Low back pain

85% of the population has at least one episode of acute low back pain.

LBP is classified as specific, caused by a specific pathophysiologic mechanism of non-spinal or spinal origin, or nonspecific without a clear nociceptive specific cause.

Non-spinal causes of specific low back pain include hip conditions, pelvic organ diseases (prostatitis and endometriosis), and vascular (aortic aneurysms), or systemic disorders.

Low back pain with radicular component that is due to nerve root involvement have a higher prevalence, of 5 to 10%, than other spinal causes.

The two most frequent causes of such back pain are herniated disc and spinal stenosis.

The prevalence of other spinal disorders is low among patients with acute low back pain.

Nonspecific low back pain is probably a result of interaction of biological, psychological, and social factors, and accounts for 80 to 90% of all cases of low back pain.

Risk factors for nonspecific low back pain include: physical risk factors of prolonged standing or walking, and lifting heavy weights, and unhealthy lifestyle, as with obesity, psychological factors including depression and job dissatisfaction, and previous episodes of low back pain.

Triggers of a new episode of low back pain include performance of manual tasks involving heavy loads or awkward postures and distraction during an activity.

Low back pain is usually classified according to pain duration as acute, six weeks or less, subacute, 6 to 12 weeks, or chronic greater than 12 weeks.

Spinal causes of low back pain include herniated disc, spinal stenosis, fracture, tumor, infection, and axial spondylarthritis.

Low back pain is generally defined as pain below the costal margins and above the inferior gluteal folds, with or without leg pain.

The number one cause of disability worldwide, and one of the three top reasons for people to seek medical care.

Low back pain accounts for 2.4% ED visits, and results in 2.7 million visits annually.

Lifetime incidence of 51-84%.

The mean point prevalence of low back pain in the general adult population is approximately 12%.

A higher prevalence among persons 40 years of age or older, and among women there is a lifetime prevalence was approximately 40%.

In the primary care setting the prevalence of serious low back pain pathology is less than 1%.

Among the top 10 diseases in the US. 


Its prevalence is increasing  due to longer lifespans.


Estimated healthcare costs is just behind ischemic heart disease.

NIH estimates that more than half of all US adults have a musculoskeletal pain disorder, of whom 1/5 report having low back pain.

The leading cause of disability worldwide.

Red flags include: focal neurologic deficits such as motor weakness, bowel and bladder changes, saddle anesthesia, asymmetry in reflexes and strength,  history of cancer or trauma, parenteral drug use, long-term steroid, use, immunocompromised state, fever, and unexplained weight loss.
Red flags, are a consideration for a serious diagnosis of cancer, infection, or inflammatory disease.
Age greater than 70 years, trauma, prolonged use of glucocorticoids are associated with a high specificity for, and considerable increase probability of spinal fracture, with the highest probability of fracture seen with multiple features of present.

Diagnostic testing is not recommended for back pain lasting less than six weeks, in the absence of red flags.

Low back pain estimated to cost $30 billion in direct healthcare costs and 100-$200 billion in decreased wages and disability in the US annually.

Classification is based on the distribution of pain as axial pain meaning pain localized to the low back, or radicular neuropathic pain radiating to the lower extremities.

The distribution of back pain is a corollary to frequently occurring diseases involving the lumbar spine.

More than 85% of patients seen in primary care have a nonspecific LBP, meaning low back pain is without an identified specific underlying condition.

Common causes of low back pain in an axial distribution include: the intravertebral disc, facet joint, sacroiliac joint, and paraspinal muscles.

An under recognized cause of chronic low back pain is axial spondyloarthritis, an inflammatory rheumatic disease that predominately involves spine and sacroiliac joints.
Distinguishing between causes of low back pain and leg pain requires a thorough examination and includes provocative tests such as straight leg raise,.
The straight leg raise has a sensitivity of 91% and specificity of 26% in detecting disc herniation.

The Patrick’s test involving flexion, abduction, external rotation is used to evaluate SI joint and hip pathology.: Ipsilateral anterior pain over the hip can indicate hip joint pathology, with contralateral posterior pain more indicative of SI joint disease.

