Goal of the review?
In this paper, 1 the authors provide a research-based overview of the epidemiology, causes, and risk factors. They also describe the clinical presentation and diagnostic criteria, and treatment options for low back pain.
Epidemiology and Socioeconomic burden
The economic impact of lower back pain is widely significant, with estimates of £2.8 billion in the UK and $100 billion in the US. Almost two-thirds of the economic costs from lower back pain stem from indirect costs such as loss of productivity. One study done in 195 countries found low back pain the leading cause of productivity loss in 126 countries.
Low back pain can be classified as mechanical, neuropathic or nociplastic. Studies have shown that the prevalence of neuropathic pain ranges from 16% and 55% in patients with chronic lower back pain. One systematic review illustrated the prevalence of low back pain to range from 11.9% – 23.3 %, increasing with age and most common in middle-aged to older women.
There is a multitude of factors and causes of lower back pain. These include disc degeneration, radicular (neuropathic) pain, facet arthropathy, myofascial pain, sacroiliac joint pain, spondyloarthropathies (ankylosing spondylitis and psoriatic arthritis), and nociplastic pain (non-specific low back pain).
Brain change, behavioural and genetic factors
Low back pain can be caused by changes in the brain, such as alterations in blood flow and changes to white and grey matter in the brain. Behavioural factors can also play a role. Studies show the role that emotion and emotional experiences can have on low back pain. For example, negative expectations, depression, and anxiety have been shown to predict poor pain outcomes in patients. Finally, there are also genetic factors that contribute to low back pain. Research has illustrated that heritability contributed to 26% lifetime prevalence of low back pain, 36% for functional limitations and 25% to pain intensity.
Clinical presentation, diagnosis, and screening
Low back and leg pain can be a manifestation of intervertebral disc herniation. Often, this type of pain will resolve itself in a few weeks. However, some patients can have recurring pain for up to two years.
A large percentage of back pain is non-specific and resolves without any formal diagnosis. However, most guidelines recommend that patients have a physical exam and that history is taken. Some patients may require a neurological exam or vascular-focused exams to differentiate different types of claudication. Routine imaging is not required for most lower back pain cases. However, CT scan, MRI, and x-ray can be useful depending on the case.
Different screening tools have been developed that assist in preventing and treating low back pain, identifying patients prone to chronic pain, and distinguishing neuropathic from non-neuropathic pain.
Prevention and Treatment
Research demonstrates that a combination of exercise, education and ergonomic changes are effective as prevention strategies for lower back pain. These behavioural, non-pharmacological approaches are also used as first-line treatment. This can include clarification-oriented and exposure-based interventions that can help patients self-manage their pain and pain behaviours.
For patients whose pain persists, pharmacological and procedural options can be explored. The American College of Physicians Guidelines recommends that treatment begins with non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants, tramadol, or duloxetine as second-line treatment and opioids as the last choice. Due to the addictive potential and negative side effects, opioid treatment is not recommended for most patients.
There are also non-pharmacological interventions for low back pain. Steroid injections in the foramen, between the vertebrae, and in the sacroiliac joints have positive therapeutic effects. Other interventions such as facet joint blocks and radiofrequency are used but have mixed evidence supporting them. Spinal cord stimulation has shown positive outcomes and can be cost-effective, depending on the patient.
When other interventions have not been successful, surgery may be an option for some patients. Research shows that for herniated nucleus pulposus, surgery can provide relief for a period but does not result in long-term benefits. For patients with lumbar spinal stenosis, decompression surgery can provide substantial improvement compared to a traditional approach.
Low back pain is globally prevalent and increasing as lifestyles become more sedentary. Lower back pain is a complex condition with various factors; therefore, diagnosis and treatment can be challenging. Existing research provides important evidence that can be used to develop inter-disciplinary and multimodal approaches to treatment and diagnosis.