Low Back Pain Evaluation and Management

 
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Bill McCarberg
 
Founder
Chronic Pain Management Program
Kaiser Permanente
San Diego, California
 
Adjunct Assistant Clinical Professor
University of California
School of Medicine
San Diego, California
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Discuss the differential diagnosis
for low back pain (LBP) and the
importance of clinical red and yellow
flags in evaluation of LBP
 
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In 2007, the American College of
Physicians (ACP) and American Pain
Society (APS) issued comprehensive
joint clinical practice guidelines for
diagnosis and treatment of LBP
 
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Clinicians should conduct a focused history
and physical examination to help place
patients with LBP into 1 of 3 broad categories
Nonspecific LBP
Back pain potentially associated with radiculopathy
or spinal stenosis
Back pain potentially associated with another
specific spinal cause
The history should include assessment of
psychosocial risk factors, which predict risk
for chronic disabling back pain
Strong recommendation
Moderate-quality evidence
 
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Determine presence and level of
neurological involvement
1,2
Classify patients into 3 broad categories
Nonspecific LBP potentially associated with radiculopathy
Spinal stenosis
Back pain potentially associated with another specific
spinal cause
Patients with serious or progressive neurologic deficits
or underlying conditions requiring prompt evaluation
Tumor
Infection
Cauda equina syndrome
Patients with other conditions that may respond to
specific treatments
Ankylosing spondylitis
Vertebral compression fracture
 
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Site
Length of illness
Spread
Quality
Intensity
Frequency
 
Duration
Time of onset
Mode of onset
Precipitating factors
Aggravating factors
Relieving factors
Associated features
 
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90% of American adults experience an
episode of back pain during their lifetime
Of patients who have acute back pain
90% to 95% have a non–life-threatening condition
Although up to 85% cannot be given an exact diagnosis,
nearly all recover within 4 to 6 weeks
For 5% to 10% of patients, acute back pain
is a manifestation of more serious pathology
Vascular catastrophes, malignancy, spinal
cord compressive syndromes, and infectious
disease processes
 
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In minority of patients presenting for initial evaluation
in primary care setting, LBP is caused by
1
Cancer (approximately 0.7% of cases)
Compression fracture (4%)
Spinal infection (0.01%)
Estimates for prevalence of ankylosing spondylitis
in primary care patients range from 0.3%1 to 5%
2
Spinal stenosis and symptomatic herniated disc are
present in about 3% and 4% of patients, respectively
Cauda equina syndrome most commonly associated
with massive midline disc herniation, but rare
Estimated prevalence of 0.04%
3
 
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LBP is one of top 10 reasons patients seek care from
family physicians
1
Prevalence of LBP has varied from 7.6% to 37%
Peak prevalence between 45 and 60 years of age
2
Also reported by adolescents and by adults of all ages
80% of adults seek care at some time for acute LBP
3
One-third of US disability costs are due to low
back disorders
3
Direct costs of diagnosing and treating LBP in United
States estimated in 1991 to be $25
*
 billion annually
4
Indirect costs, including lost earnings, are even higher
4
Proper diagnosis and appropriate treatment of LBP
saves healthcare resources, relieves suffering
 
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Nonspecific LBP
Back pain potentially associated
with radiculopathy or spinal stenosis
Back pain potentially associated
with another specific spinal cause
 
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Muscles of the back
1,2
Interspinous ligaments
2-4
Zygapophyseal joints
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Sacroiliac joint(s)
8
Intervertebral discs
9-12
Mechanical
12
 or chemical irritation
of dura mater
13
 
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Possible sources of back pain have
been demonstrated; causes have been
more elusive
Refuted: conditions traditionally considered
to be possible causes are actually not causes
Eg, spondylolysis, spondylolisthesis, degenerative
changes (spondylosis)
Accepted: tumors and infections
Untested: muscle sprain, ligament sprain,
segmental dysfunction, and trigger points
Known source, unknown cause: sacroiliac joints,
zygapophyseal joints, internal disc disruption
 
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Inquire about
Location of pain
Frequency of symptoms
Duration of pain
History of previous symptoms, treatment,
and response to treatment
Consider possibility of LBP due to problems
outside the back
Pancreatitis
Nephrolithiasis
Aortic aneurysm
Systemic illnesses (eg, endocarditis or
viral syndromes)
 
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Clinicians should not routinely obtain
imaging or other diagnostic tests
in patients with nonspecific LBP
Strong recommendation
Moderate-quality evidence
 
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There is no evidence that routine plain radiography in
patients with nonspecific LBP is associated with a greater
improvement in patient outcomes than selective imaging
1-3
Exposure to unnecessary ionizing radiation should be
avoided, particularly in young women (amount of gonadal
radiation from obtaining a single plain radiograph [2 views]
of the lumbar spine is equivalent to daily chest radiograph
for more than 1 year)
4
Routine advanced imaging (computed tomography [CT]
or magnetic resonance imaging [MRI]) is not associated
with improved patient outcomes,
5
 identifies radiographic
abnormalities poorly correlated with symptoms,
6
 and could
lead to additional, possibly unnecessary interventions
7,8
 
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;
3
2
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7
2
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.
 
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:
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.
 
5
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:
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.
6
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.
7
.
 
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;
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9
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:
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0
-
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1
8
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8
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(
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1
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)
.
 
2
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;
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8
(
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:
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1
6
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2
0
.
 
P
l
a
i
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X
-
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a
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s
 
f
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L
o
w
 
B
a
c
k
 
P
a
i
n
 
(
c
o
n
t
.
)
 
Plain radiography is recommended for initial
evaluation of possible vertebral compression fracture
in select high-risk patients, such as those with a
history of osteoporosis or steroid use
1
Evidence to guide optimal imaging strategies is
not available for LBP that persists for more than
1 to 2 months if there are no symptoms suggesting
radiculopathy or spinal stenosis, although plain
radiography may be a reasonable initial option
(see recommendation 4 for imaging recommendations
in patients with symptoms suggesting radiculopathy
or spinal stenosis)
2
Thermography and electrophysiologic testing are
not recommended for evaluation of nonspecific LBP
 
1.
J
a
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.
 
2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
2.
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a
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2
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0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
G
u
i
d
e
l
i
n
e
 
#
3
 
Clinicians should perform diagnostic
imaging and testing for patients with
LBP when severe or progressive
neurologic deficits are present or
when serious underlying conditions
are suspected on the basis of history
and physical examination
Strong recommendation
Moderate-quality evidence
 
C
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a
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A
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.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
C
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M
R
I
 
D
i
a
g
n
o
s
t
i
c
 
I
m
a
g
i
n
g
 
Prompt work-up with MRI or CT is
recommended if severe or progressive
neurologic deficits or suspected serious
underlying condition; delayed diagnosis
and treatment associated with
poorer outcomes
1-3
MRI is generally preferred over CT if
available; does not use ionizing radiation,
provides better visualization of soft tissue,
vertebral marrow, and the spinal canal
4
 
1
.
 
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.
 
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i
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c
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.
 
2
0
0
5
;
2
3
(
9
)
:
2
0
2
8
-
2
0
3
7
.
2
.
 
T
o
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d
 
N
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.
 
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u
r
o
s
u
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g
.
 
2
0
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5
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1
9
(
4
)
:
3
0
1
-
3
0
6
.
3
.
 
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i
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.
 
2
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4
4
4
:
3
8
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4
.
 
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a
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.
 
2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
 
C
T
 
o
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M
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I
 
D
i
a
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i
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I
m
a
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i
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(
c
o
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t
.
)
 
There is insufficient evidence to guide diagnostic
strategies in patients who have risk factors for cancer
but no signs of spinal cord compression
Proposed strategies generally recommend plain
radiography or measurement of erythrocyte
sedimentation rate
3
, with MRI reserved for patients
with abnormalities on initial testing
1,2
Alternative strategy is to directly perform MRI
in patients with a history of cancer, the strongest
predictor of vertebral cancer;
2
 for patients older than
50 without other risk factors for cancer, delaying imaging
while offering standard treatments and reevaluating
within 1 month may also be a reasonable option
4
 
1
.
 
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(
7
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:
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7
.
2
.
 
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2
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6
(
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3
.
3
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1
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)
.
 
1
9
9
5
;
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0
(
3
)
:
3
1
8
-
3
2
7
.
4
.
 
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1
9
9
7
;
2
7
7
(
2
2
)
:
1
7
8
2
-
1
7
8
6
.
 
G
u
i
d
e
l
i
n
e
 
#
4
 
Clinicians should evaluate patients
with persistent LBP and signs or
symptoms or radiculopathy or spinal
stenosis with MRI (preferred) or CT
only if they are potential candidates
for surgery or epidural steroid injection
(for suspected radiculopathy)
Strong recommendation
Moderate-quality evidence
 
C
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a
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.
 
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.
 
