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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.

TAKE-HOME MESSAGES FOR RIGHT CARE

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.

Clinical Commentary

The estimated lifetime prevalence of low back pain is as high as 60% to 80%, making it one of the most common reasons patients visit a primary care physician.1 Fortunately, only 10% of patients with acute low back pain develop chronic pain lasting longer than three months.2 Chronic low back pain is associated with significant financial, social, physical, and psychological impacts. Back pain is one of the leading causes of disability worldwide and one of the top reasons for absence from work.1,2 After diabetes mellitus and cardiovascular disease, back pain is the third most expensive chronic condition to treat, with an estimated annual cost of $87.6 billion in the United States.3 

Low back pain is most commonly caused by muscle sprains and strains, which are associated with more than 70% of all back pain diagnoses. Lumbar spondylosis is the next most common etiology, causing approximately 10% of cases, especially in older patients. Disk herniations can occur at any age and cause back pain in 5% to 10% of patients. Vertebral compression fractures and spondylolisthesis are associated with less than 5% of low back pain cases. Spinal stenosis is associated with 3% of cases but is one of the most common diagnoses leading to surgery.4 

A history and physical examination should guide diagnostic studies with attention to findings such as a history of malignancy, fever, infection, trauma, bladder or bowel incontinence, or abnormal neurologic symptoms or physical examination findings.2,5,6 Unnecessary testing and overdiagnosis are associated with increased morbidity and subsequent disability.2,5,6 Imaging studies should be avoided for at least six weeks following the onset of symptoms unless red flags are present.7 Early magnetic resonance imaging has been shown to increase unnecessary surgeries, recovery time, and medical expenses with no significant improvements in function, pain, or other clinical outcomes.8 

In contrast, a multidisciplinary and multimodality approach, including pharmacologic and nonpharmacologic therapies, produces the best outcomes.2,5,6 A comprehensive approach to care may include pharmacologic management with nonsteroidal anti-inflammatory drugs, muscle relaxants, anticonvulsants, and judicious use of opioids when indicated.2,5,6,9 Nonpharmacologic approaches include physical therapy, osteopathic manipulation, acupuncture, behavior modification, mindfulness-based stress reduction techniques, weight loss, yoga, and exercise therapy.1012 

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