Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Chronic low back pain: pharmacological, interventional and surgical strategies

Nature Reviews Neurology volume 9, pages 462–473 (2013)Cite this article

Subjects

Abstract

Chronic low back pain (CLBP) is a highly prevalent, costly and disabling condition that is associated with high levels of health-care resource utilization. Over the past few decades, there has been a paradigm shift in our understanding of CLBP. Nowadays, this condition is accepted as a biopsychosocial phenomenon in which anatomical injury interplays with psychosocial factors. The considerable progress made in elucidating the aetiology of low back pain and the sharp increase in related health-care costs have not translated into a decreased prevalence of CLBP or the development of therapies with markedly improved efficacy and safety. Classic medical–technical interventions for CLBP always need to be placed in a broader therapeutic framework comprising physical, psychosocial and behavioural strategies, and must address the patient's welfare in a holistic context. A common key finding in the literature on these interventions for CLBP is their disappointing magnitude of pain reduction and gain in functionality. This Review summarizes general concepts of CLBP and focuses on evidence supporting the classic medical–technical approaches to CLBP; that is, pharmacotherapy, interventional pain management and surgery.

Key Points

  • Chronic low back pain (CLBP) is a highly prevalent, costly and disabling condition for which no effective cure exists

  • Classic medical–technical interventions must be placed in a broad therapeutic framework, including physical, psychosocial and behavioural strategies

  • Pharmacotherapy for CLBP includes paracetamol, NSAIDs, weak and strong opioids, and antidepressants, but the effect sizes are small

  • Combination pharmacotherapy may be indicated, especially if neuropathic pain components are present

  • Epidural steroid injections are only indicated in well-selected patients with radicular pain; radiofrequency neurolysis can be considered after a positive response to lumbar medial branch blocks

  • Spine surgery should only be considered in patients with refractory CLBP after a prolonged period of appropriate conservative care

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Mechanisms in low back pain: an overview of the three classes of pain.
Figure 2: Lumbar medial branch radiofrequency neurolysis.
Figure 3: Epidural injections for radicular pain.

Similar content being viewed by others

References

  1. Nielens, H. et al. Chronic low back pain. Belgian Health Care Knowledge Centre (KCE) [online], (2006).

    Google Scholar 

  2. Airaksinen. O. et al. European guidelines for the management of chronic nonspecific low back pain. Eur. Spine J. 15 (Suppl. 2), S192–S300 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  3. Walker, B. F. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J. Spinal Disord. 13, 205–217 (2000).

    Article  CAS  PubMed  Google Scholar 

  4. Freburger, J. K. et al. The rising prevalence of chronic low back pain. Arch. Intern. Med. 169, 251–258 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  5. Institute for Health Metrics and Evaluation. The Global Burden of Disease: Generating Evidence, Guiding Policy. (Institute for Health Metrics and Evaluation, 2013).

  6. Vos, T. et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2163–2196 (2013).

    Article  Google Scholar 

  7. Deyo, R. A., Mirza, S. K. & Martin, B. I. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine 31, 2724–2727 (2006).

    Article  PubMed  Google Scholar 

  8. Neuhauser, H., Ellert, U. & Ziese, T. Chronic back pain in the general population in Germany 2002/2003: prevalence and highly affected population groups [German]. Gesundheitswesen 67, 685–693 (2005).

    Article  CAS  PubMed  Google Scholar 

  9. Webb, R. et al. Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population. Spine 28, 1195–1202 (2003).

    PubMed  Google Scholar 

  10. Verbunt, J. A., Smeets, R. J. & Wittink, H. M. Cause or effect? Deconditioning and chronic low back pain. Pain 149, 428–430 (2010).

    Article  PubMed  Google Scholar 

  11. Nordeman, L., Gunnarsson, R. & Mannerkorpi, K. Prevalence and characteristics of widespread pain in female primary health care patients with chronic low back pain. Clin. J. Pain. 28, 65–72 (2012).