2
0
0
7
;
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4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
I
m
a
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i
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g
 
f
o
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L
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w
 
B
a
c
k
 
P
a
i
n
 
The natural history of lumbar disc herniation with
radiculopathy in most patients is for improvement within
the first 4 weeks with noninvasive management
1,2
There is no compelling evidence that routine imaging
effects treatment decisions or improves outcomes
3
For prolapsed lumbar disc with persistent radicular
symptoms despite noninvasive therapy, discectomy
or epidural steroids are potential treatment options
4-8
Surgery is also a treatment option for persistent
symptoms associated with spinal stenosis
9-12
 
1
.
 
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:
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2
3
.
2
.
 
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(
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)
.
 
1
9
8
3
;
8
(
2
)
:
1
3
1
-
1
4
0
.
3
.
 
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2
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4
.
 
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6
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.
 
2
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2
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(
5
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:
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5
1
5
.
 
7
.
 
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2
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8
.
 
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2
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9
.
9
.
 
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1
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.
 
2
0
0
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;
2
5
(
1
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2
4
-
1
4
3
5
.
1
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.
 
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(
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1
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.
 
2
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(
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9
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6
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9
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3
.
1
1
.
 
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2
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7
;
3
5
6
(
2
2
)
:
2
2
5
7
-
2
2
7
0
.
1
2
.
 
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a
l
m
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a
a
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a
 
A
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(
P
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a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
7
;
3
2
(
1
)
:
1
-
8
.
 
M
R
I
 
f
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L
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B
a
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k
 
P
a
i
n
 
MRI (preferred if available) or CT is recommended for
evaluating patients with persistent back and leg pain
who are potential candidates for invasive interventions
Plain radiography cannot visualize discs or accurately evaluate
the degree of spinal stenosis
1
However, clinicians should be aware that findings on
MRI or CT (such as bulging disc without nerve root
impingement) are often nonspecific
Recommendations for specific invasive interventions,
interpretation of radiographic findings, and additional
work-up beyond scope of guideline, but decisions
should be based on clinical correlation between
symptoms and radiographic findings, severity of
symptoms, patient preferences, surgical risks,
and costs and will generally require specialist input
2
 
1
.
 
J
a
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J
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2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
2
.
 
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d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
C
r
i
t
i
c
a
l
 
C
l
i
n
i
c
a
l
 
I
n
d
i
c
a
t
o
r
s
o
f
 
P
a
t
h
o
l
o
g
y
 
In patients with back and leg pain, a typical
history for sciatica (back and leg pain in
a typical lumbar nerve root distribution)
has a fairly high sensitivity, but uncertain
specificity for herniated disc
1,2
>90% of symptomatic lumbar disc
herniations (back and leg pain due to a
prolapsed lumbar disc compressing a nerve
root) occur at L4/L5 and L5/S1 levels
3
 
1
.
 
v
a
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d
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n
 
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e
n
 
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M
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(
P
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i
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a
 
P
a
 
1
9
7
6
)
.
 
1
9
9
5
;
2
0
(
3
)
:
3
1
8
-
3
2
7
.
2
.
 
V
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.
 
J
 
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.
 
1
9
9
9
;
2
4
6
(
1
0
)
:
8
9
9
-
9
0
6
.
3
.
 
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a
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.
 
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.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
C
r
i
t
i
c
a
l
 
C
l
i
n
i
c
a
l
 
I
n
d
i
c
a
t
o
r
s
o
f
 
P
a
t
h
o
l
o
g
y
 
(
c
o
n
t
.
)
 
A focused examination that includes
straight-leg-raise testing and a
neurologic examination that includes
evaluation of knee strength and reflexes
(L4 nerve root), great toe and foot
dorsiflexion strength (L5 nerve root),
foot plantarflexion and ankle reflexes
(S1 nerve root), and distribution of
sensory symptoms should be done to
assess the presence and severity of
nerve root dysfunction
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
n
t
e
r
n
 
M
e
d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
C
r
i
t
i
c
a
l
 
C
l
i
n
i
c
a
l
 
I
n
d
i
c
a
t
o
r
s
o
f
 
P
a
t
h
o
l
o
g
y
 
(
c
o
n
t
.
)
 
A positive result on straight-leg-raise test
(defined as reproduction of the patient’s
sciatica between 30 and 70 degrees
of leg elevation) has a relatively high
sensitivity (91% 
[95% CI, 82% to 94%])
, but
modest specificity (26% 
[CI, 16% to 38%])
for diagnosing herniated disc
Crossed straight-leg-raise test is more
specific (88% 
[CI, 86% to 90%])
, but
less sensitive (29% 
[CI, 24% to 34%])
 
D
e
v
i
l
l
e
 
W
L
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
0
;
2
5
(
9
)
:
1
1
4
0
-
1
1
4
7
.
 
C
r
i
t
i
c
a
l
 
C
l
i
n
i
c
a
l
 
I
n
d
i
c
a
t
o
r
s
o
f
 
P
a
t
h
o
l
o
g
y
 
(
c
o
n
t
.
)
 
All patients should be evaluated for
Presence of rapidly progressive
or severe neurologic deficits
Motor deficits at more than 1 level, fecal
incontinence, and bladder dysfunction
Most frequent finding in cauda
equina syndrome is urinary retention
(90% sensitivity)
Without urinary retention, probability
is approximately 1 in 10,000
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
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e
r
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M
e
d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
D
e
y
o
 
R
A
,
 
e
t
 
a
l
.
 
J
A
M
A
.
 
1
9
9
2
;
2
6
8
(
6
)
:
7
6
0
-
7
6
5
.
 
Y
e
l
l
o
w
 
F
l
a
g
s
 
Identify psychosocial problems in
acute phase
Slow progress to recovery may be
due to undetected, or unrevealed
psychosocial factors
Pertain to patient's beliefs and behaviors
concerning physical activity and domestic,
social, and vocational responsibilities
Example: patient believes physical activity might harm
back, make pain worse, so avoids activities
Most destructive is aversion to work
Belief that work caused pain, work aggravates pain,
work is too heavy, and work should not be done
 
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Stronger predictors of LBP outcomes than either physical
findings or severity/duration of pain
1-3
Assessment of psychosocial factors identifies patients who
may have delayed recovery and could help target interventions
1 trial in referral setting found intensive multidisciplinary rehabilitation more
effective than usual care in patients with acute or subacute LBP identified
as having risk factors for chronic back pain disability
4
Direct evidence on effective primary care interventions for
identifying and treating such factors in patients with acute LBP
is lacking
5,6
Evidence is currently insufficient to recommend optimal methods
for assessing psychosocial factors and emotional distress
7
However, psychosocial factors that may predict poorer LBP
outcomes include presence of depression, passive coping
strategies, job dissatisfaction, higher disability levels, disputed
compensation claims, or somatization
8-10
 
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History
Gradual onset of back pain
Age <20 years or >50 years
Thoracic back pain
Pain lasting longer than 6 weeks
History of trauma
Fever/chills/night sweats
Unintentional weight loss
Pain worse with recumbency
Pain worse at night
Unrelenting pain despite
supratherapeutic doses of analgesics
History of malignancy
History of immunosuppression
Recent procedure causing bacteremia
History of intravenous drug use
 
Physical Examination
Fever
Hypotension
Extreme hypertension
Pale, ashen appearance
Pulsatile abdominal mass
Pulse amplitude differentials
Spinous process tenderness
Focal neurologic signs
Acute urinary retention
 
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Vertebral infection
Intravenous drug use, recent infection
Vertebral compression fracture
Older age, history of osteoporosis,
and steroid use
Musculoskeletal
Inactivity
In general
Emotional distress
 
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Large, prospective study from a primary
care setting
History of cancer (positive likelihood ratio, 14.7)
Unexplained weight loss (positive likelihood ratio, 2.7)
Failure to improve after 1 month (positive likelihood
ratio, 3.0)
Age >50 years (positive likelihood ratio, 2.7)
Posttest probability of cancer increases from
approximately 0.7% to 9% in patients with a history
of cancer (not including nonmelanoma skin cancer)
In patients with any 1 of the other 3 risk factors,
the likelihood of cancer only increases to
approximately 1.2%
 
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Features predicting vertebral infection not well studied,
but may include fever, intravenous drug use, or
recent infection
1
Consider risk factors for vertebral compression fracture,
such as older age, history of osteoporosis, and steroid
use; and for ankylosing spondylitis, such as younger
age, morning stiffness, improvement with exercise,
alternating buttock pain, and awakening due to back
pain during the second part of the night only
2
Clinicians should be aware that criteria for diagnosing
early ankylosing spondylitis (before the development
of radiographic abnormalities) are evolving
3
 
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To communicate effectively with all patients
Always use simple words, not medical jargon
Determine what the patient/caregiver already
knows or believes about his/her health situation
Encourage questions by asking, “What
questions do you have?” (allows for an open-
ended response), instead of “Do you have any
questions?” (allows for a “no” response, ending
the conversation)
Use the “teach-back” method to confirm the
level of understanding: Ask patients/family
members to restate what was just
communicated in the appointment or meeting
 
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.
 