Common causes of radicular pain include a herniated intervertebral disc, and spinal stenosis.

Approximately half of patients experience a recurrence of LBP within one year after recovering from a previous episode.

More than 50% of Americans have back pain each year.

Accounts for 2% of all physician office visits and is the fifth most common reasons for primary care office visits.

Physical inactivity increases the risk of lumbar radicular pain in abdominally obese individuals, but not in persons with normal weight circumference.

Trends reveal increased use of advanced imaging tests, increased use of opiates, and increased use of invasive surgical /interventional procedures, and increased costs, but the prevalence and burden associated with low back pain are on the rise.

Acute low back pain, unless accompanied by: neurologic deficit, recent significant trauma, recent mild trauma in a patient older than 50 years, history of prolonged steroid use, history of osteoporosis, history of cancer, history of recent infection or an older patients with new onset back pain, do not require routine plain-film evaluation within the first month of symptoms.

Point prevalence is 25% and half of those with such pain seek health care (Walker BF).

Annual incidence is estimated at 5%.

Estimated 70% of individuals from industrialized Western countries have back pain in their lives.

90% of acute episodes resolve within 6 weeks.

25% or more of patients with back pain have recurrence within the next year.

For acute pain treatment is generally nonsteroidal anti-inflammatory agent, skeletal muscle relaxants and opioid analgesics.

Evidence of long-term opioid efficacy is lacking for acute or chronic low back pain.

Opioids do not provide meaningful pain relief in people with chronic low back pain.

In a controlled study adding to a nonsteroidal anti-inflammatory drug, a skeletal muscle relaxant or an opioid analgesic did not improve functional outcomes or pain of acute non traumatic non radicular, back pain at one week follow-up (Friedman BW et al).

Chronic low back pain develops in 7% of patients with acute back pain (Speed C).

Individuals who do not recover from acute back pain within three months are at increase risk of developing chronic axial low back pain.

Patients with chronic back pain often are refractory to treatment and account for the majority of costs associated with low back pain.

Preventing transition from acute to chronic low back pain processes is a goal in the evaluation and management strategy of LBP.

Upwards of 30% of patients with low back pain will experience persistent or frequent recurrence (Henschke N, et al).

Cancer, infection and inflammatory disorders account for 1% of cases of low back pain.

Compression fractures, spinal stenosis, and disc herniation account for 10-15% of low back pain.

85% of cases back pain is idiopathic or nonspecific and most often associated with chronic or recurrent symptoms.

Neuropathic pain is associated with greater levels of physical and psychological dysfunction compared with other types of pain.

The incidence of new onset radicular pain ranges from 1/12-18.5 percent, and the incident of lumbar spinal stenosis is estimated to be 5 per100,000 people.

In most cases the cause is unknown.

Principal goal is to continue normal daily activities.

Bed rest does not relieve pain better than maintaining activity and leads to a decrease in function.

Skeletal muscle relaxants are helpful in treatment of acute nonspecific back pain.

Skeletal muscle relaxants have a risk of drowsiness, dependency and are not recommended for prolonged use and should not be used in the elderly or in patients with hepatic impairment.

Acute episodes less than 3 months in duration account for 90% of events and are usually benign and require no specific treatment.

In axial low back pain approximately 28% do not fully recover by 12 months.

Persistence of back pain associated with older age, greater degree of pain and dysfunction, depression, fear of pain persistence, and ongoing compensation claims.

Chronic back pain accounts for no more than 10% of cases with costs of 100-200 billion dollars a year in the U.S.

Some patients do not recover from acute back pain and will develop chronic low back pain that lasts for three months or longer.

Recurrences are common with subsequent low back pain episodes ranging from 20 to 44% within one year and lifetime recurrences of up to 85% (Van Tulder).

Second most common cause of disability in adults and the most common reason for lost work days.

The longer a patient is off work the greater the risk of chronic pain and the lower the chance of ever returning to work.

Spinal manipulative therapy is not superior to standard treatments.

Back pain is a complex bio psycho social process. 

Degenerative findings on spinal imaging testing correlates poorly with the presence or severity of low back pain or the likelihood of developing chronic and disabling symptoms.