    Article  PubMed  Google Scholar 

  12. Adamson, J., Hunt, K. & Nazareth, I. The influence of socio-demographic characteristics on consultation for back pain--a review of the literature. Fam. Pract. 28, 163–171 (2011).

    Article  PubMed  Google Scholar 

  13. van Tulder . et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur. Spine J. 15 (Suppl. 2), S169–S191 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  14. Croft, P. R., Macfarlane, G. J., Papageorgiou, A. C., Thomas, E. & Silman, A. J. Outcome of low back pain in general practice: a prospective study. BMJ 316, 1356–1359 (1998).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Andersson, G. B. Epidemiological features of chronic low-back pain. Lancet 354, 581–585 (1999).

    Article  CAS  PubMed  Google Scholar 

  16. Itz, C. J., Geurts, J. W., van Kleef, M. & Nelemans, P. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur. J. Pain 17, 5–15 (2013).

    Article  CAS  PubMed  Google Scholar 

  17. Woolf, C. J. What is this thing called pain? J. Clin. Invest. 120, 3742–3744 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Treede, R. D. et al. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology 70, 1630–1635 (2008).

    Article  CAS  PubMed  Google Scholar 

  19. Morlion, B. Pharmacotherapy of low back pain: targeting nociceptive and neuropathic pain components. Curr. Med. Res. Opin. 27, 11–33 (2011).

    Article  CAS  PubMed  Google Scholar 

  20. Cohen, S. P., Argoff, C. E. & Carragee, E. J. Management of low back pain. BMJ 337, 100–106 (2008).

    Google Scholar 

  21. Deyo, R. A. & Weinstein, J. N. Low back pain. N. Engl. J. Med. 344, 363–370 (2001).

    Article  CAS  PubMed  Google Scholar 

  22. Freynhagen, R. & Baron, R. The evaluation of neuropathic components in low back pain. Curr. Pain Headache Rep. 13, 185–190 (2009).

    Article  PubMed  Google Scholar 

  23. Balague, F., Mannion, A. F., Pellise, F. & Cedraschi, C. Non-specific low back pain. Lancet 379, 482–491 (2012).

    Article  PubMed  Google Scholar 

  24. Dagenais, S., Tricco, A. C. & Haldeman, S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 10, 514–529 (2010).

    Article  PubMed  Google Scholar 

  25. Nicholas, M. K., Linton, S. J., Watson, P. J., Main, C. J. & “Decade of the Flags” Working Group. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys. Ther. 91, 737–753 (2011).

    Article  PubMed  Google Scholar 

  26. Chou, R. & Shekelle, P. Will this patient develop persistent disabling low back pain? JAMA 303, 1295–1302 (2010).

    Article  CAS  PubMed  Google Scholar 

  27. Chou, R., Fu, R., Carrino, J. A. & Deyo, R. A. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 373, 463–472 (2009).

    Article  PubMed  Google Scholar 

  28. Nachemson, A. A critical look at the treatment for low back pain. Scand. J. Rehabil. Med. 11, 143–147 (1979).

    CAS  PubMed  Google Scholar 

  29. Johnson, E. W. Pain generator. Am. J. Phys. Med. Rehabil. 79, 411 (2000).

    Article  CAS  PubMed  Google Scholar 

  30. Pradhan, B., Brox, J. I. & Indahl, A. in Evidence-Based Management of Low Back Pain (eds Dagenais, S. & Haldeman, S.) 55–72 (Elsevier Mosby, 2012).

    Book  Google Scholar 

  31. Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N. & Turk, D. C. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol. Bull. 133, 581–624 (2007).

