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PATIENT STORY

A 60-year-old woman presents with chronic low back pain that began many years ago. Her back pain waxes and wanes, and she has taken acetaminophen and ibuprofen with some relief. About 3 months ago, she began to have daily pain. She recalls no trauma. Her examination is unremarkable other than some decreased flexion. Straight-leg raise test is negative. As the patient is older than 55 years of age, radiographs are ordered, and they demonstrate degenerative changes in her lumbar spine (Figure 101-1). She is started on an exercise program and yoga.

FIGURE 101-1

Lateral view shows grade 1 degenerative spondylolisthesis at L4-L5 (arrow), moderate facet osteoarthritis of L5-S1. Marked T12-L1 disc degeneration (arrowhead) and mild L4-L5 disc degeneration.

INTRODUCTION

Back pain is one of the most common reasons that adults see their physician. Most acute back pain is a result of mechanical causes. Serious pathology is rare and occurs in the presence of red flags. Acute back pain is treated with reassurance, returning to activities, and nonsteroidal anti-inflammatory drugs (NSAIDs). Psychological factors increase the risk of development of chronic pain. Chronic back pain is difficult to treat, and the best outcomes are typically achieved by an interprofessional team.

EPIDEMIOLOGY

  • Six percent of visits to primary care physicians are for back pain.1

  • 28.9% of community-living adults have had back pain in the last 3 months.2

  • The incidence of low back pain (LBP) is 139 per 100,000 person years.3

  • Thoracic back pain prevalence in working adults ages 20–59 is 10% in men and 20% in women.4

  • Treatment for back and neck problems accounted for approximately $90 billion in health care expenditures in the United States per year; lost productivity is estimated to cost an additional $10 to $20 billion.5

  • Prevalence of fracture in patients with LBP presenting to primary care is 1% to 4%6; less than 1% will have a malignancy.7

ETIOLOGY AND PATHOPHYSIOLOGY

  • LBP can be caused by pain in the muscles, ligaments, joints, bones, discs, nerves, or blood vessels.8

  • In 90% of cases, the specific cause of LBP is unclear.8

  • In 10% of cases, a specific cause such as an infection, fracture, or cancer is identified.8

RISK FACTORS

  • Older age—Prevalence of LBP increases with age into the sixth decade.8

  • Low educational status.8

  • Occupational factors—Manual labor, bending, twisting, and whole-body vibration.8

  • Psychosocial factors increase the risk of transition from acute to chronic pain.8

  • Risk factors for cancer—Previous history of cancer (positive likelihood ratio [LR+] 20.0, negative likelihood ratio [LR–] 0.46).7

DIAGNOSIS

The diagnosis can be classified into three categories:

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