Chronic Low Back Pain: A Comprehensive Guide to Differential Diagnosis

Introduction

Chronic low back pain stands as a pervasive health issue, prompting numerous patient consultations in both primary and emergency care settings. The economic burden is substantial, with billions spent annually on management, coupled with significant losses in work productivity and compensation claims.[1] While back pain’s origins are diverse, ranging from mechanical to non-specific causes, mechanical issues constitute the majority, approximately 90% of cases. This prevalence of common etiologies can sometimes overshadow rarer, but potentially serious, underlying conditions.[2, 3] For clinicians, the critical aspects of managing back pain lie in effectively identifying red flags that signal severe pathologies and establishing an accurate diagnosis to guide appropriate treatment strategies. While most cases respond to conservative management, the presence of nerve dysfunction or other alarming symptoms necessitates thorough investigation and a multidisciplinary approach.[4] Effective pharmacological interventions span pain relievers targeting both peripheral and central neurological pathways, as well as muscle relaxants.[5] Non-pharmacological options, including various forms of physical therapy, offer alternatives for patients seeking to avoid medication or recover from injuries.[6] Acupuncture has also emerged as a complementary therapy showing moderate benefits in alleviating back pain. Surgical intervention remains a last resort, typically reserved for cases involving severe nerve dysfunction or serious underlying causes such as malignancy.[7, 8] For persistent back pain lasting beyond six weeks post-injury, imaging techniques like radiography, CT scans, or MRI become crucial for detailed assessment. A comprehensive evaluation is paramount to pinpoint the root cause of back pain, facilitating the development of a tailored treatment plan. Addressing the underlying etiology is key to significantly improving a patient’s functional capacity and overall quality of life. In the realm of automotive repair, much like in human health, accurate diagnosis is the cornerstone of effective treatment. Just as we meticulously diagnose vehicle issues at xentrydiagnosis.store, healthcare professionals must adeptly navigate the complexities of Chronic Low Back Pain Differential Diagnosis to ensure optimal patient outcomes.

Etiology of Chronic Low Back Pain: A Differential Diagnostic Perspective

Chronic low back pain, defined as pain persisting for 12 weeks or longer, presents a complex diagnostic challenge due to its diverse etiologies. Understanding these different causes is crucial for differential diagnosis and targeted treatment. Back pain can be broadly categorized, each category requiring careful consideration in the diagnostic process:[9]

• Traumatic Injuries: While trauma is often associated with acute back pain, unresolved or improperly managed injuries can lead to chronic conditions. Whiplash injuries, persistent strains, and inadequately healed traumatic fractures can all be sources of chronic pain. Differential Diagnosis Consideration: Rule out acute injury exacerbations and consider the psychological impact of the initial trauma contributing to chronic pain perception.

• Degenerative Conditions: Age-related degeneration of musculoskeletal structures is a common culprit in chronic back pain. Conditions like intervertebral disc herniation and degenerative disc disease progressively worsen over time. Differential Diagnosis Consideration: Distinguish between normal age-related changes and pathological degeneration causing significant pain and functional limitation. Consider osteoarthritis of the facet joints as well.

• Oncologic Causes: Primary or secondary malignant lesions in the back’s anatomical structures can manifest as chronic back pain. Pathologic fractures due to bone weakening from tumors are also possible. Differential Diagnosis Consideration: Malignancy, though less common, is a critical ‘red flag’ to rule out, especially in patients with risk factors or persistent, unexplained pain.

• Infections: Infections of the musculoskeletal structures, either from direct inoculation or spread from another site, can lead to chronic pain if not effectively treated. Differential Diagnosis Consideration: Consider infections like vertebral osteomyelitis, discitis, and epidural abscess, particularly in immunocompromised individuals or those with recent spinal procedures.

• Inflammatory Conditions: Inflammatory conditions not linked to infection or malignancy, such as ankylosing spondylitis and sacroiliitis, are significant causes of chronic back pain. Chronic inflammation can also lead to spinal arthritis. Differential Diagnosis Consideration: Differentiate inflammatory back pain from mechanical pain by assessing for morning stiffness, pain improvement with activity, and extra-articular manifestations.

• Metabolic Disorders: Metabolic imbalances affecting calcium and bone metabolism, like osteoporosis and osteosclerosis, can contribute to chronic back pain and increase fracture risk. Differential Diagnosis Consideration: Evaluate bone density and consider metabolic bone diseases, especially in elderly patients or those with risk factors for osteoporosis.