    Article  PubMed  Google Scholar 

  32. Waddell, G. Biopsychosocial analysis of low back pain. Baillieres Clin. Rheumatol. 6, 523–557 (1992).

    Article  CAS  PubMed  Google Scholar 

  33. Vlaeyen, J. W. & Linton, S. J. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85, 317–332 (2000).

    Article  CAS  PubMed  Google Scholar 

  34. Haldeman, S. & Dagenais, S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J. 8, 1–7 (2008).

    Article  PubMed  Google Scholar 

  35. Wolfe, F. & Hauser, W. Fibromyalgia diagnosis and diagnostic criteria. Ann. Med. 43, 495–502 (2011).

    Article  PubMed  Google Scholar 

  36. Lapossy, E., Maleitzke, R., Hrycaj, P., Mennet, W. & Muller, W. The frequency of transition of chronic low back pain to fibromyalgia. Scand. J. Rheumatol. 24, 29–33 (1995).

    Article  CAS  PubMed  Google Scholar 

  37. Kindler, L. L., Jones, K. D., Perrin, N. & Bennett, R. M. Risk factors predicting the development of widespread pain from chronic back or neck pain. J. Pain. 11, 1320–1328 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  38. Savigny, P., Watson, P. & Underwood, M. Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ 338, 1441–1445 (2009).

    Article  Google Scholar 

  39. Chou, R. et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann. Intern. Med. 147, 478–491 (2007).

    Article  PubMed  Google Scholar 

  40. Manchikanti, L. et al. Guidelines warfare over interventional techniques: is there a lack of discourse or straw man? Pain Physician 15, E1–E26 (2012).

    PubMed  Google Scholar 

  41. Boswell, M., Abdi, S. & Manchikanti, L. Misinterpretation of evidence synthesis and ASIPP guidelines by Chou. Pain Med. 10, 422–424 (2009).

    Article  PubMed  Google Scholar 

  42. Manchikanti, L. et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician 13, E141–E174 (2010).

    PubMed  Google Scholar 

  43. Keller, A., Hayden, J., Bombardier, C. & van Tulder, M. Effect sizes of non-surgical treatments of non-specific low-back pain. Eur. Spine J. 16, 1776–1788 (2007).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Carey, T. S. et al. A long way to go: practice patterns and evidence in chronic low back pain care. Spine 34, 718–724 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  45. Reese, C. & Mittag, O. Psychological interventions in the rehabilitation of patients with chronic low back pain: evidence and recommendations from systematic reviews and guidelines. Int. J. Rehabil. Res. 36, 6–12 (2013).

    Article  PubMed  Google Scholar 

  46. Henschke, N. et al. Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews, Issue 7. Art. No.:CD002014. http://dx.doi.org/10.1002/14651858.CD002014.pub3.

  47. Turk, D. C., Wilson, H. D. & Cahana, A. Treatment of chronic non-cancer pain. Lancet 377, 2226–2235 (2011).

    Article  CAS  PubMed  Google Scholar 

  48. van Tulder, M., Malmivaara, A., Esmail, R. & Koes, B. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 25, 2784–2796 (2000).

    Article  CAS  PubMed  Google Scholar 

  49. Koes, B. W., van Tulder, M. W., Ostelo, R., Kim Burton, A. & Waddell, G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 26, 2504–2513 (2001).

    Article  CAS  PubMed  Google Scholar 

  50. Davies, R. A., Maher, C. G. & Hancock, M. J. A systematic review of paracetamol for non-specific low back pain. Eur. Spine J. 17, 1423–1430 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  51. Williams, C. M. et al. PACE--the first placebo controlled trial of paracetamol for acute low back pain: design of a randomised controlled trial. BMC Musculoskelet. Disord. 11, 169 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Holt, M. & Ju, C. Drug-induced liver injury. Handb. Exp. Pharmacol. 196, 3–27 (2010).

    Article  CAS  Google Scholar 

  53. Kuehn, B. M. FDA focuses on drugs and liver damage: labeling and other changes for acetaminophen. JAMA 302, 369–371 (2009).

    Article  CAS  PubMed  Google Scholar 

  54. Roelofs, P. D., Deyo, R. A., Koes, B. W., Scholten, R. J. & van Tulder, M. W. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine 33, 1766–1774 (2008).