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C
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Ensure that patients/consumers receive effective,
understandable, and respectful care that is
provided in a manner compatible with their
cultural health beliefs and practices and
preferred language
Implement strategies to recruit, retain, and
promote at all levels of the organization a diverse
staff and leadership that are representative of the
demographic characteristics of the service area
Ensure that staff, at all levels and across all
disciplines, receives ongoing education and
training in CLAS delivery
 
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M
P
H
 
Make pain assessment mandatory
Give a nonopioid analgesic at triage
Track reasons for unscheduled returns
Audit for ethnic bias
Consider which pain scales should
be used
Use multilingual laminated cards
 
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i
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e
 
Categorize patients into 1 of 3 broad groups:
nonspecific low back pain, back pain
potentially associated with radiculopathy
or spinal stenosis, or back pain potentially
associated with another specific spinal cause
Evaluate psychosocial risk factors to predict
the risk for chronic, disabling low back pain
Provide patients with evidence-based
information on expected course of low back
pain, effective self-care options, and
recommend that they be physically active
 
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s
 
Roger Chou, MD, FACP
Associate Professor of Medicine,
Department of Medicine
Department of Medical Informatics
and Clinical Epidemiology
Oregon Health & Science University
 
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Dr. Chou has disclosed that he
has no actual or potential conflict
of interest in regard to this activity
His presentation will include off-label
discussion of anticonvulsants,
benzodiazepines, and tricyclic
antidepressants for the treatment
of low back pain (LBP)
 
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Integrate evidence-based pharmacologic
and nonpharmacologic therapies into
a comprehensive treatment plan for
chronic LBP
 
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LBP is the fifth most common reason
for US office visits, and the second
most common symptomatic reason
1-2
$90.7 billion dollars in total healthcare
expenditures in 1998
3
LBP is the most common cause for
activity limitations in persons under
the age of 45
4
 
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9
%
 
2
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:
 
1
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2
%
 
P
r
a
c
t
i
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e
 
P
a
t
t
e
r
n
s
 
Spine surgery rates in the US are the
highest in the world
Rates in the US 5 times higher than in the UK
20-fold variation in fusion: 4.6 per 1000 in
Idaho Falls to 0.2 per 1000 in Bangor, Maine
Interventional therapies are also
widely used
Intradiscal electrothermal therapy estimated
at 7000-10,000 annually
20-fold variation in epidural steroid injections:
104 per 1000 in Palm Springs to 5.6 per 1000
in Honolulu
 
D
e
y
o
 
R
A
,
 
e
t
 
a
l
.
 
C
l
i
n
 
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r
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o
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s
.
 
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.
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e
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.
 
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p
i
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e
 
(
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h
i
l
a
 
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a
 
1
9
7
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)
.
 
2
0
0
6
;
3
1
(
2
3
)
:
2
7
0
7
-
2
7
1
4
.
 
“
7
 
B
a
c
k
 
P
a
i
n
 
B
r
e
a
k
t
h
r
o
u
g
h
s
:
A
r
e
 
y
o
u
 
h
u
r
t
i
n
g
?
 
H
e
r
e
’
s
 
h
e
l
p
.
”
 
Reader’s Digest
July 2007
End Back
Pain Agony
(Michael J. Weiss)
 
W
e
i
s
s
 
M
J
.
 
R
e
a
d
e
r
'
s
 
D
i
g
e
s
t
.
 
J
u
l
y
,
 
2
0
0
7
.
 
R
e
a
d
e
r
’
s
 
D
i
g
e
s
t
 
“
C
u
r
e
s
”
f
o
r
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
“Cures” based on anecdotal evidence, not
yet approved, and/or only in animal studies
Infrared belt: $2335
“Magic Spinal Wand”
Percutaneous automatic discectomy
Flexible fusion
Stem cells
Site-directed bone growth
New bed
Based on an unpublished observational study funded
by a sleep products trade group
 
W
e
i
s
s
 
M
J
.
 
R
e
a
d
e
r
'
s
 
D
i
g
e
s
t
.
 
J
u
l
y
,
 
2
0
0
7
.
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
G
u
i
d
e
l
i
n
e
s
 
P
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e
c
t
O
v
e
r
v
i
e
w
 
a
n
d
 
T
i
m
e
l
i
n
e
 
Began 2004; primary care guidelines published
October 2007
Address both acute and chronic LBP, and nonspecific
LBP and LBP with radiculopathy or spinal stenosis
Guideline for interventional therapies/surgery
published May 2009
Partnership between the American Pain Society
and the American College of Physicians (ACP)
Funded by the American Pain Society
Multidisciplinary panel with 25 members;
over 15 specialties/organizations represented
Series of 3 face-to-face meetings to
develop guidelines
Consensus achieved for all recommendations
 
R
e
c
o
m
m
e
n
d
a
t
i
o
n
 
G
r
i
d
A
C
P
 
M
e
t
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o
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s
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
n
t
e
r
n
 
M
e
d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
S
t
r
e
n
g
t
h
 
o
f
 
R
e
c
o
m
m
e
n
d
a
t
i
o
n
 
B
a
s
i
c
 
P
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i
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c
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o
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T
h
e
r
a
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f
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r
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
For most LBP, labeling with a specific etiology
doesn’t help inform therapy choices
Most patients with acute LBP will improve
regardless of which therapy is chosen
For chronic LBP, therapies are moderately
effective at best
Use interventions with proven efficacy
Noninvasive approaches to most LBP
Consider psychosocial factors
 
R
e
c
o
m
m
e
n
d
a
t
i
o
n
T
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e
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t
m
e
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t
 
o
f
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
Provide patients with evidence-based
information about their expected
course, advise patients to remain
active, and provide information
about effective self-care options
Strong recommendation
Moderate-quality evidence
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
n
t
e
r
n
 
M
e
d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
A
d
v
i
c
e
 
a
n
d
 
S
e
l
f
-
C
a
r
e
f
o
r
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
Inform patients of generally favorable
prognosis of acute LBP with or without sciatica
Discuss need for re-evaluation if not improved
Advise to remain active
Consider self-care education books
Superficial heat moderately effective for
acute LBP
No evidence to support use of lumbar supports
Firm mattresses inferior to medium-firm
mattresses (1 RCT)
 
R
C
T
=
r
a
n
d
o
m
i
z
e
d
 
c
o
n
t
r
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e
d
 
t
r
i
a
l
.
 
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e
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o
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d
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T
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n
t
 
o
f
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
Consider the use of medications with
proven benefits in conjunction with
back care information and self-care …
for most patients, first-line medication
options are acetaminophen or NSAIDs
Strong recommendation
Moderate-quality evidence
 
N
S
A
I
D
s
=
n
o
n
s
t
e
r
o
i
d
a
l
 
a
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2
0
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7
;
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4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
P
h
a
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m
a
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I
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r
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s
 
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.
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p
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b
y
 
t
h
e
 
U
S
 
F
D
A
.
 
P
h
a
r
m
a
c
o
l
o
g
i
c
 
I
n
t
e
r
v
e
n
t
i
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n
s
 
(
c
o
n
t
.
)
 
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h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
n
t
e
r
n
 
M
e
d
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2
0
0
7
;
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4
7
(
7
)
:
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7
8
-
4
9
1
.
C
h
o
u
 
R
,
 
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t
 
a
l
.
 
A
n
n
 
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n
t
e
r
n
 
M
e
d
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2
0
0
7
;
1
4
7
(
7
)
:
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0
5
-
5
1
4
.
T
h
i
s
 
i
n
f
o
r
m
a
t
i
o
n
 
i
n
c
l
u
d
e
s
 
a
 
u
s
e
 
t
h
a
t
 
h
a
s
 
n
o
t
 
b
e
e
n
 
a
p
p
r
o
v
e
d
 
b
y
 
t
h
e
 
U
S
 
F
D
A
.
 
R
e
c
o
m
m
e
n
d
a
t
i
o
n
T
r
e
a
t
m
e
n
t
 
o
f
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
For patients who do not improve with
self-care options, consider the addition of
nonpharmacologic therapy with proven benefits
For chronic or subacute LBP, options include
Intensive interdisciplinary
rehabilitation
Exercise therapy
Acupuncture
Massage therapy
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
n
t
e
r
n
 
M
e
d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
 
Spinal manipulation
Yoga
Cognitive-behavioral
therapy
Progressive relaxation
 
Weak recommendation
Moderate-quality evidence
 
N
o
n
i
n
v
a
s
i
v
e
 
I
n
t
e
r
v
e
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t
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r
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b
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L
B
P
 
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h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
n
t
e
r
n
 
M
e
d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
9
2
-
5
0
4
.
 
N
o
n
i
n
v
a
s
i
v
e
 
I
n
t
e
r
v
e
n
t
i
o
n
s
 
f
o
r
C
h
r
o
n
i
c
 
o
r
 
S
u
b
a
c
u
t
e
 
L
B
P
 
(
c
o
n
t
.
)
 
T
E
N
S
=
t
r
a
n
s
c
u
t
a
n
e
o
u
s
 
e
l
e
c
t
r
i
c
a
l
 
n
e
r
v
e
 
s
t
i
m
u
l
a
t
i
o
n
.
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
A
n
n
 
I
n
t
e
r
n
 
M
e
d
.
 
