Years ago, at a spine conference, I came across one of the authors of several landmark
studies on the causes of low back pain (LBP) published in the mid-90s. During the
coffee break, I casually asked the author's opinion on how often we could identify
a pain generator in LBP with certainty. The answer was, “in about half of the cases.”
We face this challenge every time we encounter a patient with LBP. Our patients often
ask us the same question, “Doc, what is causing my back pain?”
Keywords
Abbreviations:
LBP (Low back pain), NSLBP (Nonspecific low back pain), SIJ (Sacroiliac joint), IDD (Internal disc disruption), RFA (Radiofrequency ablation), APS (American Pain Society), NICE (National Institute for Health and Care Excellence), CLBP (Chronic low back pain)To read this article in full you will need to make a payment
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References
- Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.Arthritis Rheum. 2009; 60: 3072-3080
- Aetiology of low back pain in Mulago hospital.Uganda. Afr Health Sci. 2005; 5: 164-167
- What can the history and physical examination tell us about low back pain?.JAMA. 1992; 268: 760-765
- Prevalence and “red flags” regarding specific causes of back pain in older adults presenting in general practice.Phys Ther. 2016; 96: 305-312
- The results of lumbo-sacral fusion for low back pain.J Bone Joint Surg Br. 1956; 38-B: 485-497
- Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians.Spine. 1987; 12: S1-S59
- Medical management of acute & chronic LBP. An evidence based approach. Pain research and clinical management.in: Chapter 14. Elsevier, Amsterdam2002: 115
- The prevalence and clinical features of internal disc disruption in patients with chronic low back pain.Spine. 1995; 20: 1878-1883
- Evaluation of the relative contributions of various structures in chronic low back pain.Pain Physician. 2001; 4: 308-316
- What is the source of chronic low back pain and does age play a role?.Pain Med. 2011; 12: 224-233
- Clinical features of patients with pain stemming from the lumbar zygapophysial joints: is the lumbar facet syndrome a clinical entity?.Spine. 1994; 19: 1132-1137
- Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain.Ann Rheum Dis. 1995; 54: 100-106
- The sacroiliac joint in chronic low back pain.Spine. 1995; 20: 31-37
- Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain.Spine. 1996; 21: 1889-1892
- Non-specific low back pain.Lancet. 2017; 389: 736-747
- Diagnosis and treatment of low back pain.BMJ. 2006; 332: 1430-1434
- Low back pain.N ENgl J Med. 2001; 344: 363-370
- Lancet low back pain series working group.Lancet. 2018; 391: 2356-2367
- Spinal radiographic findings and NSLBP. A systemic review of observational studies.Spine. 1997; 22: 427-434
- Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis.Eur Spine J: Off Publ Eur Spine Soc, Eur Spinal Deformity Soc, Eur Section Cervical Spine Res Soc. 2015; 24: 1289-1295
- Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population.Spine. 2009; 34: 199-205
- The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation.Spine. 2003; 28 (discussion 1035): 1027-1035
- Association of early imaging for back pain with clinical outcomes in older adults.JAMA. 2015; 313: 1143-1153
- Imaging strategies for low-back pain: systematic review and meta-analysis.Lancet. 2009; 373: 463-472
- Clinical practice guidelines for the noninvasive management of low back pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.Eur J Pain. 2016; 21: 201-216
- Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.JBJS. 1990; 72: 403-408
- Magnetic resonance imaging of the lumbar spine in people without back pain.N Engl J Med. 1994; 331: 69-73
- Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.Am J Neuroradiol. 2015; 36: 811-816
- MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: a systematic review and meta-analysis.Am J Neuroradiol. 2015; 36: 2394-2399
- Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.Pain. 2000; 85: 317-332
- Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial.JAMA. 2003; 289: 2810-2818
- The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain.Spine (Phila Pa 1976). 2014; 39: 1433-1440
- Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain.Eur Spine J. 2007; 16: 1539-1550
- Is lumbar discography a determinate of discogenic low back pain: provocative discography reconsidered.Curr Rev Pain. 2000; 4: 301-308
- False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection.Spine. 1999; 24: 2542-2547
- A gold standard evaluation of the "discogenic pain" diagnosis as determined by provocative discography.Spine. 2006; 31: 2115-2123
- Operative and nonoperative treatment approaches for lumbar degenerative disc disease have similar long-term clinical outcomes among patients with positive discography.World Neurosurg. 2014; 82: 872-878
- Outcome of unoperated discogram-positive low back pain.Spine. 1995; 20: 1997-2000
- 2009 ISSLS prize winner: does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study.Spine. 2009; 34: 2338-2345
- Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study.Spine J. 2016; 16: 273-280
- Systematic review of patient history and physical examination to diagnose chronic low back pain originating from the facet joints.Eur J Pain. 2017; 21: 403-414
- Facet joint osteoarthritis and low back pain in the community-based population.Spine. 2008; 33: 2560-2565
- Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain.Spine. 2000; 25: 1270-1277
Maas ET, Ostelo RWJG, Niemisto L, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database of Syst Rev 2015 (10): Art. No.: CD008572.