• Referred Pain: Pain originating from visceral organs, such as in biliary colic, lung disease, or aortic/vertebral artery pathology, can be referred to the back and become chronic if the underlying condition is unresolved. Differential Diagnosis Consideration: Thoroughly assess for visceral causes of back pain, especially if the pain pattern is atypical or accompanied by systemic symptoms. Consider abdominal and pelvic organ pathology.

• Postural Factors: Prolonged upright postures, pregnancy, and certain occupations can contribute to postural back pain that may become chronic due to sustained strain on spinal structures. Differential Diagnosis Consideration: Evaluate posture and ergonomic factors in the patient’s daily life and work environment.

• Congenital Anomalies: Inborn conditions affecting the axial skeleton, such as kyphoscoliosis and tethered spinal cord, can cause chronic back pain from childhood or adolescence. Differential Diagnosis Consideration: Consider congenital spinal abnormalities, especially in younger patients with long-standing back pain or associated neurological findings.

• Psychiatric Factors: Chronic pain syndromes and mental health conditions can manifest as chronic back pain. Malingering should also be considered, though it’s a diagnosis of exclusion. Differential Diagnosis Consideration: Assess psychological factors, including depression, anxiety, and pain catastrophizing, as they can significantly influence chronic pain perception and management.

Understanding the diverse etiology of chronic low back pain is paramount for formulating an effective differential diagnosis. A systematic approach, considering each of these categories, will guide clinicians towards accurate diagnosis and appropriate management strategies.

Epidemiology of Chronic Low Back Pain: Implications for Differential Diagnosis

The widespread nature of back pain, particularly chronic low back pain (CLBP), underscores its significance as a global health concern and emphasizes the need for robust differential diagnostic skills. Studies reveal that CLBP affects a substantial portion of the adult population worldwide, with estimates reaching up to 23%.[10] Furthermore, the recurrence rates are alarmingly high, ranging from 24% to 80% within a year, highlighting the persistent and often relapsing nature of this condition.[11] The lifetime prevalence of back pain is even more striking, affecting as many as 84% of adults at some point in their lives.[12]

While less prevalent in pediatric populations compared to adults, back pain is not uncommon in children and adolescents. A Scandinavian study indicated a point prevalence of approximately 1% in 12-year-olds and 5% in 15-year-olds. By late adolescence and early adulthood, around 50% of individuals would have experienced at least one episode of back pain.[13] The lifetime prevalence in adolescents steadily increases with age, approaching adult levels by age 18.[14]

Epidemiological Considerations for Differential Diagnosis:

• High Prevalence: The sheer prevalence of CLBP means it will be a frequent presenting complaint in clinical practice. Clinicians must be adept at efficiently and accurately differentiating between various causes.
• Recurrence: The high recurrence rate suggests that even after initial treatment, patients may return with similar symptoms. Differential diagnosis should be revisited in recurrent cases to rule out new or previously missed etiologies.
• Age-Related Differences: While CLBP is more common in adults, its increasing prevalence in adolescents necessitates age-specific differential diagnostic considerations. Etiologies and red flags may differ between age groups.
• Global Impact: As a global health issue, CLBP affects diverse populations. Epidemiological data may vary across regions, potentially influencing the likelihood of certain etiologies based on geographical factors and demographics.

Understanding the epidemiology of chronic low back pain provides crucial context for differential diagnosis. It reinforces the need for a systematic and thorough approach to evaluation, considering the high prevalence, recurrence, and age-related nuances of this condition. This epidemiological perspective helps frame the clinical challenge and underscores the importance of accurate and timely diagnosis to mitigate the individual and societal burden of chronic low back pain.

History and Physical Examination in Chronic Low Back Pain: Guiding the Differential Diagnosis

A comprehensive history and physical examination are the cornerstones of effectively navigating the differential diagnosis of chronic low back pain. These initial steps are crucial for narrowing down the possibilities and guiding further investigations.

History Taking:

• Onset and Duration: Establishing the onset of pain is paramount. Chronic back pain is defined as pain lasting longer than 12 weeks. Understanding whether the onset was gradual or sudden, and if related to any specific event, is crucial. Differential Diagnosis Clue: Gradual onset may suggest degenerative or inflammatory conditions, while sudden onset, even in chronic pain, could indicate an acute exacerbation or new pathology.