2
0
0
7
;
1
4
7
(
7
)
:
4
9
2
-
5
0
4
.
 
R
e
c
o
m
m
e
n
d
a
t
i
o
n
I
n
t
e
r
v
e
n
t
i
o
n
a
l
 
T
h
e
r
a
p
i
e
s
 
f
o
r
N
o
n
r
a
d
i
c
u
l
a
r
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
In patients with persistent nonradicular LBP,
facet joint corticosteroid injection,
prolotherapy, and intradiscal corticosteroid
injection are not recommended
Strong recommendation
Moderate-quality evidence
There is insufficient evidence to adequately
evaluate benefits of other interventional
therapies for nonradicular LBP
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
 
I
n
t
e
r
v
e
n
t
i
o
n
a
l
 
T
h
e
r
a
p
i
e
s
 
f
o
r
N
o
n
r
a
d
i
c
u
l
a
r
 
L
o
w
 
B
a
c
k
 
P
a
i
n
 
Interventional therapies not proven to be effective
in placebo-controlled, randomized trials
No trials (SI joint injection), trials showing no benefit
(facet joint injection), inconsistent results (IDET, RFDN),
or poor-quality evidence (trigger point injections)
Promising results from nonrandomized studies
not replicated in randomized trials
IDET
Facet joint steroid injection
Not clear if interventions are ineffective,
or if patients were not accurately selected
 
I
D
E
T
=
i
n
t
r
a
d
i
s
c
a
l
 
e
l
e
c
t
r
o
t
h
e
r
m
a
l
 
t
h
e
r
a
p
y
.
R
F
D
N
=
r
a
d
i
o
f
r
e
q
u
e
n
c
y
 
d
e
n
e
r
v
a
t
i
o
n
.
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
 
P
l
a
c
e
b
o
-
C
o
n
t
r
o
l
l
e
d
 
T
r
i
a
l
s
 
o
f
 
R
F
D
N
f
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r
 
P
r
e
s
u
m
e
d
 
F
a
c
e
t
 
J
o
i
n
t
 
P
a
i
n
 
N
S
=
n
o
t
 
s
i
g
n
i
f
i
c
a
n
t
.
 
P
l
a
c
e
b
o
-
C
o
n
t
r
o
l
l
e
d
 
T
r
i
a
l
s
 
o
f
 
R
F
D
N
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r
 
P
r
e
s
u
m
e
d
 
F
a
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t
 
J
o
i
n
t
 
P
a
i
n
 
P
l
a
c
e
b
o
-
C
o
n
t
r
o
l
l
e
d
 
T
r
i
a
l
s
 
o
f
 
R
F
D
N
f
o
r
 
P
r
e
s
u
m
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d
 
F
a
c
e
t
 
J
o
i
n
t
 
P
a
i
n
 
(
c
o
n
t
.
)
 
R
e
c
o
m
m
e
n
d
a
t
i
o
n
S
u
r
g
e
r
y
 
f
o
r
 
N
o
n
r
a
d
i
c
u
l
a
r
L
o
w
 
B
a
c
k
 
P
a
i
n
 
In patients with nonradicular LBP,
common degenerative spinal
changes, and persistent and disabling
symptoms … discuss risks and
benefits of surgery as an option
Weak recommendation
High-quality evidence
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
 
S
u
r
g
e
r
y
 
f
o
r
 
N
o
n
r
a
d
i
c
u
l
a
r
 
L
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w
 
B
a
c
k
P
a
i
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W
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D
e
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n
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r
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t
i
v
e
 
C
h
a
n
g
e
s
 
Benefits vary depending on comparator
Benefits of fusion vs standard nonsurgical therapy
less than 15 points on a 100-point pain or function
scale (1 RCT)
No difference vs intensive interdisciplinary
rehabilitation (3 RCTs)
All enrollees failed >1 year of nonsurgical management
and are not at higher risk for poor surgical outcomes
Fewer than half experience optimal outcomes
(relief of pain, return to work, decreased analgesic use)
No evidence that instrumentation improves outcomes
Shared decision-making approach recommended
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
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p
i
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e
 
(
P
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a
 
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)
.
 
2
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;
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.
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(
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2
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;
3
4
(
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.
 
R
e
c
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m
m
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d
a
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i
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n
I
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r
v
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r
a
p
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s
f
o
r
 
R
a
d
i
c
u
l
a
r
 
L
B
P
 
In patients with persistent radiculopathy
due to herniated lumbar disc … discuss
risks and benefits of epidural steroid
injection as an option
Weak recommendation
Moderate-quality evidence
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
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1
9
7
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)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
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6
6
-
1
0
7
7
.
 
I
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t
e
r
v
e
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t
i
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l
 
T
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r
a
p
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f
o
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a
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u
l
o
p
a
t
h
y
/
P
r
o
l
a
p
s
e
d
 
D
i
s
c
 
Epidural steroid injection
Short-term benefits in some higher-quality
trials, but data are inconsistent (could be
related to comparator used in trials)
No long-term benefits
No route clearly superior
Limited evidence of no benefit for
spinal stenosis
Shared decision-making
approach recommended
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
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1
9
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)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
 
R
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c
o
m
m
e
n
d
a
t
i
o
n
S
u
r
g
e
r
y
 
f
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a
r
 
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w
 
B
a
c
k
P
a
i
n
 
a
n
d
 
S
p
i
n
a
l
 
S
t
e
n
o
s
i
s
 
In patients with persistent radiculopathy
due to herniated lumbar disc or
persistent and disabling leg pain due
to spinal stenosis … discuss risks
and benefits of surgery as an option
Strong recommendation
High-quality evidence
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
0
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:
1
0
6
6
-
1
0
7
7
.
 
S
u
r
g
e
r
y
 
f
o
r
 
H
e
r
n
i
a
t
e
d
 
D
i
s
c
W
i
t
h
 
R
a
d
i
c
u
l
o
p
a
t
h
y
 
Discectomy associated with more
rapid improvement in symptoms than
nonsurgical therapy
Patients improved either with or without surgery
No progressive neurologic deficits without
immediate surgery
Long-term (after 1-2 years) outcomes similar
in some trials
Most trials evaluated standard open discectomy
or microdiscectomy
Shared decision-making approach recommended
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
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7
7
.
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o
u
 
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,
 
e
t
 
a
l
.
 
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p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
9
4
-
1
1
0
9
.
 
S
u
r
g
e
r
y
 
f
o
r
 
S
p
i
n
a
l
 
S
t
e
n
o
s
i
s
 
Decompressive laminectomy associated with
superior outcomes vs nonsurgical therapy
Mild improvement with nonsurgical therapy
No severe neurologic deficits without
immediate surgery
Benefits may diminish with long-term
(>2 years) follow-up
Shared decision-making approach recommended
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
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1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
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:
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6
6
-
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7
7
.
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.
 
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(
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a
 
P
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1
9
7
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)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
9
4
-
1
1
0
9
.
 
C
o
n
c
l
u
s
i
o
n
s
 
The quality of evidence for different LBP
therapies varies
A number of therapies appear similarly
and moderately effective for LBP
Guidelines can provide clinicians with a
useful framework for choosing therapies
Factors that influence choices from
recommended therapies include patient
preferences, availability, and costs
Shared decision-making can help make
decisions consistent with patient values
and preferences
undefined
P
P
l
l
e
e
a
a
s
s
e
e
 
 
p
p
a
a
s
s
s
s
 
 
y
y
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q
q
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c
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m
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.
.
 
 
?
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Q
Q
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?
?
undefined
 
C
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a
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o
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t
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o
n
i
c
i
t
y
 
o
f
L
o
w
 
B
a
c
k
 
P
a
i
n
 
Bill McCarberg, MD
Founder, Chronic Pain Management Program
Kaiser Permanente San Diego
Adjunct Assistant Clinical Professor,
University of California, San Diego
 
D
i
s
c
l
o
s
u
r
e
:
 
B
i
l
l
 
M
c
C
a
r
b
e
r
g
,
 
M
D
 
Dr. McCarberg’s presentation will not include
discussion of off-label, experimental, and/or
investigational uses of drugs or devices
 
L
e
a
r
n
i
n
g
 
O
b
j
e
c
t
i
v
e
 
Evaluate early interventions for acute
back pain in patients considered at
high risk for transition to chronic low
back pain (CLBP)
 
D
i
s
a
b
i
l
i
t
y
 
f
r
o
m
 
B
a
c
k
 
P
a
i
n
 
The minority of cases which involve disability
account for a disproportionate percentage
of overall healthcare costs
The most cost-effective approach is to more
aggressively pursue 
secondary prevention
efforts on 
subacute patients 
before chronic
disability is fully established
1
Acute: <3 weeks
Subacute: >3 weeks but <3 months
Chronic: >3 months, or more than 6 episodes
in 12 months
 
1
.
 
W
a
d
d
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l
l
 
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,
 
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a
l
.
 
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c
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p
 
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e
d
 
(
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o
n
d
)
.
 
2
0
0
1
;
5
1
(
2
)
:
1
2
4
-
1
3
5
.
 
