Chronic Back Pain

  • 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


  • 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.