• Pain провоцирующие and Alleviating Factors: Identifying factors that worsen or relieve the pain provides significant diagnostic clues. Differential Diagnosis Clue: Mechanical pain often worsens with activity and improves with rest, while inflammatory pain may improve with movement and worsen with prolonged rest. Pain aggravated by coughing or sneezing might suggest disc herniation.

• Pain Quality and Location: Describing the pain quality (e.g., sharp, dull, burning, aching) and precise location helps differentiate between visceral and somatic pain. Well-localized pain often points to a musculoskeletal origin. Differential Diagnosis Clue: Radiating pain down the leg (radiculopathy) suggests nerve root involvement, often from disc herniation or spinal stenosis.

• Associated Symptoms: Inquiring about associated symptoms is vital for identifying systemic conditions or red flags. Differential Diagnosis Clue: Fever, night sweats, unexplained weight loss, or bowel/bladder dysfunction are red flags for serious conditions like infection, malignancy, or cauda equina syndrome.

• Medical, Family, Occupational, and Social History: Gathering information about past medical conditions, family history of autoimmune diseases, occupational demands, and social factors provides valuable context. Differential Diagnosis Clue: History of cancer, autoimmune disease, recent infection, or osteoporosis increases the likelihood of back pain being secondary to these conditions. Occupations involving repetitive lifting or prolonged sitting can contribute to mechanical back pain.

Physical Examination:

• Inspection: Visual inspection of the back may reveal postural abnormalities, deformities, skin lesions, or signs of inflammation. Differential Diagnosis Clue: Scoliosis, kyphosis, or lordosis can contribute to chronic back pain. Skin changes might suggest underlying inflammatory conditions.

• Palpation: Palpation helps identify areas of tenderness, muscle spasm, and bony abnormalities. Differential Diagnosis Clue: Localized tenderness over the spinous processes could indicate vertebral fracture or infection. Muscle spasm suggests muscle strain or guarding due to underlying pain.

• Range of Motion (ROM): Assessing spinal ROM (flexion, extension, lateral bending, rotation) helps evaluate mechanical dysfunction and pain provocation. Differential Diagnosis Clue: Limited ROM and pain with specific movements can indicate facet joint pathology, muscle strain, or discogenic pain.

• Neurological Examination: A thorough neurological exam is crucial to assess for nerve root compression or neurological deficits. This includes testing:

  • Strength: Assess muscle strength in major muscle groups of the lower extremities.
  • Sensation: Test light touch, pinprick, and vibration sensation in dermatomal patterns.
  • Reflexes: Evaluate deep tendon reflexes (patellar, Achilles).
  • Straight Leg Raise (SLR) Test: This provocative test is useful for diagnosing lumbar disc herniation. Pain radiating down the leg during SLR suggests nerve root irritation. Differential Diagnosis Clue: A positive SLR test is suggestive of lumbar radiculopathy, often due to disc herniation.

• Provocative Maneuvers: Specific maneuvers like the Stork test (for spondylolysis) and Adam’s test (for scoliosis) can be performed based on clinical suspicion.

Red Flags in History and Physical Exam:

Identifying red flags is paramount for prompt recognition of potentially serious underlying conditions requiring immediate attention.

Adult Red Flags:

• History:
  • History of malignancy
  • Unexplained weight loss
  • Fever, chills, night sweats
  • Recent infection (especially UTI, skin infection, IV drug use)
  • Immunosuppression
  • Trauma (significant for age)
  • Prolonged corticosteroid use
  • Osteoporosis
  • Age > 70 years
• Physical Exam:
  • Focal tenderness to palpation
  • Fever
  • Neurological deficits: progressive motor or sensory loss, saddle anesthesia, bowel/bladder dysfunction (urinary retention or incontinence, fecal incontinence), anal sphincter atony, significant motor weakness.

Pediatric Red Flags:

• History:
  • Age < 4 years
  • Nighttime pain
  • Unexplained weight loss
  • Fever, chills, night sweats
  • History of TB exposure
  • Morning stiffness > 30 minutes (improving with activity)
• Physical Exam:
  • Focal tenderness to palpation
  • Fever
  • Limited range of motion
  • Neurological deficits (though less common than in adults)

The history and physical examination provide the essential framework for the differential diagnosis of chronic low back pain. By systematically gathering information and performing a focused physical exam, clinicians can effectively narrow the diagnostic possibilities and identify patients who require further investigation or specialist referral. Recognizing red flags is critical for ensuring timely intervention in serious conditions.

