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]Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020 Mar;8(6):299. https://www.doi.org/10.21037/atm.2020.02.175 http://www.ncbi.nlm.nih.gov/pubmed/32355743?tool=bestpractice.com [2]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 ​ The point prevalence is 7.5% and the lifetime prevalence exceeds 80%.[1]Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020 Mar;8(6):299. https://www.doi.org/10.21037/atm.2020.02.175 http://www.ncbi.nlm.nih.gov/pubmed/32355743?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.[2]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.