A
d
v
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r
s
e
 
P
r
o
g
n
o
s
t
i
c
 
I
n
d
i
c
a
t
o
r
s
 
Yellow flags are psychosocial
indicators suggesting increased risk
of progression to long-term distress,
disability, and pain
Can be applied more broadly to assess
likelihood of development of persistent
problems from acute pain presentation
Yellow flags can relate to the patient’s
attitudes and beliefs, emotions,
behaviors, family, and workplace
 
K
e
n
d
a
l
l
 
N
A
.
 
B
a
i
l
l
i
e
r
e
s
 
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e
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t
 
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t
 
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i
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m
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l
.
 
1
9
9
9
;
1
3
(
3
)
:
5
4
5
-
5
5
4
.
 
R
i
s
k
 
F
a
c
t
o
r
s
 
f
o
r
 
C
h
r
o
n
i
c
 
L
o
w
B
a
c
k
 
P
a
i
n
:
 
Y
e
l
l
o
w
 
F
l
a
g
s
 
Belief that pain and activity are harmful
“Sickness behavior” such as extended rest
Bodily preoccupation and catastrophic thinking
Low or negative mood, anxiety, social withdrawal
Personal problems (eg, marital, financial, etc)
History of substance abuse
Problems/dissatisfaction with work (“blue flags”)
Overprotective family/lack of support
History of disability and other claims
Inappropriate expectations of treatment
Low expectation of active participation
 
The presence of yellow flags highlights the need to address
specific psychosocial factors as part of a multimodal
management approach
 
A
d
d
i
t
i
o
n
a
l
 
R
i
s
k
 
F
a
c
t
o
r
s
f
o
r
 
C
h
r
o
n
i
c
i
t
y
 
Previous history of low back pain
Age
Nerve root involvement
Poor physical fitness
Self-rated health poor
Heavy manual labor, inability for light duty
upon return to work (“black flags”)
Ongoing medico-legal actions
Obesity
*
Smoking
*
 
*
N
o
 
e
v
i
d
e
n
c
e
 
f
o
r
 
e
f
f
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o
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o
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n
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J
.
 
2
0
0
8
;
8
(
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:
1
9
5
-
2
0
2
.
 
I
n
t
e
r
v
e
n
t
i
o
n
a
l
 
T
h
e
r
a
p
i
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s
D
o
 
N
o
t
 
P
r
e
v
e
n
t
 
C
h
r
o
n
i
c
i
t
y
 
Additionally, regardless of the comparator intervention, there is
no convincing evidence that epidural steroids are associated with
long-term benefits or reduced rates of subsequent surgery
 
C
h
o
u
 
R
,
 
e
t
 
a
l
.
 
S
p
i
n
e
 
(
P
h
i
l
a
 
P
a
 
1
9
7
6
)
.
 
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
 
T
h
e
 
F
e
a
r
-
A
v
o
i
d
a
n
c
e
 
M
o
d
e
l
o
f
 
C
h
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o
n
i
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P
a
i
n
 
L
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w
 
M
,
 
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t
 
a
l
.
 
J
 
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a
v
 
M
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d
.
 
2
0
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7
;
3
0
(
1
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:
7
7
-
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4
.
V
l
a
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y
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n
 
J
W
,
 
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a
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.
 
P
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n
.
 
2
0
0
0
;
8
5
(
3
)
:
3
1
7
-
3
3
2
.
 
P
a
i
n
A
n
x
i
e
t
y
 
H
y
p
e
r
v
i
g
i
l
a
n
c
e
 
P
r
e
v
e
n
t
a
t
i
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e
M
o
t
i
v
a
t
i
o
n
 
A
r
o
u
s
a
l
 
F
e
a
r
o
f
 
P
a
i
n
 
T
h
r
e
a
t
 
P
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r
c
e
p
t
i
o
n
 
D
e
f
e
n
s
i
v
e
M
o
t
i
v
a
t
i
o
n
 
A
r
o
u
s
a
l
 
C
o
n
f
r
o
n
t
a
t
i
o
n
 
R
e
c
o
v
e
r
y
 
I
n
j
u
r
y
 
D
i
s
u
s
e
D
i
s
a
b
i
l
i
t
y
D
e
p
r
e
s
s
i
o
n
 
A
v
o
i
d
a
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c
e
 
E
s
c
a
p
e
 
C
a
t
a
s
t
r
o
p
h
i
z
i
n
g
 
N
e
g
a
t
i
v
e
 
A
f
f
e
c
t
i
v
i
t
y
T
h
r
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a
t
e
n
i
n
g
 
I
l
l
n
e
s
s
 
I
n
f
o
r
m
a
t
i
o
n
 
L
o
w
 
F
e
a
r
 
P
a
i
n
 
E
x
p
e
r
i
e
n
c
e
 
A
s
s
e
s
s
m
e
n
t
 
o
f
F
e
a
r
-
A
v
o
i
d
a
n
c
e
 
B
e
h
a
v
i
o
r
s
 
Pain Catastrophizing Scale (PCS)
1
13 items
Fear of Pain Questionnaire (FPQ)
2
30 items
Fear-Avoidance Beliefs Questionnaire (FABQ)
3
16 items
Coping Strategies Questionnaire (CSQ)
4
42 items
 
1
.
 
S
u
l
l
i
v
a
n
 
M
J
L
,
 
e
t
 
a
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.
 
P
s
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.
 
1
9
9
5
;
7
(
4
)
:
5
2
4
-
5
3
2
.
2
.
 
M
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i
l
 
D
W
,
 
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a
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.
 
J
 
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h
a
v
 
M
e
d
.
 
1
9
9
8
;
2
1
(
4
)
:
3
8
9
-
4
1
0
.
3
.
 
W
a
d
d
e
l
l
 
G
,
 
e
t
 
a
l
.
 
P
a
i
n
.
 
1
9
9
3
;
5
2
(
2
)
:
1
5
7
-
1
6
8
.
4
.
 
R
o
s
e
n
s
t
i
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l
 
A
K
,
 
e
t
 
a
l
.
 
P
a
i
n
.
 
1
9
8
3
;
1
7
(
1
)
:
3
3
-
4
4
.
 
R
e
d
u
c
i
n
g
 
C
a
t
a
s
t
r
o
p
h
i
z
i
n
g
 
Numerous interventions appear effective
Cognitive-behavioral therapies
1-4
Physiotherapy and other activity-
based interventions
5
Intensive patient education and
exposure interventions
6,
 
7
Limited understanding of the mechanisms
by which changes in catastrophizing occur
 
1
.
 
L
i
n
t
o
n
 
S
J
,
 
e
t
 
a
l
.
 
P
a
i
n
.
 
2
0
0
1
;
9
0
(
1
-
2
)
:
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-
9
0
.
2
.
 
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r
 
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D
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.
 
P
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E
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C
o
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s
.
 
1
9
9
7
;
3
1
(
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:
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1
3
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.
3
.
 
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.
 
2
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.
4
.
 
H
o
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.
 
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y
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l
.
 
2
0
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7
;
2
6
(
1
)
:
1
-
9
.
 
5
.
 
S
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t
s
 
R
J
,
 
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t
 
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.
 
J
 
P
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.
 
2
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.
6
.
 
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.
 
2
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7
.
 
L
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This informative resource delves into the evaluation, management, and prognosis of low back pain. It covers evidence-based evaluation, differential diagnosis, and the importance of clinical red and yellow flags in assessing low back pain. Guidelines from the American College of Physicians and the American Pain Society are highlighted, emphasizing the importance of conducting a focused history and physical examination to categorize patients with low back pain. The content also discusses the significance of assessing psychosocial risk factors and provides insights into conducting a thorough neurological examination and classifying patients based on specific criteria.


								
    
																		
  •   Low Back Pain
    • 
																	
  •    Evaluation
    • 
																	
  •    Management
    • 
																	
  •    Prognosis
    • 
																	
  •    Guidelines
    • 
																

								

								

									

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  1. Welcome to Low Back Pain:  Evaluation, Management,  and Prognosis
    2. 
            
            
            
  2. Welcome  and Overview Bill McCarberg Founder Chronic Pain Management Program Kaiser Permanente San Diego, California Adjunct Assistant Clinical Professor  University of California School of Medicine San Diego, California
    3. 
            
            
            
  3. Evidence-Based  Evaluation of  Patients With  Low Back Pain
    4. 
            
            
            
  4. Learning Objective    Discuss the differential diagnosis  for low back pain (LBP) and the  importance of clinical red and yellow  flags in evaluation of LBP
    5. 
            
            
            
  5. Low Back Pain Guidelines    In 2007, the American College of  Physicians (ACP) and American Pain  Society (APS) issued comprehensive  joint clinical practice guidelines for  diagnosis and treatment of LBP Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
    6. 
            
            
            
  6. Guideline #1     Clinicians should conduct a focused history  and physical examination to help place  patients with LBP into 1 of 3 broad categories     Nonspecific LBP     Back pain potentially associated with radiculopathy  or spinal stenosis      Back pain potentially associated with another  specific spinal cause      The history should include assessment of  psychosocial risk factors, which predict risk  for chronic disabling back pain     Strong recommendation     Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
    7. 
            
