Low back pain is the leading cause of disability worldwide, affecting 40% of adults, and no specific cause can be identified in 9 out of 10 cases. What do current guidelines recommend for clinical management?

Low back pain is defined as pain localized below the costal margin and above the lower gluteal folds with or without radiation to the lower extremities. It is the leading cause of years lived with disability worldwide and affects individuals of all ages. Approximately 1 in 4 US workers report experiencing low back pain, and its lifetime prevalence is approximately 40% among adults. The Global Burden of Disease study estimated that nearly 619 million individuals worldwide were affected in 2020, underscoring the considerable scale of this public health problem.

In primary care, less than 10% of cases are attributable to a specific spinal cause, such as lumbar radiculopathy due to a herniated disc or lumbar spinal stenosis, or to other diagnoses, including vertebral fracture, axial spondyloarthritis, vertebral tumor, infection, or cauda equina syndrome. When no specific cause is identified, the condition is classified as nonspecific low back pain according to its duration: acute when symptoms last less than 6 weeks, subacute when they last 6-12 weeks, and chronic when they last more than 12 weeks.

A narrative review analyzed the current evidence on the epidemiology, pathophysiology, clinical evaluation, prognosis, and treatment of nonspecific low back pain in outpatient practice. The review included 108 studies: 50 meta-analyses, 18 randomized trials, 15 systematic reviews, 13 prospective cohort studies, 8 international guidelines, 3 Delphi consensus studies, and 1 cross-sectional study.

Risk Factors

Several factors were associated with a higher prevalence of low back pain, including obesity (odds ratio [OR], 1.5; 95% CI, 1.2-1.9), depressive symptoms (OR, 1.6; 95% CI, 1.3-2.0), certain occupational exposures, particularly heavy lifting (OR, 1.10; 95% CI, 1.01-1.20), smoking, chronic diseases such as diabetes or asthma, and a personal history of low back pain. Many of these factors were also present as comorbidities among the affected patients; 72% had at least one associated condition.

Ninety percent of patients seeking care for low back pain presented with a nonspecific form. This heterogeneous condition results from interactions among multiple factors, including biological factors, such as muscular, joint, or ligament dysfunction; psychological factors such as depression, anxiety, and negative beliefs about pain; social and occupational factors, such as high physical or organizational demands and low autonomy at work; and socioeconomic factors, such as precarious living conditions or social disadvantage. The main reason for seeking care was low back pain associated with functional limitations in daily activities. The mechanisms underlying the development and persistence of low back pain remain poorly understood: Approximately 30% of patients reported no identifiable triggering event, while 76% reported at least one previous episode.

Diagnostic Assessment

The diagnosis of nonspecific low back pain is made after specific spinal and nonspinal causes have been ruled out. It relies on a targeted history and thorough physical examination. Lumbar radiculopathy and lumbar spinal stenosis account for 5%-10% of initial primary care consultations for low back pain, while vertebral fractures, axial spondyloarthritis, vertebral infections, tumors, and referred pain of visceral or vascular origin each account for less than 1% of cases.

Patient history focuses on the characteristics of pain, including its location, frequency of episodes, factors that worsen or relieve it, and its impact on daily activities. Psychosocial factors are also assessed, including kinesiophobia, depressive symptoms, and occupational factors. Clinical examination aims to rule out referred pain, hip pathology, visceral causes such as pancreatitis, vascular causes such as peripheral arterial disease, and infectious causes.

Cauda equina syndrome, which involves compression of the lumbosacral nerve roots, requires particular attention. Although it occurs in only approximately 0.1% of cases, it constitutes a medical emergency. It typically presents with recent urinary retention or incontinence, saddle anesthesia, and progressive motor deficits in the lower extremities. Every patient should be assessed for severe or rapid progressive neurologic deficits, and even a slight suspicion warrants immediate MRI and urgent neurosurgical evaluation.

A systematic search for warning signs, or “red flags,” is essential during every consultation because their presence alters the diagnostic approach. A history of cancer raises suspicion for spinal metastases, with a posttest probability as high as 33% (95% CI, 22%-46%). Vertebral fracture is suspected in patients aged ≥ 70 years (posttest probability, 9%; 95% CI, 3%-25%), after severe trauma or a fall (posttest probability, 11%; 95% CI, 8%-16%), during prolonged corticosteroid therapy lasting at least 6 months (posttest probability, 33%; 95% CI, 10%-67%), or in patients with known osteoporosis. Vertebral infection was considered in the presence of fever, intravenous drug use, a recent infection, or a history of spinal surgery. In patients younger than 45 years, a gradual and insidious onset, morning stiffness lasting at least 30 minutes, improvement with exercise, buttock pain, or nighttime awakening prompts evaluation for axial spondyloarthritis.

Imaging

Routine spinal imaging, including standard radiography, CT, or MRI, is not recommended in the absence of clinical signs suggestive of a serious condition. When warning signs are present, MRI should be performed immediately.

Degenerative changes visible on standard radiographs, including disc degeneration and facet joint osteoarthritis, are common and not necessarily responsible for low back pain. Identifying these abnormalities can lead clinicians to incorrectly attribute symptoms to radiographic findings, increasing anxiety and resulting in inappropriate diagnoses or unnecessary investigation and treatment.

