Elsevier

The Lancet

Volume 379, Issue 9814, 4–10 February 2012, Pages 482-491
The Lancet

Seminar
Non-specific low back pain

https://doi.org/10.1016/S0140-6736(11)60610-7Get rights and content

Summary

Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 23%, with 11–12% of the population being disabled by low back pain. Mechanical factors, such as lifting and carrying, probably do not have a major pathogenic role, but genetic constitution is important. History taking and clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted. The mechanism of action of many treatments is unclear, and effect sizes of most treatments are low. Both patient preferences and clinical evidence should be taken into account for pain management, but generally self-management, with appropriate support, is recommended and surgery and overtreatment should be avoided.

Section snippets

Epidemiology and natural history

Non-specific low back pain is defined as low back pain not attributable to a recognisable, known specific pathology (eg, infection, tumour, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome). Low back pain became one of the biggest problems for public health systems in the western world during the second half of the 20th century, and now seems to be extending worldwide.1, 2 Data from the USA show that the proportion of physician

Pathogenesis and risk factors for non-specific low back pain

Nociceptive factors have a major role in acute pain conditions. Various structures in the spine could constitute the origin of pain in accordance with their innervation, but the clinical interpretation of abnormalities is not possible on the basis of anatomical data alone.27 In chronic pain, psychosocial dimensions become relevant, and are important to explain how people respond to back pain.28

Non-specific low back pain is, by definition, a symptom of unknown cause (ie, a symptom for which we

Prevention

Generalised primary prevention does not seem to be a realistic aim in low back pain because the symptom is highly prevalent, with the strongest risk factor for future low back pain being previous low back pain64 and with a high proportion of teenagers having already had low back pain.12 Furthermore, most prospective studies have not been able to identify many strong and modifiable risk factors for true first time low back pain.65 This situation is not surprising, since the cause of the problem

Minimisation of the effect of low back pain

Evidence-based guidelines are an important device for attempting to minimise the consequences of low back pain. However, despite the progress made in the past two decades in developing and updating guidelines, and adapting them on a national basis, uptake by health-care providers is not optimum.69 Reasons often include organisational, physician and patient factors, the process of implementation, and guideline quality and quantity. Concern for the individual patient's needs coupled with

Assessment

Recommendations for the clinical assessment and management of low back pain have not changed notably in the past decade.81 Diagnostic triage is used to distinguish those patients with non-spinal or serious spinal disorders from those with pain of musculoskeletal origin, by means of history and examination, with particular emphasis on so-called red flags.82 The red flags consistently reported in the published work include weight loss, previous history of cancer, night pain, age more than 50

Management

For acute low back pain, most clinical practice guidelines agree on the use of reassurance, recommendations to stay active, brief education, paracetamol, non-steroidal anti-inflammatory drugs, spinal manipulation therapy, muscle relaxants (as second line drugs only, because of side-effects), and weak opioids (in selected cases).84, 98 Some reviews recommend topical pharmacological treatments and superficial heat application for pain relief.99 Systemic corticosteroids are not recommended for

Outcome assessment and effect sizes

The assessment of treatment outcome is very important for both research and daily clinical practice. Patient-centred outcomes are acknowledged to be more relevant than objective clinical measures (eg, range of motion, strength). Throughout the past decade, the spine-research community has generally accepted the suggestions made by a group of low back pain experts who identified six main domains relevant to the assessment of patients with low back pain: pain symptoms, function, wellbeing, work

Conclusion

Our knowledge about low back pain has greatly increased in the past few decades and the trend continues with, for example, the development of studies oriented towards genetics and molecular events. Some of the newest lines of scientific and clinical investigation that are being undertaken in relation to low back pain are shown in panel 2. Unfortunately, these investigations have not yet translated into practical solutions, particularly for people with chronic low back pain. In all probability,

Search strategy and selection criteria

We searched the Cochrane Library and Medline for reports published in English, French, Spanish, or German, with the terms “low back pain”, “backache”, “lumbar pain”, “lumbago”, “non-specific” in successive combination with the terms “epidemiology OR incidence OR prevalence”, “clinical expression OR classification”, “pathogenesis OR pathophysiol*”, “outcomes”, “treatment OR management OR prevention”. The searches covered the years 2007–10. We searched the reference lists of articles identified

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