            
            
  7. Focused History and  Physical Examination      Determine presence and level of  neurological involvement1,2     Classify patients into 3 broad categories     Nonspecific LBP potentially associated with radiculopathy     Spinal stenosis     Back pain potentially associated with another specific  spinal cause     Patients with serious or progressive neurologic deficits  or underlying conditions requiring prompt evaluation      Tumor     Infection     Cauda equina syndrome     Patients with other conditions that may respond to  specific treatments     Ankylosing spondylitis     Vertebral compression fracture 1. Deyo RA, et al. JAMA. 1992;268(6):760-765.  2. Bigos SJ, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, No. 14; 1994.
    8. 
            
            
            
  8. Evaluation of Back Pain     Site     Duration     Length of illness     Time of onset     Spread     Mode of onset     Quality     Precipitating factors     Intensity     Aggravating factors     Frequency     Relieving factors     Associated features McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
    9. 
            
            
            
  9. Epidemiology of Low Back Pain     90% of American adults experience an  episode of back pain during their lifetime     Of patients who have acute back pain      90% to 95% have a non   life-threatening condition     Although up to 85% cannot be given an exact diagnosis,  nearly all recover within 4 to 6 weeks     For 5% to 10% of patients, acute back pain  is a manifestation of more serious pathology     Vascular catastrophes, malignancy, spinal  cord compressive syndromes, and infectious  disease processes Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
    10. 
            
            
            
  10. What Is Seen in Primary Care Practice?     In minority of patients presenting for initial evaluation  in primary care setting, LBP is caused by1     Cancer (approximately 0.7% of cases)     Compression fracture (4%)     Spinal infection (0.01%)     Estimates for prevalence of ankylosing spondylitis  in primary care patients range from 0.3%1 to 5%2     Spinal stenosis and symptomatic herniated disc are  present in about 3% and 4% of patients, respectively      Cauda equina syndrome most commonly associated  with massive midline disc herniation, but rare     Estimated prevalence of 0.04%3 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.  2. Underwood MR, et al. Br J Rheumatol. 1995;34(11):1074-1077. 3. Deyo RA, et al. JAMA. 1992;268(6):760-765.
    11. 
            
            
            
  11. Cost of Low Back Pain     LBP is one of top 10 reasons patients seek care from  family physicians1     Prevalence of LBP has varied from 7.6% to 37%     Peak prevalence between 45 and 60 years of age2     Also reported by adolescents and by adults of all ages     80% of adults seek care at some time for acute LBP3     One-third of US disability costs are due to low back disorders3     Direct costs of diagnosing and treating LBP in United  States estimated in 1991 to be $25* billion annually4     Indirect costs, including lost earnings, are even higher4     Proper diagnosis and appropriate treatment of LBP  saves healthcare resources, relieves suffering  *40 billon in 2008 using Consumer Price Index to compute the relative value of money. 1. AAFP. Facts About Family Practice; 1996.   2. Borenstein DG. Curr Opin Rheumatol. 1997;9(2):144-150.  3. Kuritzky L, et al. Prim Care Rep 1995;1:29-38.   4. Frymoyer JW, et al. Orthop Clin North Am. 1991;22(2):263-271.
    12. 
            
            
            
  12. Etiology of Low Back Pain    Nonspecific LBP    Back pain potentially associated  with radiculopathy or spinal stenosis     Back pain potentially associated  with another specific spinal cause Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
    13. 
            
            
            
  13. Structural Sources of Low Back Pain    Muscles of the back1,2     Interspinous ligaments2-4    Zygapophyseal joints5-7    Sacroiliac joint(s)8    Intervertebral discs9-12    Mechanical12 or chemical irritation  of dura mater13 1. Kellgren JH. Clin Sci. 1938;3:175-190.  2. Bogduk N. Med J Aust. 1980;2(10):537-541.  3. Kellgren JH. Clin Sci. 1939;4:35-46.  4. Feinstein B, et al. J Bone Joint Surg Am. 1954;36-A(5):981-997.  5. Mooney V, et al. Clin Orthop Relat Res. 1976(115):149-156.  6. McCall IW, et al. Spine (Phila Pa 1976). 1979;4(5):441-446.  7. Fukui S, et al. Clin J Pain. 1997;13(4):303-307. 8. Fortin JD, et al. Spine (Phila Pa 1976). 1994;19(13):1475-1482.  9. Wilberg G. Acta Orthop Scand. 1947;19:211-221.  10. Falconer MA, et al. J Neurol Neurosurg Psychiatry. 1948;11(1):13-26. 11. Kuslich SD, et al. Orthop Clin North Am. 1991;22(2):181-187.  12. O'Neill CW, et al. Spine (Phila Pa 1976). 2002;27(24):2776-2781.  13. El-Mahdi MA, et al. Neurochirurgia (Stuttg). 1981;24(4):137-141.
    14. 
            
            
            
  14. Causes of Low Back Pain     Possible sources of back pain have  been demonstrated; causes have been more elusive     Refuted: conditions traditionally considered  to be possible causes are actually not causes     Eg, spondylolysis, spondylolisthesis, degenerative  changes (spondylosis)     Accepted: tumors and infections     Untested: muscle sprain, ligament sprain,  segmental dysfunction, and trigger points     Known source, unknown cause: sacroiliac joints,  zygapophyseal joints, internal disc disruption McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1105-1122.
    15. 
            
            
            
  15. Diagnostic Triage Guides  Subsequent Decision-Making     Inquire about      Location of pain      Frequency of symptoms     Duration of pain     History of previous symptoms, treatment, and response to treatment      Consider possibility of LBP due to problems  outside the back     Pancreatitis     Nephrolithiasis      Aortic aneurysm     Systemic illnesses (eg, endocarditis or viral syndromes)
    16. 
            
            
            
  16. Differential Diagnosis  for Acute Low Back Pain Patient  Age  (Years) Disease or  Condition Location  of Pain Low back,  buttock,  posterior thigh Aggravating or  Relieving Factors Quality of Pain Signs Increased with activity  or bending Local tenderness, limited  spinal motion Back strain 20-40 Ache, spasm Sharp, shooting,  or burning pain;  paresthesia in leg Decreased with  standing; increased  with bending or sitting Increased with walking,  especially up an  incline; decreased with  sitting Positive straight leg  raise test, weakness,  asymmetric reflexes Mild decrease in  extension of spine;  may have weakness  or asymmetric reflexes Exaggeration of the lumbar  curve, palpable    step off     (defect between spinous  processes), tight hamstrings Decreased back  motion, tenderness  over sacroiliac joints Fever, percussive  tenderness; may have  neurologic abnormalities or  decreased motion May have localized  tenderness, neurologic  signs, or fever Acute disc  herniation Low back to  lower leg 30-50 Low back to  lower leg;  often bilateral Ache, shooting  pain,    pins and  needles    sensation Osteoarthritis or  spinal stenosis 30-50 Back,  Increased with activity  or bending Spondylolisthesis Any age Ache posterior thigh Sacroiliac  joints,  lumbar spine Ankylosing  spondylitis 15-40 Ache Morning stiffness Lumbar spine,  sacrum Infection Any age Sharp pain, ache Varies Dull ache,  throbbing pain;  slowly progressive Affected  bone(s) Increased with  recumbency or cough Malignancy >50 Adapted from: Patel AT, et al. Am Fam Physician. 2000;61(6):1779-1786.
    17. 
            
            
            
  17. Guideline #2    Clinicians should not routinely obtain  imaging or other diagnostic tests  in patients with nonspecific LBP    Strong recommendation    Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
    18. 
            
            
            
  18. Plain X-Rays for Low Back Pain     There is no evidence that routine plain radiography in  patients with nonspecific LBP is associated with a greater  improvement in patient outcomes than selective imaging1-3     Exposure to unnecessary ionizing radiation should be  avoided, particularly in young women (amount of gonadal  radiation from obtaining a single plain radiograph [2 views]  of the lumbar spine is equivalent to daily chest radiograph  for more than 1 year)4     Routine advanced imaging (computed tomography [CT]  or magnetic resonance imaging [MRI]) is not associated  with improved patient outcomes,5 identifies radiographic  abnormalities poorly correlated with symptoms,6 and could  lead to additional, possibly unnecessary interventions7,8 1. Deyo RA, et al. Arch Intern Med. 1987;147(1):141-145.  2. Kendrick D, et al. BMJ. 2001;322(7283):400-405.  3. Kerry S, et al. Br J Gen Pract. 2002;52(479):469-474.  4. Jarvik JG. Neuroimaging Clin N Am. 2003;13(2):293-305.  5. Gilbert FJ, et al. Radiology. 2004;231(2):343-351.  6. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.  7. Jarvik JG, et al. JAMA. 2003;289(21):2810-2818.  8. Lurie JD, et al. Spine (Phila Pa 1976). 2003;28(6):616-620. 
    19. 
            
