What Neurologists Look For In Patients With Lower Back Pain

Dr. Giedrė Armalienė

Relevance of the Problem

Lower back pain is one of the most common complaints in both family physician and specialist practice. Essentially, it is not a specific nosological entity; this category includes a group of symptoms (pain, muscle tension, specific antalgic postures, etc.), the causes of which are often undetermined. In clinical practice, for convenience (and also when evaluating treatment effectiveness), this pain is often classified as acute (up to 4-6 weeks), subacute (>4-6 weeks to 12 weeks), and chronic (>12 weeks) (1, 5).

According to the World Health Organization, chronic lower back pain is one of the ten leading conditions associated with both increased years lived with disability (without optimal quality of life) and lost workdays. It is estimated that in developed countries, approximately 60-70% of the population experience lower back pain at some point in their lives, most commonly between the ages of 35 and 55, although younger people, including adolescents, have increasingly been affected in recent years (1). This is likely related to lower levels of physical activity and the widespread use of smart technologies in society, with less attention given to active leisure (2).

Since pain tends to recur (especially if the first episode significantly limited physical activity), it is sometimes difficult to assess the frequency of new cases. Among adults, the annual incidence is reported to range from 6.3 to 15.4%, while pain recurrence after the first episode may occur in 24-80% of patients (3).

Risk Factors: Patient Selection And Diagnostic Tactics

Lower back pain is most commonly caused by nonspecific reasons, and only rarely does it indicate a serious underlying disease or condition. Essentially, the primary task of both the family physician and the specialist is to rule out so-called red flag signs, i.e., historical data or symptoms indicating a specific origin of pain (e.g., trauma or spinal tumors). It is believed that these causes account for less than 15% of all cases (according to various authors, 5-15%) (1).

The remaining 85-95% of patients usually do not require additional testing or specific interventions. Patients generally recover with conservative treatment in primary care, except for those whose pain becomes chronic and leads to long-term disability (11-12% of patients suffering from nonspecific lower back pain) (4).

Guidelines from the American College of Physicians and the American Pain Society recommend dividing all patients complaining of back pain into 3 groups based on medical history and primary clinical examination:

● nonspecific lower back pain;
● back pain associated with radiculopathy or spinal stenosis;
● back pain caused by other specific reasons (5).

Nonspecific lower back pain (especially chronic pain) may result from changes in many structures — muscles, tendons, facet joints, intervertebral discs, or microstructural vertebral changes, as well as altered blood flow in the spinal cord and nerves. All of these tissues may be compressed, stretched, or otherwise mechanically affected, leading to local sterile inflammation caused by the production of cytokines and/or chemokines in affected structures.

These substances act on nerve fibers and cause pain, while inflammatory edema may also develop. These changes worsen local blood flow, reducing tissue oxygenation and nutrient supply, while inflammatory mediators are removed more slowly. As a result, a vicious cycle develops and the process may become chronic (1).

These changes are not visible on routine imaging studies, making it difficult to explain patients’ symptoms and reassure them that the condition is benign.

Are patients in the second and third groups common? According to American authors, spinal tumors or metastases are detected in 0.7% of cases, compression fractures in 4%, and infectious processes (spondylodiscitis, paravertebral abscesses) in 0.01% of primary cases. Specific rheumatic diseases such as ankylosing spondylitis account for 0.3-5% of cases.

Vertebrogenic causes of back pain — disc herniation and spinal canal stenosis — account for 3-4% of back pain cases, while severe conditions such as cauda equina syndrome are identified in only 0.04% of patients complaining of lower back pain (5).

During the initial consultation, patients should be asked to describe the pain (nature, duration, intensity according to the Visual Analog Scale (VAS), aggravating and relieving factors), associated symptoms, and treatment effectiveness. It is also important to assess risk factors that may contribute to lower back pain.

Specific occupational positions are important, as work-related factors may contribute to up to 37% of nonspecific lower back pain cases, especially activities involving repeated bending and twisting movements, prolonged static postures, and vibration exposure. Healthcare workers, construction workers, and professional drivers are considered among the highest-risk occupational groups.

Psychological factors, including high levels of stress and anxiety, psychiatric comorbidity, and poor socioeconomic conditions, may also contribute. Lower back pain is more common among pregnant women, overweight individuals, and tall patients, who are more prone to intervertebral disc herniation, instability, and facet joint pathology.

If pain presentation is atypical, internal organ pathology such as pancreatitis, kidney stones, or aortic aneurysm should be ruled out. Additionally, if there is a history of malignancy, intravenous drug use, or accompanying symptoms such as unexplained weight loss, fever, systemic infection signs, or joint pain, systemic disease or oncological progression must be excluded (1).

Both American and European guidelines indicate that additional instrumental examinations are unnecessary when nonspecific lower back pain is suspected based on history and physical examination, as imaging does not alter treatment strategy or clinical outcomes (1, 5).

There is also no evidence supporting imaging studies when pain persists for 1-2 months without neurological deficits or other emerging symptoms (5).