    Article  PubMed  Google Scholar 

  55. van Tulder, M. W., Scholten, R. J., Koes, B. W. & Deyo, R. A. Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 25, 2501–2513 (2000).

    Article  CAS  PubMed  Google Scholar 

  56. McGettigan, P. & Henry, D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA 296, 1633–1644 (2006).

    Article  CAS  PubMed  Google Scholar 

  57. McGettigan, P. & Henry, D. Cardiovascular risk with non-steroidal anti-inflammatory drugs: systematic review of population-based controlled observational studies. PLoS Med. 8, e1001098 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Whelton, A. Renal and related cardiovascular effects of conventional and COX-2-specific NSAIDs and non-NSAID analgesics. Am. J. Ther. 7, 63–74 (2000).

    Article  CAS  PubMed  Google Scholar 

  59. Bessone, F. Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage? World J. Gastroenterol. 16, 5651–5661 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  60. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J. Am. Geriatr. Soc. 57, 1331–1346 (2009).

  61. Henry, D. et al. Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis. BMJ 312, 1563–1566 (1996).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Roubille, C., Martel-Pelletier, J., Davy, J. M., Haraoui, B. & Pelletier, J. P. Cardiovascular adverse effects of anti-inflammatory drugs. Antiinflamm. Antiallergy Agents Med. Chem. 12, 55–67 (2012).

    Article  Google Scholar 

  63. Pinto, A., Farrar, J. T. & Hersh, E. V. Prescribing NSAIDs to patients on SSRIs: possible adverse drug interaction of importance to dental practitioners. In Compend. Contin. Educ. Dent. 30, 142–151 (1995).

    Google Scholar 

  64. Farkouh, M. E. et al. Cardiovascular outcomes in high risk patients with osteoarthritis treated with ibuprofen, naproxen or lumiracoxib. Ann. Rheum. Dis. 66, 764–770 (2007).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Cheetham, T. C., Levy, G., Niu, F. & Bixler, F. Gastrointestinal safety of nonsteroidal antiinflammatory drugs and selective cyclooxygenase-2 inhibitors in patients on warfarin. Ann. Pharmacother. 43, 1765–1773 (2009).

    Article  CAS  PubMed  Google Scholar 

  66. Mackenzie, I. S., Coughtrie, M. W., MacDonald, T. M. & Wei, L. Antiplatelet drug interactions. J. Intern. Med. 268, 516–529 (2010).

    Article  CAS  PubMed  Google Scholar 

  67. de Leon-Casasola, O. A. Opioids for chronic pain: new evidence, new strategies, safe prescribing. Am. J. Med. 126, S3–S11 (2013).

    Article  CAS  PubMed  Google Scholar 

  68. Baldini, A., Von Korff, M. & Lin, E. H. A review of potential adverse effects of long-term opioid therapy: a practitioner's guide. Prim. Care Companion CNS Disord. 14, pii: PCC.11m01326 (2012).

    Google Scholar 

  69. Gomes, T., Mamdani, M. M., Dhalla, I. A., Paterson, J. M. & Juurlink, D. N. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch. Intern. Med. 171, 686–691 (2011).

    CAS  PubMed  Google Scholar 

  70. Chou, R. & Huffman, L. H. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann. Intern. Med. 147, 505–514 (2007).

    Article  PubMed  Google Scholar 

  71. Steiner, D., Munera, C., Hale, M., Ripa, S. & Landau, C. Efficacy and safety of buprenorphine transdermal system (BTDS) for chronic moderate to severe low back pain: a randomized, double-blind study. J. Pain 12, 1163–1173 (2011).

    Article  CAS  PubMed  Google Scholar 

  72. Yarlas, A. et al. A randomized, placebo-controlled study of the impact of the 7-day buprenorphine transdermal system on health-related quality of life in opioid-naive patients with moderate-to-severe chronic low back pain. J. Pain 14, 14–23 (2013).

