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Am Fam Physician. 2022;105(6):667-670

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Case Scenario

A 48-year-old former construction worker presents for a comprehensive evaluation. The examination does not reveal a history of cancer, trauma, or fever, and the neurologic examination findings are normal. Five years earlier, the patient began having low back pain when lifting heavy materials, and his physician prescribed nonsteroidal anti-inflammatory drugs, a muscle relaxant, and physical therapy. However, the patient was unable to return to work. When his symptoms did not improve, he underwent spinal radiography and magnetic resonance imaging, which showed a small herniated lumbar disk. The patient was referred to a pain management specialist and had three epidural injections that did not improve his symptoms. He was then referred to a spine surgeon and underwent a lumbar laminectomy that did not result in significant improvement. The patient is still unemployed and would like to discuss further therapy with you. His surgeon recommends spinal fusion, but the patient has concerns after reading about the procedure and its risks.


A methodical and comprehensive approach to the evaluation of back pain reduces inappropriate early imaging (< 6 weeks since pain onset).

A conservative and integrative approach to treatment that avoids most interventional procedures is often appropriate.

Interventional procedures and back surgery have limited effectiveness for back pain and should be avoided, except when there is a concern for loss of neurologic function

Patients with failed back surgery syndrome should undergo spinal fusion procedures only when there are no other options to preserve neurologic function.

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Lown Institute Right Care Alliance is a grassroots coalition of clinicians, patients, and community members organizing to make health care institutions accountable to communities and to put patients, not profits, at the heart of health care.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Lown Right Care published in AFP is available at

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