            
            
  19. Plain X-Rays for Low Back Pain (cont.)     Plain radiography is recommended for initial  evaluation of possible vertebral compression fracture  in select high-risk patients, such as those with a  history of osteoporosis or steroid use1     Evidence to guide optimal imaging strategies is  not available for LBP that persists for more than  1 to 2 months if there are no symptoms suggesting  radiculopathy or spinal stenosis, although plain  radiography may be a reasonable initial option (see recommendation 4 for imaging recommendations  in patients with symptoms suggesting radiculopathy or spinal stenosis)2     Thermography and electrophysiologic testing are not recommended for evaluation of nonspecific LBP 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 
    20. 
            
            
            
  20. Guideline #3    Clinicians should perform diagnostic  imaging and testing for patients with  LBP when severe or progressive  neurologic deficits are present or  when serious underlying conditions  are suspected on the basis of history  and physical examination     Strong recommendation    Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 
    21. 
            
            
            
  21. CT or MRI Diagnostic Imaging     Prompt work-up with MRI or CT is  recommended if severe or progressive  neurologic deficits or suspected serious  underlying condition; delayed diagnosis  and treatment associated with  poorer outcomes1-3     MRI is generally preferred over CT if  available; does not use ionizing radiation,  provides better visualization of soft tissue,  vertebral marrow, and the spinal canal4 1. Loblaw DA, et al. J Clin Oncol. 2005;23(9):2028-2037.  2. Todd NV. Br J Neurosurg. 2005;19(4):301-306.  3. Tsiodras S, et al. Clin Orthop Relat Res. 2006;444:38-50.  4. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 
    22. 
            
            
            
  22. CT or MRI Diagnostic Imaging (cont.)     There is insufficient evidence to guide diagnostic  strategies in patients who have risk factors for cancer  but no signs of spinal cord compression     Proposed strategies generally recommend plain  radiography or measurement of erythrocyte  sedimentation rate3, with MRI reserved for patients  with abnormalities on initial testing1,2     Alternative strategy is to directly perform MRI  in patients with a history of cancer, the strongest  predictor of vertebral cancer;2 for patients older than  50 without other risk factors for cancer, delaying imaging  while offering standard treatments and reevaluating  within 1 month may also be a reasonable option4 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.  2. Joines JD, et al. J Gen Intern Med. 2001;16(1):14-23.  3. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327.  4. Suarez-Almazor ME, et al. JAMA. 1997;277(22):1782-1786. 
    23. 
            
            
            
  23. Guideline #4    Clinicians should evaluate patients  with persistent LBP and signs or  symptoms or radiculopathy or spinal  stenosis with MRI (preferred) or CT  only if they are potential candidates  for surgery or epidural steroid injection  (for suspected radiculopathy)    Strong recommendation    Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 
    24. 
            
            
            
  24. Imaging for Low Back Pain     The natural history of lumbar disc herniation with  radiculopathy in most patients is for improvement within  the first 4 weeks with noninvasive management1,2     There is no compelling evidence that routine imaging  effects treatment decisions or improves outcomes3     For prolapsed lumbar disc with persistent radicular  symptoms despite noninvasive therapy, discectomy  or epidural steroids are potential treatment options4-8     Surgery is also a treatment option for persistent  symptoms associated with spinal stenosis9-12 1. Vroomen PC, et al. Br J Gen Pract. 2002;52(475):119-123.  2. Weber H. Spine (Phila Pa 1976). 1983;8(2):131-140.  3. Modic MT, et al. Radiology. 2005;237(2):597-604.  4. Gibson JN, et al. Cochrane Database Syst Rev. 2000(3):CD001350.  5. Gibson JN, et al. Cochrane Database Syst Rev. 2005(4):CD001352.  6. Nelemans PJ, et al. Spine (Phila Pa 1976). 2001;26(5):501-515.  7. Peul WC, et al. N Engl J Med. 2007;356(22):2245-2256.  8. Weinstein JN, et al. JAMA. 2006;296(20):2451-2459.  9. Amundsen T, et al. Spine (Phila Pa 1976). 2000;25(11):1424-1435.  10. Atlas SJ, et al. Spine (Phila Pa 1976). 2005;30(8):936-943.  11. Weinstein JN, et al. N Engl J Med. 2007;356(22):2257-2270.  12. Malmivaara A, et al. Spine (Phila Pa 1976). 2007;32(1):1-8. 
    25. 
            
            
            
  25. MRI for Low Back Pain     MRI (preferred if available) or CT is recommended for  evaluating patients with persistent back and leg pain  who are potential candidates for invasive interventions     Plain radiography cannot visualize discs or accurately evaluate  the degree of spinal stenosis1     However, clinicians should be aware that findings on  MRI or CT (such as bulging disc without nerve root  impingement) are often nonspecific      Recommendations for specific invasive interventions,  interpretation of radiographic findings, and additional  work-up beyond scope of guideline, but decisions  should be based on clinical correlation between  symptoms and radiographic findings, severity of  symptoms, patient preferences, surgical risks,  and costs and will generally require specialist input2 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
    26. 
            
            
            
  26. Critical Clinical Indicators  of Pathology     In patients with back and leg pain, a typical  history for sciatica (back and leg pain in  a typical lumbar nerve root distribution)  has a fairly high sensitivity, but uncertain  specificity for herniated disc1,2     >90% of symptomatic lumbar disc  herniations (back and leg pain due to a  prolapsed lumbar disc compressing a nerve  root) occur at L4/L5 and L5/S1 levels3 1. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327.  2. Vroomen PC, et al. J Neurol. 1999;246(10):899-906.  3. Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 
    27. 
            
            
            
  27. Critical Clinical Indicators  of Pathology (cont.)    A focused examination that includes  straight-leg-raise testing and a  neurologic examination that includes  evaluation of knee strength and reflexes  (L4 nerve root), great toe and foot  dorsiflexion strength (L5 nerve root),  foot plantarflexion and ankle reflexes  (S1 nerve root), and distribution of  sensory symptoms should be done to  assess the presence and severity of  nerve root dysfunction Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
    28. 
            
            
            
  28. Critical Clinical Indicators  of Pathology (cont.)    A positive result on straight-leg-raise test  (defined as reproduction of the patient   s  sciatica between 30 and 70 degrees  of leg elevation) has a relatively high  sensitivity (91% [95% CI, 82% to 94%]), but  modest specificity (26% [CI, 16% to 38%]) for diagnosing herniated disc    Crossed straight-leg-raise test is more  specific (88% [CI, 86% to 90%]), but less sensitive (29% [CI, 24% to 34%]) Deville WL, et al. Spine (Phila Pa 1976). 2000;25(9):1140-1147.
    29. 
            
            
            
  29. Critical Clinical Indicators  of Pathology (cont.)    All patients should be evaluated for    Presence of rapidly progressive  or severe neurologic deficits     Motor deficits at more than 1 level, fecal  incontinence, and bladder dysfunction    Most frequent finding in cauda  equina syndrome is urinary retention  (90% sensitivity)    Without urinary retention, probability is approximately 1 in 10,000 Chou R, et al. Ann Intern Med. 2007;147(7):478-491. Deyo RA, et al. JAMA. 1992;268(6):760-765.
    30. 
            
            
            
  30. Yellow Flags     Identify psychosocial problems in  acute phase     Slow progress to recovery may be  due to undetected, or unrevealed  psychosocial factors     Pertain to patient's beliefs and behaviors  concerning physical activity and domestic,  social, and vocational responsibilities     Example: patient believes physical activity might harm  back, make pain worse, so avoids activities     Most destructive is aversion to work     Belief that work caused pain, work aggravates pain,  work is too heavy, and work should not be done McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
    31. 
            
            
            
  31. Psychosocial Factors  of Low Back Pain     Stronger predictors of LBP outcomes than either physical  findings or severity/duration of pain1-3     Assessment of psychosocial factors identifies patients who  may have delayed recovery and could help target interventions      1 trial in referral setting found intensive multidisciplinary rehabilitation more  effective than usual care in patients with acute or subacute LBP identified  as having risk factors for chronic back pain disability4     Direct evidence on effective primary care interventions for  identifying and treating such factors in patients with acute LBP is lacking5,6     Evidence is currently insufficient to recommend optimal methods  for assessing psychosocial factors and emotional distress7     However, psychosocial factors that may predict poorer LBP  outcomes include presence of depression, passive coping  strategies, job dissatisfaction, higher disability levels, disputed  compensation claims, or somatization8-10 1. Pengel LH, et al. BMJ. 2003;327(7410):323.  2. Fayad F, et al. Ann Readapt Med Phys. 2004;47(4):179-189.  3. Pincus T, et al. Spine (Phila Pa 1976). 2002;27(5):E109-120.  4. Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.  5. Hay EM, et al. Lancet. 2005;365(9476):2024-2030.  6. Jellema P, et al. BMJ. 2005;331(7508):84. 7. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.  8. Steenstra IA, et al. Occup Environ Med. 2005;62(12):851-860.  9. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727.  10. Carey TS, et al. Spine (Phila Pa 1976). 1996;21(3):339-344. 
    32. 
            