    Article  CAS  PubMed  Google Scholar 

  73. Wild, J. E. et al. Long-term safety and tolerability of tapentadol extended release for the management of chronic low back pain or osteoarthritis pain. Pain Pract. 10, 416–427 (2010).

    Article  PubMed  Google Scholar 

  74. Buynak, R. et al. Efficacy and safety of tapentadol extended release for the management of chronic low back pain: results of a prospective, randomized, double-blind, placebo- and active-controlled phase III study. Expert Opin. Pharmacother. 11, 1787–1804 (2010).

    Article  CAS  PubMed  Google Scholar 

  75. Afilalo, M. & Morlion, B. Efficacy of tapentadol ER for managing moderate to severe chronic pain. Pain Physician 16, 27–40 (2013).

    PubMed  Google Scholar 

  76. Pergolizzi, J. et al. Tapentadol in the management of chronic low back pain: a novel approach to a complex condition? J. Pain Res. 4, 1–8 (2011).

    Google Scholar 

  77. Chou, R., Atlas, S. J., Stanos, S. P. & Rosenquist, R. W. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine 34, 1078–1093 (2009).

    Article  PubMed  Google Scholar 

  78. Finnerup, N. B., Sindrup, S. H. & Jensen, T. S. The evidence for pharmacological treatment of neuropathic pain. Pain 150, 573–581 (2010).

    Article  PubMed  Google Scholar 

  79. Skljarevski, V. et al. Efficacy and safety of duloxetine in patients with chronic low back pain. Spine 35, E578–E585 (2010).

    Article  PubMed  Google Scholar 

  80. Skljarevski, V. et al. A double-blind, randomized trial of duloxetine versus placebo in the management of chronic low back pain. Eur. J. Neurol. 16, 1041–1048 (2009).

    Article  CAS  PubMed  Google Scholar 

  81. Skljarevski, V. et al. Duloxetine versus placebo in patients with chronic low back pain: a 12-week, fixed-dose, randomized, double-blind trial. J. Pain 11, 1282–1290 (2010).

    Article  CAS  PubMed  Google Scholar 

  82. Mazza, M., Mazza, O., Pazzaglia, C., Padua, L. & Mazza, S. Escitalopram 20 mg versus duloxetine 60 mg for the treatment of chronic low back pain. Expert Opin. Pharmacother. 11, 1049–1052 (2010).

    Article  CAS  PubMed  Google Scholar 

  83. Highlights of prescribing information. FDA [online], (2013).

  84. Manchikanti, L., Pampati, V., Falco, F. J. & Hirsch, J. A. Growth of spinal interventional pain management techniques: analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine 2, 157–168 (2012).

    Google Scholar 

  85. American Society of Anesthesiologists Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 112, 810–833 (2010).

  86. Manchikanti, L. et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician 13, E215–E264 (2010).

    PubMed  Google Scholar 

  87. van Tulder, M. W., Koes, B., Seitsalo, S. & Malmivaara, A. Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Eur. Spine J. 15 (Suppl. 1), S82–S92 (2006).

    Article  PubMed  Google Scholar 

  88. Chou, R., Atlas, S. J., Loeser, J. D., Rosenquist, R. W. & Stanos, S. P. Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse? J. Pain 12, 833–839 (2011).

    Article  PubMed  Google Scholar 

  89. Chou, R. et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 34, 1066–1077 (2009).

    Article  PubMed  Google Scholar 

  90. The British Pain Society. The NICE Back Pain Issue The controversy discussed. The British Pain Society [online], (2009).

  91. van Kleef, M., Mekhail, N. & van Zundert, J. Evidence-based guidelines for interventional pain medicine according to clinical diagnoses. Pain Pract. 9, 247–251 (2009).

