Low back pain

Abstract

Low back problems are extremely common. In the United States, it is estimated that 15% to 20% of the population, and approximately half of working-age adults, admit to back pain each year. Low back pain (LBP) is a symptom and not a specific disease, and there are a large number of potential causes. The vast majority of patients with LBP have a musculoskeletal cause. Ninety percent of patients with acute low back problems recover within a month with very conservative treatment. Because of the multiple possible causes in the musculoskeletal category, and because of the self-limited nature of most patients' pain, only about 15% of patients can be given a specific diagnosis to explain their LBP. Although 90% of patients with LBP have self-limited disease, recurrent attacks of pain are common, and approximately 10% of patients develop chronic LBP. In general, LBP is over-evaluated and over-treated, which results in wasted money and medical resources, and often yields inferior clinical outcomes. The physician's job, when evaluating a patient with acute LBP, is to look for "red flags"--symptoms and signs that should prompt additional evaluation and treatment. Without "red flag" conditions, LBP should be treated with "comfort control" measures only. These measures include activity modification and the use of simple analgesics. Manipulation therapy may be helpful in the short term (within the first month of onset), although other physical therapies are more helpful beyond 1 month from onset. Surgical intervention on the spine for patients without tumors, infection, and fracture should be reserved for patients with progressive or unrelenting compression of one or more lumbosacral nerve roots by a herniated intervertebral disk. Neurologists should be involved in the evaluation and treatment of patients with LBP, because many of the worrisome underlying conditions affect the nerve roots, and most of the surgical interventions are based on documentation of the presence of nerve root impingement. Neurologists can determine if these indications are present, and do not have a vested interest in recommending costly procedures.