Management

International guidelines agree that all patients should initially receive clear information and therapeutic education. The goals were to reassure patients, encourage continued physical activity, discourage prolonged bed rest, and promote self-management. Patients should be informed that substantial improvement in pain and function is expected within 6 weeks, with or without treatment, and that approximately 72% of patients recover within 12 months after symptom onset. In chronic low back pain, this proportion falls to 42%, underscoring the importance of early and appropriate management.

For nonpharmacological management, the French recommendations from the Haute Autorité de Santé (HAS) prioritize self-management, early resumption of daily activities, including work when possible, and adapted physical activity. Physical therapy is indicated from the outset for patients with risk factors for chronicity. The recommendations of the American College of Physicians (ACP) are consistent with these principles and also include, on the basis of a low level of evidence, approaches aimed at short-term pain relief, including massage, local heat, and acupuncture.

For spinal manipulation, ACP lists it as a first-line treatment, whereas HAS recommends it only as a second-line treatment and as part of a multimodal approach that includes a supervised exercise program because of the rare but documented risk for vascular complications. ACP does not recommend a structured exercise program as a first-line treatment, except for patients with risk factors for chronicity.

In patients whose low back pain significantly limits functional abilities, first-line pharmacologic treatment consists of nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen or naproxen. No difference in efficacy was observed between selective cyclooxygenase-2 inhibitors and nonselective NSAIDs. Centrally acting muscle relaxants, including cyclobenzaprine or tizanidine, provide only modest pain relief compared with placebo and carry a risk for adverse effects, particularly sedation or drowsiness. Acetaminophen monotherapy, benzodiazepines, including diazepam, because of the risk for abuse and dependence, and systemic corticosteroids are not recommended at this stage.

Opioids are reserved for severe and disabling conditions and are prescribed for short periods in immediate-release formulations. However, international recommendations differ. The National Institute for Health and Care Excellence (NICE) permits weak opioids, such as codeine, when an NSAID is contraindicated, poorly tolerated, or ineffective. The ACP makes no recommendations because of insufficient evidence, whereas joint recommendations from the ACP and the American Academy of Family Physicians advise against opioid use, including tramadol.

The recommendations of the ACP, NICE, and World Health Organization (WHO) agree on one key point: nonpharmacologic treatments are the first-line treatment for nonspecific chronic low back pain, with exercise serving as the cornerstone. Exercise is recommended before pharmacological treatment, either alone or in combination with psychological interventions. Psychological interventions, particularly cognitive behavioral therapy, are associated with a small to moderate but statistically significant reduction in pain intensity compared with patients on a waiting list. Therapeutic education remains important throughout follow-up, with an emphasis on maintaining physical activity, reducing avoidance behaviors linked to fear of movement, and correcting counterproductive beliefs about pain.

In patients with significant functional disability or an inadequate response to first-line treatments, multidisciplinary rehabilitation programs incorporating physical, occupational, and behavioral components delivered by multiple healthcare professionals result in moderate reductions in pain and disability.

Recommendations for spinal manipulation and acupuncture differ. ACP and WHO recommend both, whereas NICE, like HAS, recommends spinal manipulation only as part of a multimodal treatment approach, and does not recommend acupuncture. Mobility aids such as walking canes can also be recommended to improve functional abilities and participation in daily activities. Spinal traction, therapeutic ultrasound, electrotherapy, particularly transcutaneous electrical nerve stimulation, and lumbar belts and braces are not recommended because of insufficient evidence of their effectiveness.

Treatment Escalation

Drug treatment is considered for chronic low back pain only when nonpharmacologic treatments have failed or proved insufficiently effective. NSAIDs remain the standard pharmacologic treatment. ACP recommends duloxetine, a serotonin and norepinephrine reuptake inhibitor, as a second-line treatment, whereas NICE and the WHO advise against antidepressants because of their adverse effects. Acetaminophen, systemic corticosteroids, muscle relaxants such as cyclobenzaprine and tizanidine, and antiepileptic drugs such as gabapentin and pregabalin are not recommended.

For opioids, ACP reserves their use for patients with severe chronic low back pain that is resistant to other treatments, whereas NICE and the WHO advise against their use. Evidence on cannabis-based treatments remains too limited to support these recommendations.

Invasive treatments, including spinal injections, radiofrequency denervation, spinal cord stimulation, and spinal surgery, are rarely indicated. They are considered only when a plausible anatomic source of pain has been identified and first- and second-line treatments have proven insufficient, given their limited benefit and risk for adverse effects.

Limitations

The review had two significant methodological limitations: The quality of the included studies was not systematically assessed, and the literature search was limited to articles published in English.

The review also noted that chronic low back pain had a poor long-term prognosis and was a major source of functional disability among working-age adults. French clinical practice and the broader European approach, therefore, placed greater emphasis on localized interventional treatments targeting the underlying anatomic cause, including facet joint injections, epidural injections, and even intradiscal corticosteroid injections. Controlled trials showed the efficacy of these techniques in improving pain and functional scores.

This story was translated from JIM.