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Low back pain remains a leading cause of pain and disability worldwide, and 90% of patients presenting for care have nonspecific low back pain rather than a serious spinal disorder, according to a new clinical review published in JAMA. Nonspecific low back pain is defined as pain below the costal margin and above the inferior gluteal folds that does not have clinical features associated with an underlying condition or referred pain, according to the authors. They analyzed 108 studies and trials and found that serious causes such as vertebral fracture, malignancy, infection, or cauda equina syndrome each account for fewer than 1% of presentations, while lumbar radiculopathy or spinal stenosis accounts for 5%–10%. For cases of nonspecific low back pain, routine imaging is usually not recommended for patients without red flags because degenerative findings are common even in asymptomatic adults and may lead to unnecessary testing. Most patients with acute nonspecific low back pain improve in time, and approximately 72% recover within 12 months. The authors present suggestions for assessment as well as a detailed algorithm for a diagnostic approach, which includes indications for when magnetic resonance imaging or computed tomography might be needed.
Treatment options: Initial management of nonspecific low back pain might emphasize reassurance, maintaining normal activity, and self-management rather than bed rest. For acute pain, the study’s evidence supports heat therapy, spinal manipulation, massage, acupuncture, nonsteroidal anti-inflammatory drugs, and skeletal muscle relaxants when appropriate. Acetaminophen alone and benzodiazepines are not recommended because they have not demonstrated meaningful benefit, according to the authors.