Evaluation and Diagnostic Testing in Chronic Low Back Pain Differential Diagnosis

While history and physical examination are often sufficient to guide initial management, further evaluation with diagnostic testing becomes necessary in certain scenarios, particularly in the context of chronic low back pain differential diagnosis. The decision to pursue imaging or laboratory tests is guided by the presence of red flags, persistent symptoms despite conservative management, and the need to rule out specific conditions.

Imaging Modalities:

• Plain Radiographs (X-rays): AP and lateral radiographs are useful for detecting bony pathologies such as fractures, tumors, infections, and degenerative changes. (See Image. Multiple Myeloma Involving the Spine) Differential Diagnosis Application: Initial imaging for suspected fractures, tumors, or infections involving bone. Less sensitive for soft tissue pathology.

  Alt Text: Lateral lumbar spine X-ray showing lytic lesions in the L1 and L4 vertebral bodies, indicative of Multiple Myeloma.

• Magnetic Resonance Imaging (MRI): MRI is the imaging modality of choice for evaluating soft tissues, including intervertebral discs, nerves, ligaments, and spinal cord. It is highly sensitive for detecting disc herniation, spinal stenosis, soft tissue tumors, infections (osteomyelitis, discitis, epidural abscess), and inflammatory conditions. [24, 25] Differential Diagnosis Application: Indicated for suspected disc herniation, radiculopathy, spinal stenosis, infection, tumor, cauda equina syndrome, and inflammatory conditions when soft tissue involvement is suspected.

• Computed Tomography (CT): CT scans are excellent for visualizing bony details and are often used to further evaluate findings from plain radiographs or MRI, particularly in cases of trauma, complex fractures, and bony stenosis. CT myelography (CT scan after injecting contrast into the spinal canal) can be used to visualize nerve root compression in patients who cannot undergo MRI. Differential Diagnosis Application: Useful for clarifying bony pathology seen on X-ray or MRI, especially in trauma, spinal stenosis, and pre-operative planning. CT myelography can be considered when MRI is contraindicated and nerve root compression needs to be assessed.

• Bone Scan: Bone scans are highly sensitive for detecting areas of increased bone turnover, such as in osteomyelitis, discitis, stress fractures, and metastatic bone disease. However, they are less specific than MRI and CT. [26] Differential Diagnosis Application: May be used as a screening tool for infection, fracture, or tumor when MRI is not readily available or contraindicated. Often followed by more specific imaging like MRI or CT.

• Electromyography (EMG) and Nerve Conduction Studies (NCS): These electrodiagnostic tests assess nerve and muscle function. EMG/NCS can help identify nerve root compression (radiculopathy), peripheral neuropathy, and muscle disorders. Differential Diagnosis Application: Useful for confirming radiculopathy, differentiating nerve root compression from peripheral neuropathy, and evaluating patients with persistent neurological symptoms or prior spinal surgery.

• Diagnostic Injections: Image-guided injections into facet joints, sacroiliac joints, or nerve roots can be used to diagnose the source of pain. Pain relief following injection supports the involvement of the targeted structure. [92] Differential Diagnosis Application: Can help confirm facet joint pain, sacroiliac joint dysfunction, or nerve root pain when clinical and imaging findings are inconclusive.

Laboratory Tests:

Laboratory tests are less commonly used in routine evaluation of chronic low back pain but may be indicated when infection, inflammation, malignancy, or metabolic disorders are suspected in the differential diagnosis.

• Inflammatory Markers (ESR, CRP): Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can suggest infection or inflammatory conditions. [30] Differential Diagnosis Application: Non-specific markers of inflammation. Elevated levels support the diagnosis of infection or inflammatory conditions, but normal levels do not rule them out.

• Complete Blood Count (CBC): CBC can help detect infection (elevated white blood cell count) or malignancy (anemia, abnormal white blood cell counts). Differential Diagnosis Application: May reveal signs of infection or malignancy, but not specific for back pain etiology.

• Blood Cultures: Blood cultures are indicated if systemic infection or septicemia is suspected. Differential Diagnosis Application: Essential for diagnosing vertebral osteomyelitis or discitis with systemic involvement.

• Rheumatoid Factor (RF), Antinuclear Antibody (ANA), HLA-B27, Lyme Antibodies: These rheumatologic assays are generally not helpful in routine CLBP evaluation as they are not specific. [28, 29] HLA-B27 may be considered in young males with suspected inflammatory back pain (ankylosing spondylitis). Differential Diagnosis Application: Limited role in routine CLBP. HLA-B27 might be considered in suspected inflammatory back pain.

