Evaluation of back pain

Back pain is extremely common, and low back pain (LBP) in particular causes more disability globally than any other condition.​[1]Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 9;391(10137):2356-67. http://www.ncbi.nlm.nih.gov/pubmed/29573870?tool=bestpractice.com [2]GBD 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023 Jun;5(6):e316-29. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(23)00098-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/37273833?tool=bestpractice.com ​The global age-standardized rate of prevalence of low back pain in 2020 was 7460 per 100,000.[2]GBD 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023 Jun;5(6):e316-29. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(23)00098-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/37273833?tool=bestpractice.com ​​[3]Balagué F, Mannion AF, Pellisé F, et al. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91. http://www.ncbi.nlm.nih.gov/pubmed/21982256?tool=bestpractice.com ​​ LBP accounts for over 4% of emergency department visits, making it one of the ten most common presenting complaints.[4]Edwards J, Hayden J, Asbridge M, et al. Prevalence of low back pain in emergency settings: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2017 Apr 4;18(1):143. https://www.doi.org/10.1186/s12891-017-1511-7 http://www.ncbi.nlm.nih.gov/pubmed/28376873?tool=bestpractice.com

The primary purpose of the initial encounter is to evaluate whether the symptoms suggest a more serious underlying condition.[5]Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018 Nov;27(11):2791-2803. https://www.doi.org/10.1007/s00586-018-5673-2 http://www.ncbi.nlm.nih.gov/pubmed/29971708?tool=bestpractice.com History and exam provides useful information on the pattern of pain (e.g., radicular vs. lumbosacral pain) but rarely identifies a precise anatomical site.[1]Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 9;391(10137):2356-67. http://www.ncbi.nlm.nih.gov/pubmed/29573870?tool=bestpractice.com ​ Etiologies may be subdivided into mechanical, systemic or referred, with mechanical being far the most common.[6]Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001 Feb 1;344(5):363-70. http://www.ncbi.nlm.nih.gov/pubmed/11172169?tool=bestpractice.com ​ Most patients with low back pain, with or without sciatica, do not routinely require imaging when presenting in a nonspecialist setting.[7]National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. Dec 2020 [internet publication]. https://www.nice.org.uk/guidance/ng59

A subset of patients develop chronic LBP, defined as symptoms persistent for >12 weeks.[8]Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. https://www.doi.org/10.7326/M16-2367 http://www.ncbi.nlm.nih.gov/pubmed/28192789?tool=bestpractice.com Factors found to increase the risk include maladaptive pain coping behaviors, nonorganic signs, functional impairment, poor general health status, sleep disturbance, and psychiatric comorbidities.[9]Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010 Apr 7;303(13):1295-302. http://www.ncbi.nlm.nih.gov/pubmed/20371789?tool=bestpractice.com [10]Beynon AM, Hebert JJ, Hodgetts CJ, et al. Chronic physical illnesses, mental health disorders, and psychological features as potential risk factors for back pain from childhood to young adulthood: a systematic review with meta-analysis. Eur Spine J. 2020 Mar;29(3):480-96. http://www.ncbi.nlm.nih.gov/pubmed/31907659?tool=bestpractice.com [11]Felício DC, Filho JE, de Oliveira TMD, et al. Risk factors for non-specific low back pain in older people: a systematic review with meta-analysis. Arch Orthop Trauma Surg. 2022 Dec;142(12):3633-42. http://www.ncbi.nlm.nih.gov/pubmed/34021388?tool=bestpractice.com [12]Amiri S, Behnezhad S. Sleep disturbances and back pain: systematic review and meta-analysis. Neuropsychiatr. 2020 Jun;34(2):74-84. http://www.ncbi.nlm.nih.gov/pubmed/32166629?tool=bestpractice.com ​ The clinician should be aware of these risk factors when counseling and treating patients.