From ATLANTA Medicine, Vol. 86, No. 1
It’s safe to say that most people will experience low back pain at least once during their lifetime. In fact, the 2010 Global Burden of Disease Study found that low back caused more disability worldwide than any other of the 291 conditions studied with a point prevalence of nearly 10 percent.1 Similarly, low back pain is ubiquitous in American society, with greater than 70 percent of the population experiencing it at some point in their lives. Annual incidence is estimated to be between 15 percent to 45 percentwith a point prevalence of between 20 percent to 30 percent and has been reported to be the third most common condition for a patient to seek treatment after skin and joint problems.2, 3
Low back pain is the most common reason for disability in the United States for patients under 45 years old and accounts for $20 billion in workers compensation claims annually. For most, back pain will resolve quickly in a matter of days to weeks, however recurrence is the norm in 20 to 72 percent of patients. Unfortunately, between 5 and 10 percent of patients may have a more chronic form, defined as lasting more than 12 weeks. Despite accounting for only a small percentage of those who experience low back pain, patients with chronic low back pain can be especially difficult to treat and account for 75 percent of healthcare expenditures for this condition.4
Several known etiologies for low back pain exist: tumor or infection within the boney or spinal canal, trauma, strain, spinal stenosis and lumbar disc herniation. Asoften as 85 percent of the time, however, the cause is idiopathic.
Non-specific low back pain is a term that has been coined to describe this type of back pain, as no specific cause can be found clinically. The pain is usually worse with activity and better with rest. Onset may be acute or insidious. Many patients recall no preceding event or may give a vague history of trauma to explain their symptoms. Because the underlying pathology of nonspecific low back pain is poorly understood and the patient’s desire to know “what is wrong,†is high, a clinician may attribute a patient’s low back pain to degenerative changes of the intervertebral disc and joints of the spine noted on X-ray or MRI. These same changes however, are commonly found on the radiographic imaging of age-matched patients who have deny any history of low back pain.5, 6
Upon presentation patients should be screened for “red flagâ€signs during the history and physical such as fevers, chills, night sweats, pain that does not improve with rest or unexplained weight loss, as these constitutional symptoms may be harbingers of more serious pathology such as tumor or infection. Also, patients must be queried for acute urinary retention or loss of bowel control along with saddle anesthesia. These symptoms along with severe low back pain with or without lower extremity pain describe cauda equina syndrome –a surgical emergency.
Treatments for nonspecific low back pain vary. While none have shown definitive superiority, several have been shown to help alleviate symptoms and facilitate return of function. The ideal treatment should be cost effective and accessible while minimizing side effects. Because the natural history of an episode of low back pain for most patients is resolution even without any treatment, the purpose of treatment is mitigation of symptoms during convalescence.
Non-steroidal anti-inflammatories (NSAIDs), acetaminophen, brief periods of rest, physical therapy, manual manipulation, ice and/or heat, as well as education and reassurance are common remedies for those suffering from acute low back pain. These treatments have little risk for most patients, the majority of whom will recover from this self-limiting condition within a few weeks to months.
Chronic low back pain has similar treatment options; however opioid narcotics use is controversial due to concern for addiction. Moreover, narcotics have not been shown to be superior to NSAIDs for symptom relief7, nor have antidepressants been shown to impart any difference in pain relief or functional improvement compared to placebo.7
If the presumed pain generator is a degenerative disc in the absence of scoliosis, spondylolisthesis or kyphosis,  spinal fusion for chronic low back pain is an option, but it is controversial. One randomized, controlled study compared relief of low back pain between a cohort that underwent spinal fusion and another that underwent physical therapy. Sixty-three percent of spinal fusion patients reported their pain as “betterâ€or “much betterâ€versus 29 percent in the non-operative cohort, while 36 percent of the surgical group returned to work opposed to 13 percent of non-operative patients.8
Other studies have shown more equivocal results demonstrating no superiority of lumbar fusion over a structured physical therapy program combined with cognitive behavioral therapy.9, 10 In countries or regions where such treatments are not available, lumbar fusion may be a reasonable option for patients who have one or two level disc degeneration and have exhausted non-operative treatments.11
Low back pain, and more specifically chronic low back pain, continues to be a significant cause of disability in the United States and indeed the world. While acute low back pain tends to be self-limiting even without treatment, few good treatment options exist for chronic low back pain sufferers, despite a substantial amount of healthcare dollars being directed towards relief of symptoms.
Future directions will focus on identifying genetic and environmental links to patients who may be at risk for chronic low back pain. Treatments will have to be proven to be effective with an eye on budgetary considerations in the face of an aging population.
References
1) Hoy D, March L, Brooks P The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014 Jun;73(6):968-74.
2) Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from US national surveys, 2002. Spine 2006;31: 2724–7.
3) St Sauver JL, Warner DO, Yawn BP. Why patients visit their doctors: assessing the most prevalent conditions in a defined American population. Mayo Clin Proc. 2013 Jan;88(1):56-67.
4) Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006;88:21–4.
5) Boden SD, Davis DO, Dina TS. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.
6) Jensen MC, Brant-Zawadzki MN, Obuchowski N. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73.
7) White AP, Arnold PM, Norvell DC. Pharmacologic management of chronic low back pain: synthesis of the evidence. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S131-43.
8) Fritzell P, Hägg O, Wessberg P, Nordwall A, Swedish Lumbar Spine Study Group: 2001 Volvo Award Winner in Clinical Studies. Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976) 26:2521–2532, 2001.
9) Brox JI, Sørensen R, Friis A, NygaardØ, Indahl A, Keller A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine (Phila Pa 1976) 28:1913–1921, 2003.
10) Fairbank J, Frost H, Wilson-MacDonald J, et al: Randomised controlled trial to compare surgical stabilization of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 330:1233, 2005
11)Â Eck JC, Sharan A, Ghogawala Z. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine. 2014 Jul;21(1):42-7.
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