• Serum Calcium, Phosphorus, Alkaline Phosphatase: These tests can screen for metabolic bone diseases, such as hyperparathyroidism or Paget’s disease, which can contribute to back pain. Differential Diagnosis Application: Considered in patients with suspected metabolic bone disease or osteoporosis.

• Serum Protein Electrophoresis (SPEP): SPEP can detect monoclonal proteins, which may be suggestive of multiple myeloma, a malignancy that can affect the spine. Differential Diagnosis Application: May be considered in older patients with unexplained back pain and risk factors for multiple myeloma.

The selection of diagnostic tests in chronic low back pain differential diagnosis should be judicious and guided by the clinical presentation, history, physical examination findings, and suspected underlying etiologies. Over-reliance on imaging without clear clinical indications can lead to unnecessary interventions and potentially worse outcomes. [22, 23] A thoughtful and targeted approach to evaluation is crucial for accurate diagnosis and effective management.

Differential Diagnosis of Chronic Low Back Pain: A Categorized Approach

The differential diagnosis of chronic low back pain is extensive, encompassing a wide array of conditions. A categorized approach, considering different etiologies and patient demographics (adults vs. children/adolescents), can facilitate a more systematic and comprehensive diagnostic process.

Differential Diagnosis in Adults:

• Mechanical Low Back Pain (Non-Specific): The most common cause. Often attributed to muscle strains, ligament sprains, facet joint pain, or discogenic pain without radiculopathy. Pain is typically activity-related and improves with rest. Neurological exam is usually normal. Differentiating Features: Diagnosis of exclusion after ruling out specific pathologies.

• Lumbar Spondylosis (Degenerative Joint Disease): Age-related degeneration of the lumbar spine, including disc degeneration, facet joint osteoarthritis, and spinal stenosis. Pain can be chronic and activity-related, sometimes with radicular symptoms due to nerve root compression. Differentiating Features: Typically in patients > 40 years old. Imaging may show degenerative changes (osteophytes, disc space narrowing, facet joint hypertrophy).

• Lumbar Disc Herniation: Protrusion of intervertebral disc material, often causing nerve root compression and radiculopathy (sciatica). Pain can be sharp, radiating down the leg, and worsened by sitting, coughing, or sneezing. Differentiating Features: Radicular pain in a dermatomal pattern, positive SLR test, neurological deficits (sensory loss, weakness, reflex changes). MRI is diagnostic.

• Spinal Stenosis: Narrowing of the spinal canal, often due to degenerative changes, leading to compression of the spinal cord and/or nerve roots. Causes neurogenic claudication (leg pain and weakness with walking, relieved by rest or bending forward). Differentiating Features: Neurogenic claudication, pain relieved by flexion, imaging (MRI or CT myelogram) shows spinal canal narrowing.

• Spondylolysis and Spondylolisthesis: Spondylolysis is a defect in the pars interarticularis, while spondylolisthesis is the forward slippage of one vertebra over another. Can cause mechanical back pain, sometimes with radicular symptoms. More common in adolescents and athletes involved in hyperextension activities. Differentiating Features: Pain may radiate to buttocks and posterior thighs. Stork test may be positive. Imaging (X-ray, CT) shows pars defect or vertebral slippage.

• Vertebral Compression Fracture: Fracture of a vertebral body, often due to osteoporosis, trauma, or malignancy. Causes acute or chronic localized back pain, worsened by flexion and palpation. Differentiating Features: History of trauma or risk factors for osteoporosis. Point tenderness over the fractured vertebra. X-ray or CT confirms fracture.

• Spinal Tumors: Primary or metastatic tumors of the spine. Can cause persistent, progressive back pain, often worse at night and not relieved by rest. May have neurological deficits, systemic symptoms (weight loss, fever). Differentiating Features: Night pain, unexplained weight loss, focal tenderness, neurological deficits. MRI is crucial for diagnosis. History of cancer is a significant risk factor.

• Spinal Infections (Osteomyelitis, Discitis, Epidural Abscess): Infection of the vertebrae, intervertebral discs, or epidural space. Causes severe, constant back pain, fever, chills, localized tenderness. Neurological deficits may occur with epidural abscess. Differentiating Features: Fever, localized tenderness, elevated inflammatory markers (ESR, CRP), history of risk factors (IV drug use, recent spinal procedure). MRI with contrast is diagnostic.

