From the Guidelines
Back pain can be categorized based on patient history into three main types: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, and back pain potentially associated with another specific spinal cause. These categories are based on the American College of Physicians and the American Pain Society's guidelines, which emphasize the importance of a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement 1. Patient history also helps classify back pain as mechanical, neuropathic, or inflammatory, and as specific or non-specific. Red flag symptoms in patient history, such as unexplained weight loss, fever, or history of cancer, may indicate serious underlying conditions requiring immediate attention. Understanding these categories through careful history-taking helps clinicians determine appropriate diagnostic approaches and treatment strategies for each patient's unique presentation.
Key Considerations
- A focused history and physical examination are essential to categorize back pain and determine the likelihood of specific underlying conditions 1.
- The American College of Physicians and the American Pain Society's guidelines provide a framework for categorizing back pain into three main types: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, and back pain potentially associated with another specific spinal cause 1.
- Patient history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain 1.
- Red flag symptoms, such as unexplained weight loss, fever, or history of cancer, may indicate serious underlying conditions requiring immediate attention 1.
Categorization of Back Pain
- Nonspecific low back pain: accounts for the majority of cases, with no identifiable underlying cause 1.
- Back pain potentially associated with radiculopathy or spinal stenosis: characterized by symptoms such as sciatica or pseudoclaudication 1.
- Back pain potentially associated with another specific spinal cause: includes conditions such as ankylosing spondylitis, vertebral compression fracture, or spinal infection 1.
Recent Guidelines
- The 2021 update of the ACR Appropriateness Criteria for low back pain emphasizes the importance of a focused history and physical examination, reassurance, initial pain management medications if necessary, and consideration of physical therapies without routine imaging in patients with nonspecific LBP 1.
- The American College of Physicians and the American Pain Society's guidelines provide a framework for categorizing back pain and determining the likelihood of specific underlying conditions 1.
From the Research
Categorization of Back Pain
Back pain can be categorized based on patient history into several types, including:
- Acute back pain: lasts for less than 12 weeks 2
- Chronic low back pain: defined as lumbar pain persisting for 12 weeks or more, occurs in about 13% of U.S. adults 2
- Mechanical back pain: accounts for 97% of cases, arising from spinal structures such as bone, ligaments, discs, joints, nerves, and meninges 3
- Nociceptive, neuropathic and nociplastic, or non-specific pain: different types of pain that frequently overlap 4
Causes of Back Pain
The causes of back pain can be categorized into:
- Spinal stenosis
- Herniated discs
- Zygapophysial joint pain
- Discogenic pain
- Vertebral fractures
- Sacroiliac joint pain
- Myofascial pain 3
- Psychological, environmental, and social factors (yellow flags) 2
Diagnosis and Treatment
Diagnosis of back pain involves:
- History and physical examination to identify red flags and yellow flags 2
- Evaluation for radicular symptoms 2
- Imaging and diagnostic injections, although their use is controversial 4 Treatment options include:
- Nonpharmacologic treatment, such as counseling, exercise therapy, spinal manipulation, and physical therapy 2
- Pharmacologic interventions, such as nonsteroidal anti-inflammatory drugs and duloxetine 2
- Surgical options, such as decompression, disc replacement, and fusion, for carefully selected patients 4
Prevention and Management
Prevention of chronic low back pain is recognized as a pivotal challenge in high-risk populations 4 Management of back pain depends on pain classification and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods 4 A multimodal interdisciplinary approach is necessary to address the complex nature of back pain 4