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Exercise, oral NSAIDs, and serotonin and norepinephrine reuptake inhibitors (duloxetine) were shown in a systematic review to produce a clinically meaningful reduction in pain, with exercise being the only intervention that demonstrated sustained benefit after the intervention ended.

A 2021 meta-analysis comparing fusion and nonfusion surgeries for lumbar spinal stenosis found no difference in clinical effects and complications, highlighting the challenge of surgical intervention for lumbar spinal stenosis.

A 2020 Cochrane review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the treatment effects are small (mean difference < 10%) and short-term for improving radicular pain for individuals.

There is level I evidence for the use of transforaminal injections for radicular pain from disk herniation.



  • Nerve root impingement is suspected when pain is leg-dominant rather than back-dominant.

  • Alarming symptoms include unexplained weight loss, failure to improve with treatment, severe pain for > 6 weeks, and night or rest pain.

  • Cauda equina syndrome is an emergency; often presents with bowel or bladder symptoms (or both).

General Considerations

Low back pain remains the number one cause of disability globally and is the second most common cause for primary care visits. The annual prevalence of low back pain is 15–45%. Annual health care spending for low back and neck pain is estimated to be $87.6 billion. Low back pain is the condition associated with the highest years lived with disability. Approximately 80% of episodes of low back pain resolve within 2 weeks and 90% resolve within 6 weeks. The exact cause of the low back pain is often difficult to diagnose; its cause is often multifactorial. There are usually degenerative changes in the lumbar spine involving the disks, facet joints, and vertebral endplates (Modic changes).

Clinical Findings

A. Symptoms and Signs

Aggravating factors of flexion and prolonged sitting commonly suggest anterior spine disk problems, while extension pain suggests facet joint, stenosis, or sacroiliac joint problems. Alarming symptoms for back pain caused by cancer include unexplained weight loss, failure to improve with treatment, pain for more than 6 weeks, and pain at night or rest. History of cancer and age older than 50 years are other risk factors for malignancy. Alarming symptoms for infection include fever, rest pain, recent infection (urinary tract infection, cellulitis, pneumonia), or history of immunocompromise or injection drug use. The cauda equina syndrome is suggested by urinary retention or incontinence, saddle anesthesia, decreased anal sphincter tone or fecal incontinence, bilateral lower extremity weakness, and progressive neurologic deficits. Risk factors for back pain due to vertebral fracture include use of corticosteroids, age over 70 years, history of osteoporosis, severe trauma, and presence of a contusion or abrasion. Back pain may also be the presenting symptom in other serious medical problems, including abdominal ...

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