Conversely, if neurological deficits are detected during the initial examination, especially if progressing over days or weeks, or if another underlying pathology is suspected, patients should be referred to a specialist for further evaluation and management.

One proposed diagnostic algorithm is presented in Table 1.

Table 1. Possible Specific Causes of Low Back Pain and Recommended Diagnostic Methods

Possible Cause of Low Back Pain	Medical History / Examination Findings	Recommended Imaging Tests	Laboratory Tests
Oncological disease	History of cancer and newly developed back pain Unexplained weight loss Condition worsening for >1 month Age >50 years Multiple risk factors	MRI Lumbosacral spine X-ray MRI or X-ray	ESR
Infectious process	Fever Intravenous drug use History of infectious disease	MRI	ESR and/or CRP
Cauda equina syndrome	Urinary retention Severe neurological deficit Fecal incontinence “Saddle” anesthesia	MRI	Not indicated
Compression fractures	Osteoporosis Long-term glucocorticoid use Older age	Lumbosacral spine X-ray	Not indicated
Ankylosing spondylitis	Morning stiffness Pain relief with activity Alternating buttock pain Pain worsening during the second half of the night Young age	Pelvic X-ray in AP and lateral views	ESR and/or CRP, HLA-B27 test
Severe or progressive neurological deficit	Progressive motor deficit	MRI	Electrography and myelography may be useful
Disc herniation	Back pain radiating to the legs along L4/L5/S1 pathways Positive Lasègue test Symptoms lasting >1 month	Not indicated initially MRI	Electrography and myelography may be useful
Spinal canal stenosis	Pain radiating to both legs Older age (Pseudo-claudication symptoms are less informative diagnostically) Symptoms lasting >1 month	Not indicated initially MRI	Electrography and myelography may be useful

MRI – Magnetic Resonance Imaging; ESR – Erythrocyte Sedimentation Rate; CRP – C-reactive Protein.

It is important to note that imaging studies, when intervertebral disc pathology or spinal canal stenosis is suspected, are recommended only if symptoms persist for more than 1 month. Radiculopathy caused by disc herniation usually improves with conservative treatment, and patients typically show improvement within approximately 4 weeks. Therefore, additional testing is necessary only when conservative treatment is ineffective or when invasive procedures — such as neurosurgical interventions or epidural steroid injections — are being considered (5).

On the other hand, if lower back pain does not improve and persists for more than 4 weeks without alarming symptoms, recommendations in most countries suggest evaluating so-called yellow flag signs, i.e., possible psychosocial factors contributing to the development of chronic pain (6).

These factors include psychiatric comorbidity, work and/or family problems, poor socioeconomic conditions, and others. Such patients often do not believe that their back pain is unrelated to a serious underlying condition, are afraid to exercise or engage in more active physical activity because they believe it will inevitably trigger another episode of pain (they tend to trust passive treatment methods more than active ones), and usually show a tendency toward negative mood or pessimism.

Various questionnaires and screening tools are recommended for identifying these patients in primary care settings, such as the Keele STarT Back Screening Tool (freely available online in English), which can help identify high-risk patients and refer them for targeted support, including psychotherapy, rehabilitation, or assistance with social issues, while avoiding unnecessary interventions (e.g., surgical treatment).

Table 2. Conservative Treatment Methods for Low Back Pain

(Level B evidence-based methods are presented; there are no Level A recommendations for clinical practice)

Treatment Category	Method	Acute Pain (up to 4 weeks)	Subacute or Chronic Pain (>4 weeks)
Patient-directed measures	Physical activity	+	+
	Patient education and information	+	+
	Heat compresses	+
Medication treatment	Paracetamol	+	+
	NSAIDs	+	+
	Muscle relaxants	+
	Antidepressants (tricyclics)		+
	Benzodiazepines	+	+
	Tramadol, opioid analgesics	+	+
Non-pharmacological treatment	Manual therapy (chiropractic)	+	+
	Exercise therapy		+
	Massage		+
	Acupuncture		+
	Yoga		+
	Cognitive behavioral therapy		+
	Relaxation techniques		+
	Comprehensive rehabilitation		+

Tactics For Treating Lower Back Pain

There are quite a few individual research groups and various society recommendations defining the principles of treating nonspecific lower back pain, but there are no universally accepted level A recommendations. The results of randomized clinical trials conducted on this condition are often uninformative or inconclusive.

On one hand, this is frequently due to heterogeneous patient samples and poor patient selection (including patients suffering from nonspecific back pain, radiculopathic pain, or recurrent episodes of back pain). On the other hand, study results are often inconclusive because of high dropout rates, poor study design, or other methodological limitations (6).

Nevertheless, when comparing different recommendations, similar trends are observed, which clinicians generally follow in clinical practice.

First of all, all new cases of lower back pain should be evaluated and treated at the primary care level, i.e., by a family physician. Patients should be informed that lower back pain usually improves significantly or resolves completely within a month and that the prognosis is generally favorable.

