Intended for healthcare professionals

Clinical Review

Low back pain

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1119
  1. Cathy Speed, honorary consultant in rheumatology and sports medicine
  1. Addenbrookes Hospital, Cambridge


    Low back pain affects more than 70% of the population in developed countries and poses a major socioeconomic burden, accounting for 13% of sickness absences in the United Kingdom. The annual incidence in adults is up to 45%, with those aged 35-55 years affected most often. Although 90% of episodes of acute low back pain settle within six weeks, up to 7% of patients develop chronic pain.

    Causes of low back pain

    Low back pain has many causes. It may be due to disease or injury at one or more sites within the spine or it might be a feature of a systemic disease, sepsis, or malignancy. Overall, 1% of people presenting with back pain in primary care have a neoplasm, 4% have compression fractures, and 1-3% have a prolapsed disc. Pain may also be referred to the back or from it.

    Lumbosacral dermatomes

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    Causes of low back pain

    Evaluation of patients

    The first aim of evaluation of patients with back pain is to identify the source of the pain and, in particular, to identify the few patients who have a serious underlying disorder. Assessment then aims to assess the degree of pain and functional limitation, define the contributing factors where possible, evaluate the patient's expectations, and develop an appropriate management strategy.

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    Features of lumbar and nerve root lesions

    A careful history is taken, including the nature of the onset of the complaint; occupational, sporting, and general medical history; the characteristics of the pain; neurological symptoms; morning stiffness; and systemic features.

    Suspicion of an underlying complaint should be particularly high when the patient is aged under 20 years or over 55 at initial onset, when pain is non-mechanical or thoracic, and when systemic symptoms, neurological signs, a structural deformity, or a history of malignancy, steroids, or HIV infection are …

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