    Article  PubMed  Google Scholar 

  92. Guyatt, G. et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force. Chest 129, 174–181 (2006).

    Article  PubMed  Google Scholar 

  93. Van Boxem, K., Cahana, A. & Van Zundert, J. Injection therapy and denervation procedures for chronic low back pain: a systematic review--clinical value? Eur. Spine J. 5, 820–821 (2011).

    Article  Google Scholar 

  94. Carragee, E. J. et al. 2009 ISSLS Prize Winner: does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine 34, 2338–2345 (2009).

    Article  PubMed  Google Scholar 

  95. Beresford, Z. M., Kendall, R. W. & Willick, S. E. Lumbar facet syndromes. Curr. Sports Med. Rep. 9, 50–56 (2010).

    Article  PubMed  Google Scholar 

  96. Chan, C. W. & Peng, P. Failed back surgery syndrome. Pain Med. 12, 577–606 (2011).

    Article  PubMed  Google Scholar 

  97. Cohen, S. P., Huang, J. H. & Brummett, C. Facet joint pain-advances in patient selection and treatment. Nat. Rev. Rheumatol. 9, 101–116 (2013).

    Article  PubMed  Google Scholar 

  98. Cohen, S. P. et al. Establishing an optimal “cutoff” threshold for diagnostic lumbar facet blocks: a prospective correlational study. Clin. J. Pain 29, 382–391 (2013).

    Article  PubMed  Google Scholar 

  99. Armon, C., Argoff, C. E., Samuels J., Backonja, M. M. Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 68, 723–729 (2007).

    Article  CAS  PubMed  Google Scholar 

  100. Manchikanti, L. et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician 15, E199–E245 (2012).

    PubMed  Google Scholar 

  101. Deyo, R. A. et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 303, 1259–1265 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  102. Weinstein, J. N., Lurie, J. D., Olson, P. R., Bronner, K. K. & Fisher, E. S. United States' trends and regional variations in lumbar spine surgery: 1992–2003. Spine 31, 2707–2714 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  103. Gibson, J. N. & Waddell, G. Surgical interventions for lumbar disc prolapse: updated Cochrane Review. Spine 32, 1735–1747 (2007).

    Article  PubMed  Google Scholar 

  104. Gibson, J. N. & Waddell, G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine 30, 2312–2320 (2005).

    Article  PubMed  Google Scholar 

  105. Smith, Z. A. & Fessler, R. G. Paradigm changes in spine surgery-evolution of minimally invasive techniques. Nat. Rev. Neurol. 8, 443–450 (2012).

    Article  PubMed  Google Scholar 

  106. Froholdt, A., Reikeraas, O., Holm, I., Keller, A. & Brox, J. I. No difference in 9-year outcome in CLBP patients randomized to lumbar fusion versus cognitive intervention and exercises. Eur. Spine J. 21, 2531–2538 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  107. Phillips, F. M., Slosar, P. J., Youssef, J. A., Andersson, G. & Papatheofanis, F. Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review. Spine 38, E409–E422 (2013).

    Article  PubMed  Google Scholar 

  108. Willems, P. C., Staal, J. B., Walenkamp, G. H. & de Bie, R. A. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 13, 99–109 (2013).

    Article  PubMed  Google Scholar 

  109. North, R. B. et al. Failed back surgery syndrome: 5-year follow-up in 102 patients undergoing repeated operation. Neurosurgery 28, 685–690 (1991).

    Article  CAS  PubMed  Google Scholar 

  110. Simpson, E. L., Duenas, A., Holmes, M. W., Papaioannou, D. & Chilcott, J. Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin: systematic review and economic evaluation. Health Technol. Assess. 13, 1–154 (2009).

    Google Scholar 

  111. Freynhagen, R. et al. Screening of neuropathic pain components in patients with chronic back pain associated with nerve root compression: a prospective observational pilot study (MIPORT). Curr. Med. Res. Opin. 22, 529–537 (2006).