            
            
  32. Red Flags of Lower Back Pain History      Gradual onset of back pain     Age <20 years or >50 years     Thoracic back pain     Pain lasting longer than 6 weeks     History of trauma     Fever/chills/night sweats     Unintentional weight loss     Pain worse with recumbency     Pain worse at night     Unrelenting pain despite  supratherapeutic doses of analgesics     History of malignancy     History of immunosuppression     Recent procedure causing bacteremia     History of intravenous drug use Physical Examination     Fever     Hypotension     Extreme hypertension     Pale, ashen appearance     Pulsatile abdominal mass     Pulse amplitude differentials     Spinous process tenderness     Focal neurologic signs     Acute urinary retention Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
    33. 
            
            
            
  33. Risk for Chronicity    Vertebral infection    Intravenous drug use, recent infection    Vertebral compression fracture     Older age, history of osteoporosis,  and steroid use    Musculoskeletal    Inactivity    In general    Emotional distress
    34. 
            
            
            
  34. Cancer-Related Risk Factors     Large, prospective study from a primary  care setting     History of cancer (positive likelihood ratio, 14.7)     Unexplained weight loss (positive likelihood ratio, 2.7)      Failure to improve after 1 month (positive likelihood  ratio, 3.0)     Age >50 years (positive likelihood ratio, 2.7)      Posttest probability of cancer increases from  approximately 0.7% to 9% in patients with a history  of cancer (not including nonmelanoma skin cancer)      In patients with any 1 of the other 3 risk factors,  the likelihood of cancer only increases to  approximately 1.2% Deyo RA, et al. J Gen Intern Med. 1988;3(3):230-238.
    35. 
            
            
            
  35. Non-Cancer-Related Risk Factors     Features predicting vertebral infection not well studied,  but may include fever, intravenous drug use, or  recent infection1     Consider risk factors for vertebral compression fracture,  such as older age, history of osteoporosis, and steroid  use; and for ankylosing spondylitis, such as younger  age, morning stiffness, improvement with exercise,  alternating buttock pain, and awakening due to back  pain during the second part of the night only2     Clinicians should be aware that criteria for diagnosing  early ankylosing spondylitis (before the development  of radiographic abnormalities) are evolving3 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.  2. Rudwaleit M, et al. Arthritis Rheum. 2006;54(2):569-578.  3. Rudwaleit M, et al. Arthritis Rheum. 2005;52(4):1000-1008. 
    36. 
            
            
            
  36. Racial/Cultural Aspects of Assessment     To communicate effectively with all patients     Always use simple words, not medical jargon     Determine what the patient/caregiver already  knows or believes about his/her health situation     Encourage questions by asking,    What  questions do you have?    (allows for an open- ended response), instead of    Do you have any  questions?    (allows for a    no    response, ending  the conversation)     Use the    teach-back    method to confirm the  level of understanding: Ask patients/family  members to restate what was just  communicated in the appointment or meeting  Zacharoff KL. Cross-Cultural Pain Management: Effective Treatment of Pain in the Hispanic Population; 2009.
    37. 
            
            
            
  37. Culturally Competent Care     Ensure that patients/consumers receive effective,  understandable, and respectful care that is  provided in a manner compatible with their  cultural health beliefs and practices and  preferred language     Implement strategies to recruit, retain, and  promote at all levels of the organization a diverse  staff and leadership that are representative of the  demographic characteristics of the service area     Ensure that staff, at all levels and across all  disciplines, receives ongoing education and  training in CLAS delivery USDHHS OMH. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care; 2001.
    38. 
            
            
            
  38. Avoiding Racial and Cultural  Bias per Knox H. Todd, MD, MPH    Make pain assessment mandatory    Give a nonopioid analgesic at triage    Track reasons for unscheduled returns    Audit for ethnic bias    Consider which pain scales should  be used    Use multilingual laminated cards Todd KH. Medical Ethics Advisor. 1999.
    39. 
            
            
            
  39. Pearls for Practice     Categorize patients into 1 of 3 broad groups:  nonspecific low back pain, back pain  potentially associated with radiculopathy  or spinal stenosis, or back pain potentially  associated with another specific spinal cause      Evaluate psychosocial risk factors to predict  the risk for chronic, disabling low back pain      Provide patients with evidence-based  information on expected course of low back  pain, effective self-care options, and  recommend that they be physically active  Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 
    40. 
            
            
            
  40. Questions? Please pass your question card to a staff member.
    41. 
            
            
            
  41. Treatment of  Low Back Pain:  Pharmacologic and  Nonpharmacologic  Options Roger Chou, MD, FACP Associate Professor of Medicine, Department of Medicine Department of Medical Informatics  and Clinical Epidemiology Oregon Health & Science University
    42. 
            
            
            
  42. Disclosure: Roger Chou, MD, FACP    Dr. Chou has disclosed that he  has no actual or potential conflict  of interest in regard to this activity    His presentation will include off-label  discussion of anticonvulsants,  benzodiazepines, and tricyclic  antidepressants for the treatment  of low back pain (LBP)
    43. 
            
            
            
  43. Learning Objective    Integrate evidence-based pharmacologic  and nonpharmacologic therapies into  a comprehensive treatment plan for  chronic LBP
    44. 
            
            
            
  44. Low Back Pain Burden    LBP is the fifth most common reason  for US office visits, and the second  most common symptomatic reason1-2    $90.7 billion dollars in total healthcare  expenditures in 19983    LBP is the most common cause for  activity limitations in persons under  the age of 454 1. Hart LG, et al. Spine (Phila Pa 1976). 1995;20(1):11-19.  2. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727. 3. Luo X, et al. Spine (Phila Pa 1976). 2004;29(1):79-86. 4. Von Korff M, et al. Spine (Phila Pa 1976). 1996;21(24):2833-2837.
    45. 
            
            
            
  45. Increasing Rates of Back Surgery Trends in Rates of Discectomy/Laminectomy and Fusion in 1992-2003 US Average Rate of Discharges  per 1000 Medicare Enrollees Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
    46. 
            
            
            
  46. Increasing Rates of Back Injections Lumbosacral Injection Rates by Year: Age- and Sex-Adjusted per 100,000 2055.2 553.4 263.9 212.3 79.7 SI=sacroiliac. Friedly J, et al. Spine (Phila Pa 1976). 2007;32(16):1754-1760.
    47. 
            
            
            
  47. Increasing Costs Mean ($) Year Martin BI, et al. JAMA. 2008;299(6):656-664.
    48. 
            
            
            
  48. Rising Prevalence of Chronic LBP Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006 % Prevalence (95% CI) 1992: 3.9% 2006: 10.2% 1992 (n=8067) 3.9 (3.4-4.4) 2006 (n=9924) 10.2 (9.3-11.0) PRR Characteristic Total Sex Male Female Age (Years) 21-34  35-44 45-54 55-64        65 Race/Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other % Increase 162 (2.5-97.5% CI)* 2.62 (2.21-3.13) 2.9 (2.2-3.6) 4.8 (4.0-5.6) 8.0 (6.8-9.2) 12.2 (10.9-13.5) 176 154 2.76 (2.11-3.75) 2.54 (2.13-3.08) 1.4 (0.8-2.0) 4.8 (3.3-6.3) 4.2 (3.0-5.5) 6.3 (4.2-8.3) 5.9 (4.5-7.3) 4.3 (3.0-5.6) 9.2 (7.2-11.2) 13.5 (11.4-15.7) 15.4 (12.8-17.9) 12.3 (10.2-14.4) 201 92 219 146 109 3.01 (1.95-5.17) 1.92 (1.35-2.86) 3.19 (2.29-4.59) 2.46 (1.73-3.50) 2.09 (1.62-2.84) 4.1 (3.5-4.7) 3.0 (2.0-4.0) ** 4.1 (1.4-6.8) 10.5 (9.4-11.5) 9.8 (8.2-11.4) 6.3 (3.8-8.9) 9.1 (6.0-12.0) 155 226 2.55 (2.13-3.05) 3.26 (2.32-4.96) 120 2.20 (1.16-6.99) CI=confidence interval. PRR=prevalence rate ratio. *The PRRs and CI were estimated via bootstrapping; 97.5% CIs were  reported rather than to assume normality. **Unable to estimate owing to scall cell count (n<5). Freburger JK, et al. Arch Intern Med. 2009;169(3):251-258.
    49. 
            
            
            
  49. Practice Patterns     Spine surgery rates in the US are the  highest in the world     Rates in the US 5 times higher than in the UK     20-fold variation in fusion: 4.6 per 1000 in  Idaho Falls to 0.2 per 1000 in Bangor, Maine     Interventional therapies are also  widely used     Intradiscal electrothermal therapy estimated  at 7000-10,000 annually     20-fold variation in epidural steroid injections:  104 per 1000 in Palm Springs to 5.6 per 1000 in Honolulu Deyo RA, et al. Clin Orthop Relat Res. 2006;443:139-146. Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
    50. 
            
            
            
  50. 7 Back Pain Breakthroughs:  Are you hurting? Here   s help.        Reader   s Digest  July 2007     End Back  Pain Agony (Michael J. Weiss) Weiss MJ. Reader's Digest. July, 2007.
    51. 
            
            
            
							

							

					

					
					
					

						
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