- Alteration of lumbar muscle morphology and composition in relation to low back pain: a systematic review and meta-analysis.Spine J. 2022; 22: 660-676
- Clinical spinal instability and low back pain.J Electromyography Kinesiol. 2003; 13: 371-379
- A commentary on appropriate use criteria for sacroiliac pain.Pain Medicine. 2017; 18: 2055-2057
- Diagnosis and treatment of posterior sacroiliac complex pain: a systematic review with comprehensive analysis of the published data.Pain Medicine. 2015; 16: 257-265
Anatomy Gray's. The anatomic basis of clinical practice. 40th edition, Churchill Livingstone; 2008. p. 1366.
- Validity of criteria for sacroiliac joint pain: a systematic review.J Pain. 2009; 10: 354-368
- The value of medical history and physical examination in diagnosing sacroiliac joint pain.Spine. 1996; 21: 2594-2602
- The therapeutic efficacy of sacroiliac joint blocks with triamcinolone acetonide in the treatment of sacroiliac joint dysfunction without spondyloarthropathy.Spine. 2009; 34: 896-900
- Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests.Man Ther. 2005; 10: 207-218
- Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the mint randomized clinical trials.JAMA. 2017; 318: 68-81
- The strategy that will fix health care.Harvard Business Rev. 2013; 91: 50-70
- A systematic review of low back pain cost of illness studies in the United States and internationally.Spine J. 2008; 8: 8-20
- Burden of sickness absence due to chronic disease in the dutch workforce from 2007 to 2011.J Occup Rehabil. 2015; 25: 675-684
- US Spending on personal health care and public health, 1996–2013.JAMA. 2016; 316: 2627-2646
- Expenditures and health status among adults with back and neck problems.JAMA. 2008; 299: 656-664
- Is the spine field a mine field?.Spine. 2009; 34: 423-430
- Overtreating chronic back pain: time to back off?.J Am Board Fam Med. 2009; 22: 62-68
- The Effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections: a systematic review with comprehensive analysis of the published data.Pain Med. 2017; 18: 239-251
- Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. North American Spine Society (NASS), Burr Ridge, IL, USA2020
- VA/DoD clinical practice guideline: diagnosis and treatment of low back pain.J Gen Intern Med. 2019; 34: 2620-2629
- Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline.Spine. 2009; 34: 1078-1093
- Injection therapy and denervation procedures for chronic low-back pain: a systematic review.Eur Spine J. 2010; 19: 1425-1449
- Dutch multidisciplinary guideline for invasive treatment of pain syndromes of the lumbosacral spine.Pain Pract. 2016; 16: 90-110
- Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Guideline Centre (UK) London: National Institute for Health and Care Excellence (NICE), London, UK2016
- An international comparison of back surgery rates.Spine. 1994; : 1201-1206
- The case for restraint in spinal surgery: does quality management have a role to play?.Eur Spine J. 2009; 18: 331-337
- Trends in Operating room procedures in U.S. hospitals, 2001—2011. Agency for Healthcare Research and Quality, Rockville, MD, US2014
- Surgery for low back pain. A review of the evidence for an American Pain Society Clinical Practice Guideline.Spine. 2009; 34: 1094-1109
- Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials.J Spinal Disord Tech. 2014; 27: 297-304
- Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.Ann Intern Med. 2007; 147: 478-491
- Will this patient develop peristant disabling low back pain?.JAMA. 2010; 303: 1295-1302
- Understanding nociplastic pain: building a bridge between clinical psychology and medicine.J Pers Med. 2023; 13: 310
- Emotional awareness, and other emotional processes: implications for the assessment and treatment of chronic pain.Pain Manag. 2021; 11: 325-332
- The rising prevalence of chronic low back pain.Arch Intern Med. 2009; 169: 251-258https://doi.org/10.1001/archinternmed.2008.543
- Chronic non-specific low back pain – subgroups or a single mechanism?.BMJ Musculoskelet Disord. 2008; 9: 11
- Prevention and treatment of low back pain: evidence, challenges, and promising directions.Lancet. 2018; 391: 2368-2383
- Instability of the lumbar spine.Clin Orthop Relat Res. 1982; : 110-123
Article info
Publication history
Published online: April 26, 2023
Accepted:
April 18,
2023
Received:
April 17,
2023
Publication stage
In Press Journal Pre-ProofFootnotes
FDA device/drug status: Not applicable.
Author disclosures: MF: Nothing to disclose.
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