The factors that predict for the development of chronic pain primarily psychosocial.

Patients that manifest concerns that back pain signifies the onset of progressive or permanent damage may lead patients to avoid normal activities that will further damage their back.

Maladaptive coping strategies are important predictors of chronic back pain.

Advanced radiologic imaging does not improve outcomes.

routine imaging is not recommended in patients with nonspecific low back pain.

While CT and x-rays are usually performed, MRI is the imaging of choice in the evaluation of soft tissue, spinal, and nerve root compression.

Electro diagnostic testing with nerve conduction studies in electromyography can be used to distinguish between central peripheral causes of nerve pain.

Indiscriminate use of MRI accounts for some of the increasing rate of spinal surgery.

MRI is recommended in the presence of serious or progressive neurologic deficits, when a serious underlying condition is suspected, or when surgery or epidural steroid injections are considered.

The American College of Occupational and Environmental Medicine recommend MRI only in the presence of focal neurologic symptoms that persist for at least six weeks and are not improving (Glass LS et al).

The initial treatment of chronic low back pain of duration of greater than 12 weeks includes conservative measures with oral analgesics such as nonsteroidal anti-inflammatory drugs, gabapentin, and muscle relaxers.
Physical therapy may be helpful.

For sacroiliac joint pain in hip pain, conservative treatment with NSAIDs and physical therapy should be attempted prior to more invasive options.

Acetaminophen has not been shown to be affective in large current clinical trials.

The use of muscle relaxants has questionable benefits in non-specific back pain.

There  is a lack of data for benefit, and the associated risks of addiction with the use of opioids, suggest they should be avoided.

Weak opioids, such as tramadol may be considered.

Injection therapy for low back pain consists of many interventions and differences in the target tissue of the injection.

Injection therapy includes corticosteroids, local anesthetics, nonsteroidal anti-inflammatory drugs, morphine, sodium hyaluonate, benzodiazepines, and vitamin B12.

Target tissues injected include facet joints, epidural space, intravertebral discs, ligaments, muscles, or trigger points.

Radiofrequency denervation techniques can provide pain relief in patients with radicular pain.

Transforaminal epidural steroid injections may provide short-term pain relief.

Neurostimulation may provide longer duration of benefits for refractory patients.

Pain related indications for surgery include spinal decompression for radicular symptoms as well as spinal fusion or disk prosthesis for discogenic low back pain.

Education and exercise programs after LBP is effective in preventing recurrent low back pain by approximately 25-40%.

Landmark-guided sacroiliac joint injections does not result in deposition of medication inside the joint capsule in most people, yet they provide immediate pain relief comparable with that of intraarticular injections.

For sustained relief fluoroscopically guided injections provide better relief for some outcomes at three months, compared with Landmark-guide injections, although the differences are shy of statistical(Cohen S).

In the above study no significant differences in the rate of positive diagnostic injections and one month outcomes between fluoroscopically and Landmark-guided injections.

Comparable benefits on most measures, and reduction in financial costs, waiting times and radiation exposure seem to warrant landmark-guided injections.

In a study of patients with low back pain, usual care was just as effective in reducing disability and sickleave as a complex three month occupational intervention which included occupational medicine physician consultation, workplace plan to overcome ergonomic obstacles, and guidance by physical therapist on an individual exercise: at six months there was no significant difference between the groups, with more than 70% of participants in each group with fewer than seven days of sick leave due to low back pain and similar improvements in pain, disability and physical health, related quality of life and physical activities.

Factors associated with poor outcome of ongoing pain, disability in patients with low back pain includes: the presence of widespread pain, poor physical functioning, somatization, high pain intensity, long pain duration, high levels of depression, high levels of anxiety, previous episodes of low back pain, poor coping strategies, low socioeconomic status, and negative illness perceptions.

Most studies indicate that exercise has beneficial effects in alleviating nonspecific chronic low back pain and improving function as compared to minimal treatment.

Exercisers focused on isometric contractions of the core muscles, attention to body movement, improved posture, repeated movement directional exercises, postural training can reduce pain and improve function.

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