    Article  PubMed  Google Scholar 

  112. Wang, H., Schiltenwolf, M. & Buchner, M. The role of TNF-alpha in patients with chronic low back pain—a prospective comparative longitudinal study. Clin. J. Pain 24, 273–278 (2008).

    Article  PubMed  Google Scholar 

  113. Yamauchi, K. et al. Nerve growth factor of cultured medium extracted from human degenerative nucleus pulposus promotes sensory nerve growth and induces substance p in vitro. Spine 34, 2263–2269 (2009).

    Article  PubMed  Google Scholar 

  114. Katz, N. et al. Efficacy and safety of tanezumab in the treatment of chronic low back pain. Pain 152, 2248–2258 (2011).

    Article  CAS  PubMed  Google Scholar 

  115. Korhonen, T. et al. The treatment of disc-herniation-induced sciatica with infliximab: one-year follow-up results of FIRST II, a randomized controlled trial. Spine 31, 2759–2766 (2006).

    Article  PubMed  Google Scholar 

  116. Ohtori, S. et al. Epidural administration of spinal nerves with the tumor necrosis factor-alpha inhibitor, etanercept, compared with dexamethasone for treatment of sciatica in patients with lumbar spinal stenosis: a prospective randomized study. Spine 37, 439–444 (2012).

    Article  PubMed  Google Scholar 

  117. Freynhagen, R., Baron, R., Gockel, U. & Tolle, T. R. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr. Med. Res. Opin. 22, 1911–1920 (2006).

    Article  PubMed  Google Scholar 

  118. O'Connor, A. B. Neuropathic pain: quality-of-life impact, costs and cost effectiveness of therapy. Pharmacoeconomics 27, 95–112 (2009).

    Article  PubMed  Google Scholar 

  119. Schmidt, C. O. et al. Modelling the prevalence and cost of back pain with neuropathic components in the general population. Eur. J. Pain 13, 1030–1035 (2009).

    Article  PubMed  Google Scholar 

  120. Shaw, W. S., Main, C. J. & Johnston, V. Addressing occupational factors in the management of low back pain: implications for physical therapist practice. Phys. Ther. 91, 777–789 (2011).

    Article  PubMed  Google Scholar 

  121. Rozenberg, S., Foltz, V. & Fautrel, B. Treatment strategy for chronic low back pain. Joint Bone Spine 79, 555–559 (2012).

    Article  PubMed  Google Scholar 

  122. Van Boxem, K. et al. 11. Lumbosacral radicular pain. Pain Pract. 10, 339–358 (2010).

    Article  PubMed  Google Scholar 

  123. van Kleef, M. et al. 12. Pain originating from the lumbar facet joints. Pain Pract. 10, 459–469 (2010).

    Article  PubMed  Google Scholar 

  124. Vanelderen, P. et al. 13. Sacroiliac joint pain. Pain Pract. 10, 470–478 (2010).

    Article  PubMed  Google Scholar 

  125. Kallewaard, J. W. et al. 15. Discogenic low back pain. Pain Pract. 10, 560–579 (2010).

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The author would like to express his sincere gratitude to Elke Van Ael, Ph.D. for her excellent editorial support during the revision process of the manuscript.

Author information

Authors and Affiliations

  1. The Leuven Centre for Algology & Pain Management, University Hospitals Leuven, Weligerveld 1, 3212, Pellenberg, Belgium

    Bart Morlion

Authors
  1. Bart Morlion
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

B. Morlion has served as a speaker, consultant and/or clinical science investigator for Pfizer, Mundipharma, Grünenthal and Eli Lilly.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Morlion, B. Chronic low back pain: pharmacological, interventional and surgical strategies. Nat Rev Neurol 9, 462–473 (2013). https://doi.org/10.1038/nrneurol.2013.130

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrneurol.2013.130

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Translational Research

Sign up for the Nature Briefing: Translational Research newsletter — top stories in biotechnology, drug discovery and pharma.

Get what matters in translational research, free to your inbox weekly. Sign up for Nature Briefing: Translational Research