Clinical Review

Management of low back pain

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a2718 (Published 22 December 2008) Cite this as: BMJ 2008;337:a2718
  1. Steven P Cohen, associate professor and director of medical education1, director of pain research2,
  2. Charles E Argoff, professor and director3,
  3. Eugene J Carragee, professor and vice chairman4, chief5
  1. 1Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205
  2. 2Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307
  3. 3Comprehensive Pain Program, Department of Neurology, Albany Medical College, Albany, NY 12208
  4. 4Department of Orthopedic Surgery, Division of Spine Surgery, Stanford University School of Medicine, Stanford, CA 94305
  5. 5Division of Spine Surgery, Stanford University School of Medicine, Stanford, CA
  1. Correspondence to: Professor S P Cohen, 550 North Broadway, Suite 301, Baltimore, MD 21205 scohen40{at}jhmi.edu

    Summary points

    • Most people will at some time experience an episode of serious low back pain, but most cases resolve with minimal intervention

    • The main value of a history and physical examination is to determine which patients should be referred for imaging and interventions

    • Early magnetic resonance imaging has not been shown to improve outcomes for low back pain

    • The risk factors for progression to chronic back pain are predominantly psychosocial and occupational.

    • Most treatments for chronic low back pain have a small effect and/or afford transient benefits

    Back pain is the leading cause of occupational disability in the world and the most common cause of missed workdays. As the population ages and our lives become more sedentary, this situation is unlikely to change. We aim here to provide an evidence based overview of low back pain aimed at primary care physicians.

    Scope of problem

    The most frequently quoted epidemiological studies cite lifetime adult prevalence rates varying from 50% to 80%, and point prevalence rates from 15% to 30%.1 Yet even these statistics may underestimate the problem. A recent prospective study of 154 reserve soldiers with no prior history of back pain found that 64% of this low risk group developed at least moderate back pain over an 18 month period when queried monthly.w1 This suggests that reported prevalence rates may be a function of the type and frequency of surveillance.

    What features on history and examination can help identify the cause?

    History

    Box 1 lists the causes of low back pain. The origin of pain can be broadly classified as mechanical, neuropathic, or secondary to another cause. Mechanical back pain implies that the source of pain is in the spine or its supporting structures. Neuropathic back pain denotes the presence of symptoms that stem from irritation of a nerve root(s).

    Box 1 Common causes of low back pain*

    Mechanical (80-90%)
    • Unknown cause—usually attributed to muscle strain or ligamentous injury (65%-70%)

    • Degenerative disc or joint …

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