Low back pain: what we know

Here is a lay summary of a review article about non-specific low back pain published in the Lancet magazine in 2012. I find it shows well how much and how little the medical profession knows about the causes, treatment and prevention of low back pain.

What is non-specific low back pain?

It is low back pain not attributable to a recognisable, known specific pathology (eg, infection, tumour, osteoporosis, fracture, structural deformity, inflammatory disorder).

How frequent it is in population?

At least 80% of population experience acute low back pain at least once in their lifetimes, and over 20% – more than once.

In about 10–15% of patients, acute low back pain develops into chronic low back pain.

What age groups are most affected?

All age groups are affected by low back pain. Children under 14 can also experience it but not as often as teenagers and adults.

What are the causes of non-specific low back pain?

Non-specific low back pain is, by definition, a symptom of unknown cause. Many factors have been identified as possible causes of the pain or factors in its development and subsequent course:

There is a significant association between low back pain and degeneration of the lumbar discs – but the disc degeneration itself does not directly cause the low back pain, as there are many people with disc degeneration but no back pain.

Mechanical factors – occupational sitting, awkward postures, pushing or pulling, bending and twisting, lifting, or carrying have long been thought to cause low back pain. However, eight systematic reviews of research literature concluded that these factors are unlikely to independently cause low back pain.

Being overweight or obese bears an increased risk of low back pain, especially of the kind of low back pain that requires medical care and that becomes chronic.

Genetic factors are likely to play a role: studies of twins show that both low back pain and disc degeneration have a genetic background. It is estimated in such studies that from 30% to 46% of various types of back pain problems are inherited.

Finally, the strongest indicator for future low back pain being previous low back pain: once you experience it, it is likely to return, unless you take preventive measures.

How to prevent the recurrence?

Findings from systematic reviews of trials into the prevention of low back pain show that only exercise interventions consistently seem to be effective.

How the low back pain is to be managed: current clinical guidance

Recommendations for acute low back pain:

  • stay active
  • paracetamol
  • non-steroidal anti-inflammatory drugs
  • spinal manipulation therapy
  • muscle relaxants (as second line drugs only, because of side-effects)
  • weak opioids (in selected cases)
  • topical pharmacological treatments and superficial heat application for pain relief

Recommendations for chronic low back pain:

  • stay active
  • non-steroidal anti-inflammatory drugs
  • weak opioids (short-term use)
  • exercise therapy
  • spinal manipulation

How effective is back surgery?

The place for surgery in chronic non-specific low back pain (if any) is very limited and its overuse has been criticised. Results from trials that compare intensive rehabilitation with spinal fusion surgery have shown similar effects for both, but more complications (and higher costs) for back surgery.

On the use of imaging (ie X-Rays and scans)

Imaging is often overutilized (by doctors and chiropractors) compared with the recommendations of guidelines. Many abnormalities seen on imaging are equally prevalent in the healthy individuals without low back pain.

Some imaging can be harmful because of radiation exposure (radiography and CT).

Most guidelines advise that all imaging studies should be reserved for patients with progressive neurological deficit – ie problems with nerves or spinal cord, or when serious underlying causes are suspected.

 

Reference

Balagué F, Mannion AF, Pellisé F, Cedraschi F   Non-specific low back pain. Lancet 2012; 379: 482–91