management of the patient’s condition.
Radiographic studies and laboratory tests should
not be routinely ordered for patients with acute
symptoms; rather, they should be used selectively
based upon the history, physical examination, and
the initial response to treatment.
Finally, the identification of ‘yellow flags’ and
‘blue flags’ (factors that might contribute to a poor
prognosis; see Table 2) becomes relevant in patients
who do not make a rapid recovery. These factors
need to be identified and rectified early to avoid
the risk of developing chronic pain and disability. 6
Because most individuals with low back pain (90%)
will have a self-limited, non-specific mechanical
cause, the goal of the clinical evaluation is
ultimately to efficiently identify rare serious causes
as well as those patients who might be at higher
risk for delayed improvement due to neurological
impairment or psychosocial factors.
‘Chronification’ and treatment
In many countries, clinical guidelines have been
issued for the management of low back pain and,
in general, the recommendations are similar across
guidelines worldwide. Currently, the treatment for
chronic low back pain is mostly symptomatic. That
exercise (such as aquatic exercises, stretching,
strength training, and endurance) and intensive
multidisciplinary pain treatment programmes with
educational interventions and (cognitive) behaviour
therapy are effective for chronic low back pain, is
supported by strong evidence. Fewer data support
the effectiveness of analgesics, antidepressants,
NSAIDs or opioids
Although evidence of effectiveness and safety
associated with long-term treatment is currently
limited for all conventional opioids, a new molecule
characterised by a unique mechanism of action
acting at both, the nociceptive and neuropathic
components of pain has come into focus for the
treatment of a mixed pain conditions such as back
pain. The atypical opioid tapentadol is a dual
μ-opioid receptor (MOR) agonist and noradrenaline
reuptake inhibitor (NRI), which represents the first
and unique member of a new class of analgesic
agents, MOR-NRI. 13 Due to the synergistic interaction
of the two mechanisms, lower opioid activity is
needed to reach comparable analgesia and therefore
a more favourable tolerability profile is achieved,
in terms of gastrointestinal, respiratory, and
endocrinological adverse events. This is of utmost
importance, given the frequent need of long-term
treatment in patients with low back pain. But
whichever opioid is chosen, prescriptions should
always be for a limited period with the lowest
effective dose that provides meaningful pain relief
and improved function with manageable side
effects. Risk mitigation and reassessment strategies
should be routinely incorporated. It should be borne
in mind that opioids are not first-line treatment for
low back pain and might not be appropriate in all
patients; however, the benefits might outweigh the
risks after a thorough evaluation and if other drugs
are contraindicated, not tolerated, or ineffective.
Although the use of anticonvulsants (for example,
gabapentin, pregabalin) has increased substantially
in recent years, despite moderate evidence that they
are ineffective for treatment of low back and lumbar
radicular pain, the latest results suggest that the
recommendations from guidelines regarding
neuropathic pain should not be extended to
sciatica. 14 However, based on the underlying pain
type, their use in clinical routine is common,
especially if patients suffer from comorbidities such
FIGURE 1
The painDETECT screening tool
About 90% of all
patients will have
non-specific low
back pain, which,
in essence, is a
diagnosis based
on exclusion of a
specific pathology
as depression, anxiety or sleep disorders. The same
holds true for antidepressants. 1,5,15
When drugs are used for symptomatic treatment,
patients should be treated with the most suitable
agent, at the lowest possible dose and for the
shortest time possible. For patients without
significant neurological impairment, the initial
treatment should include activity modification,
non-narcotic analgesics and education; for those
whose symptoms do not improve after 2–4 weeks,
referral for physical treatments is mandatory. 5
Invasive procedures in (non-specific) chronic low
back pain (that is, facet joint, epidural, trigger point
interventions) have shown conflicting results.
Spinal cord stimulation (SCS) is gaining increasing
indications in an expanding variety of clinical
conditions. The most common application in the last
decades has been the treatment of persistent pain
following low back surgery. There is good evidence
for SCS as a treatment for failed back surgery
syndrome (FBSS) with persistent axial and radicular
complaints, as well as for SCS vs. re-operative
surgical management for FBSS. 16
Pain in the low back has proven more difficult to
treat than radiating leg pain, and no sound evidence
is available for the efficacy of surgery. Surgical
discectomy as a last resort may be considered for
selected patients with sciatica due to lumbar disc
prolapse that do not respond to initial conservative
management. Fusion surgery, under debate for
decades, has yet to show convincing evidence.
Most patients have self-limited episodes of acute
low back pain, which might resolve without
treatment. However, in some cases people present
with recurrent episodes, with longer duration and
more debilitating in their nature. In fact, it is rare
to have true remission, with a single episode of pain
never recurring. This ‘chronification’ of low back
pain is problematic because of the long-term side
effects, including risk of addiction, of some of the
drugs used to alleviate pain. 1
Although physicians typically manage patients
based upon the duration of symptoms (acute,
subacute, and chronic) and the presence of
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