Patients should also be informed that early imaging studies usually do not identify the cause of pain and do not alter treatment strategy; therefore, they are not useful during the early phase of the condition unless more serious pathology is suspected or there are indications for specialist consultation and additional testing.

During the first visit, a treatment plan should be established, and restrictions related to work and physical activity should be explained to the patient if necessary, especially when pain is severe. A follow-up visit should also be scheduled if reevaluation is needed (5).

All recommendations suggest that patients should remain active and avoid prolonged bed rest. In cases of severe pain, bed rest is recommended for no longer than 2-4 days (6).

It is important to note that, in addition to regular physical activity, comprehensive rehabilitation is generally not recommended during the acute phase and is usually reserved for the management of subacute or chronic pain (5).

Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for treating acute lower back pain. Acetaminophen has weaker analgesic properties but is considered safer. However, attention should be paid to keeping the daily dose as low as possible because of potential hepatotoxic effects.

In most cases, NSAIDs remain the first-line medications — both non-selective and selective cyclooxygenase inhibitors are considered effective. However, contraindications related to gastrointestinal disease (for non-selective NSAIDs) or cardiovascular pathology (for selective NSAIDs) should always be evaluated (5).

Tricyclic antidepressants are recommended from the group of adjuvant analgesics for relieving subacute and chronic back pain. According to clinical trial data, the effectiveness of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) in treating nonspecific lower back pain has not been proven.

However, some patients — especially those suffering from chronic back pain — may also experience depression, making medications from these groups appropriate and necessary in certain cases for more effective overall treatment.

Antiepileptic drugs (AEDs), especially gabapentin, are frequently prescribed for prolonged back pain treatment. However, their effectiveness has only been demonstrated in treating back pain associated with radiculopathy. Therefore, AEDs are not recommended for treating nonspecific back pain (unlike radiculopathic pain) (5).

During the acute phase, muscle relaxants (tizanidine, baclofen, and others) are often prescribed together with NSAIDs because of their effectiveness in relieving pain demonstrated in clinical trials (1, 5). However, they should not be used long term because of adverse effects on the central nervous system, particularly sedation.

The use of benzodiazepines and opioid analgesics should also be limited. Benzodiazepines are recommended during the acute phase as adjuvant therapy to reduce pain, partly because of their muscle-relaxing properties, but prolonged use should be avoided because of the risk of dependence.

Opioid analgesics are reserved for managing very severe acute pain (short-acting forms) and, in selected cases, for subacute and chronic pain management (extended-release forms) when adequate pain relief cannot be achieved with other medications or when contraindications to other drug groups exist (1, 5).

Systemic corticosteroids have been prescribed for acute pain relief in both nonspecific lower back pain and radiculopathic pain caused by intervertebral disc pathology. However, their use is not supported by clinical trial data, as studies have shown no statistically significant benefit compared with placebo groups. Therefore, this treatment has not been recommended in clinical practice in recent years (7, 8).

Aminophylline is used in certain countries (e.g., the Russian Federation) to treat radiculopathic pain caused by intervertebral disc herniation, but there are no clinical studies or recommendations supporting its use. Potential adverse reactions should also be considered when evaluating patient safety.

As adjuvant therapy, B-group vitamins are frequently prescribed in both injectable and oral forms. Studies and reviews evaluating the use of B-group vitamins for back pain remain controversial. According to some data, combining analgesic therapy with B-group vitamins may lead to faster symptom regression, lower pain intensity, and the possibility of using lower analgesic doses. However, other authors report no additional analgesic benefit (9, 10).

In cases of persistent pain, rehabilitative measures should be considered. Certain treatments — including acupuncture, massage, yoga, manual therapy, and cognitive behavioral therapy — have demonstrated effectiveness (5).

All recommended conservative treatment measures for both acute and chronic lower back pain are summarized in Table 2.

The question arises as to when patients should be referred to a specialist regarding possible surgical treatment or epidural steroid injections.

Clinical guidelines recommend conservative treatment during the acute phase, except in urgent neurosurgical situations where cauda equina syndrome is suspected or when neurological motor deficits progress rapidly.

In cases of nonspecific chronic lower back pain, after other treatment alternatives have been attempted, patients may be referred for consultation regarding surgical treatment or other interventions, with these options discussed carefully with the patient (5).

The timeframe defining unsuccessful conservative treatment varies considerably, ranging from 3 months to 2 years.

Epidural steroid injections are considered minimally effective for nonspecific lower back pain but somewhat effective in cases of radiculopathy and intervertebral disc pathology.

Surgical treatment may be considered for nonspecific chronic lower back pain lasting more than 1 year without red flag symptoms.

Its effectiveness, especially in older patients, remains questionable because degenerative changes observed on imaging studies are not always directly related to the patient’s symptoms. As a result, fewer than half of patients are satisfied with surgical outcomes because pain may persist after surgery.

In cases involving radiculopathy symptoms, surgical intervention during the acute phase may improve pain and disability associated with intervertebral disc pathology. However, studies have not demonstrated statistically significant differences in treatment outcomes after 1 or 2 years compared with non-operated patients (11).

 

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