29]. JAMA Psychiatry. 2021;e212669.
Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain. 2009;147:17–9.
Parreira P, Maher CG, Steffens D, Hancock MJ, Ferreira ML. Risk factors for low back pain and sciatica: an umbrella review. Spine J. 2018. Sep; 18(9):1715-1721.
Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017. Feb 18; 389: 736-747.
Urits I, Burshtein A, Sharma M, Testa L, Gold PA, Orhurhu V, Viswanath O, Jones MR, Sidransky MA, Spektor B, Kaye AD. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep. 2019 Mar 11;23(3):23.