title: Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists.
abstract: Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis. The accuracy of historical and physical examination findings has been established for sacroiliac joint pain, radiculopathy, and lumbar spinal stenosis. However, the accuracy of similar data, so-called red flags, for identifying the underlying medical sources of LBP has been overstated. Diagnostic imaging studies can be useful, and adherence to established guidelines can protect against overuse. Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related indications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence.
authors.affiliation: Mayo Clinic College of Medicine and Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN. Electronic address: hooten.william@mayo.edu.
authors.forename: W Michael
authors.initials: WM
authors.lastname: Hooten
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD; Department of Anesthesiology, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD.
authors.forename: Steven P
authors.initials: SP
authors.lastname: Cohen
mesh_terms: D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis* / Q000628:therapy*; D011320:Primary Health Care