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      Lower Back Pain

      Lower back pain is one of the most common reasons people consult healthcare professionals and a leading cause of disability worldwide. It can affect individuals of any age and may be acute (lasting less than 6 weeks), subacute (6–12 weeks), or chronic (more than 12 weeks). Though often self-limiting, it can significantly impact quality of life and work productivity.

      Causes

      • Most cases are non-specific, meaning no serious underlying cause is identified. Common causes include:
        1. Muscle strain or ligament sprain from poor posture, lifting, or overuse
        2. Degenerative disc disease or facet joint osteoarthritis
        3. Herniated discs pressing on spinal nerves
        4. Spinal stenosis (narrowing of spinal canal)
        5. Sacroiliac joint dysfunction
      • Less commonly, it can result from serious conditions such as:
        1. Vertebral fractures (especially in osteoporosis)
        2. Malignancy (metastatic or primary spinal tumours)
        3. Infections (e.g. spinal abscess, discitis)
        4. Inflammatory conditions (e.g. ankylosing spondylitis)

      Pathophysiology

      Lower back pain can originate from muscles, ligaments, vertebrae, intervertebral discs, or spinal nerves. Mechanical stress or degeneration can lead to inflammation, nerve root irritation, or altered spinal biomechanics. Chronic pain may also involve changes in pain processing pathways, increasing sensitivity (central sensitisation).

      Signs and Symptoms

      • Dull, aching or sharp pain in the lumbar region
      • Pain that may radiate to the buttocks, thighs, or legs (sciatica)
      • Stiffness, particularly after rest or in the morning
      • Limited movement or difficulty standing/walking
      • Muscle spasms in the lower back
      • In serious cases: numbness, weakness, or loss of bladder/bowel control (red flag symptoms)

      Risk Factors

      • Poor posture or sedentary lifestyle
      • Obesity
      • Heavy physical work or improper lifting technique
      • Previous back injuries
      • Smoking (impairs disc health)
      • Depression or anxiety (associated with chronic pain)
      • Ageing (increases degenerative changes)

      Investigation

      Most patients with non-specific lower back pain do not need imaging initially. NICE recommends investigations only if red flags or serious pathology is suspected. These include:

      • MRI spine: If there are neurological symptoms or suspicion of cancer/infection
      • X-ray: Limited role but may help in trauma or suspected fracture
      • Blood tests: ESR, CRP, FBC if infection or inflammatory cause is considered
      • Urinalysis: If renal causes of back pain are suspected
      • Neurological examination: To check for nerve root involvement

      Management

      1. Non-Pharmacological
      • Reassurance and education: Explain the benign nature of most cases
      • Remain active: Encourage early return to normal activities and work
      • Physiotherapy: Structured exercise, stretching, and strengthening programmes
      • Manual therapy: Such as spinal manipulation (short-term benefit)
      • Psychological therapy: Cognitive behavioural therapy (CBT) for persistent pain.
      2. Pharmacological
      • Paracetamol: Not first-line per NICE, limited efficacy alone
      • NSAIDs (e.g. ibuprofen): Effective but use lowest effective dose short-term
      • Topical treatments: May help with localised pain
      • Muscle relaxants: For short-term use in severe muscle spasm
      • Opioids: Only short-term in selected cases; avoid long-term use
      • Neuropathic pain medications: Gabapentin, pregabalin, or duloxetine for sciatica (used cautiously)
      3. Surgical

      Only indicated when conservative treatment fails and significant structural abnormality or neurological compromise is present. Options includes:

      • Discectomy: For herniated discs with nerve compression
      • Laminectomy: For spinal stenosis
      • Spinal fusion: Rarely indicated, mainly in instability or deformity

      Surgery should be discussed in specialist centres and only after shared decision-making.

      Complications

      • Chronic pain or long-term disability
      • Reduced mobility and quality of life
      • Work absenteeism and financial burden
      • Depression and anxiety due to persistent pain
      • Rarely, cauda equina syndrome (surgical emergency)

      References

      • NICE CKS: Low back pain and sciatica (last updated 2023)
      • NICE guideline NG59: Low back pain and sciatica in over 16s
      • Royal College of General Practitioners: Back pain resources
      • Royal College of Surgeons: Guidance on spinal surgery
      • GMC: Good clinical practice and shared decision-making

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