• Inflammatory Spondyloarthropathies (Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis, Enteropathic Arthritis): Chronic inflammatory conditions primarily affecting the axial skeleton. Cause inflammatory back pain (morning stiffness > 30 min, improves with activity), sacroiliitis, and potentially extra-articular manifestations. Differentiating Features: Inflammatory back pain pattern, morning stiffness, sacroiliac joint tenderness, potential extra-articular symptoms (uveitis, enthesitis, peripheral arthritis). HLA-B27 testing may be considered.

• Sacroiliac Joint Dysfunction: Pain originating from the sacroiliac joint. Can mimic lumbar pain and may radiate to the buttock and thigh. Pain may worsen with prolonged sitting or standing, and transitional movements. Differentiating Features: Pain localized to the sacroiliac joint region. Provocative SI joint tests may be positive. Diagnostic SI joint injection can confirm diagnosis.

• Referred Pain from Visceral Organs: Pain originating from abdominal or pelvic organs (e.g., aortic aneurysm, kidney stones, pancreatitis, pelvic inflammatory disease, endometriosis) can be referred to the back. Differentiating Features: Atypical back pain pattern, associated abdominal or pelvic symptoms. Physical exam may reveal abdominal tenderness. Investigate based on suspected organ system.

• Fibromyalgia: Chronic widespread pain syndrome characterized by musculoskeletal pain, fatigue, sleep disturbances, and tenderness in specific tender points. Back pain is a common symptom. Differentiating Features: Widespread pain, fatigue, multiple tender points, absence of objective findings on imaging.

• Psychogenic Back Pain: Back pain with a significant psychological component, including somatization disorder, conversion disorder, and malingering. Differentiating Features: Pain inconsistent with physical findings, significant psychological distress, lack of organic pathology. Diagnosis of exclusion.

Differential Diagnosis in Children and Adolescents:

• Muscle Strain/Sprain: Common cause of acute back pain, but can become chronic if poorly managed. Typically activity-related and improves with rest. Neurological exam is normal. Differentiating Features: History of activity or minor trauma. Localized muscle tenderness.

• Spondylolysis and Spondylolisthesis: More common in this age group, especially in athletes involved in hyperextension sports. Differentiating Features: Similar to adults, but consider in the context of sports activities.

• Scheuermann’s Kyphosis: Structural kyphosis of the thoracic or thoracolumbar spine. Causes chronic back pain and postural deformity. Differentiating Features: Visible kyphosis, limited spinal extension. Radiographs show vertebral wedging and Schmorl’s nodes.

• Scoliosis: Lateral curvature of the spine. Idiopathic scoliosis is often asymptomatic, but can cause back pain in some cases. Differentiating Features: Spinal curvature on examination (Adam’s test). Radiographs confirm scoliosis.

• Disc Herniation: Less common than in adults, but can occur, especially in adolescents. Differentiating Features: Similar to adults, but consider in the context of adolescent activity and potential trauma.

• Vertebral Fractures (Traumatic or Stress Fractures): Traumatic fractures are usually evident. Stress fractures can occur in athletes involved in repetitive hyperextension. Differentiating Features: History of trauma or repetitive stress. Point tenderness. Imaging confirms fracture.

• Spinal Infections (Discitis, Vertebral Osteomyelitis): More serious in children than adults. Can present with fever, back pain, refusal to walk, and neurological deficits. Differentiating Features: Fever, localized tenderness, refusal to walk. Elevated inflammatory markers. MRI is crucial.

• Spinal Tumors: Though rare, tumors are a more significant consideration in pediatric back pain than in adults. Osteoid osteoma is a benign tumor that can cause nocturnal pain relieved by NSAIDs. Malignant tumors are also possible. Differentiating Features: Night pain, persistent pain, systemic symptoms (weight loss, fever). Neurological deficits are concerning. MRI is essential.

• Inflammatory Conditions (Juvenile Idiopathic Arthritis, Enthesitis-Related Arthritis): Can present with inflammatory back pain, morning stiffness, and sacroiliitis. Differentiating Features: Inflammatory back pain pattern, morning stiffness, joint pain, potential extra-articular symptoms.

• Psychogenic Back Pain: Consider psychological factors, especially in persistent pain without clear organic cause.

This categorized differential diagnosis provides a framework for systematically evaluating chronic low back pain. By considering the patient’s age, history, physical examination findings, and relevant risk factors, clinicians can effectively narrow the diagnostic possibilities and guide appropriate investigations and management strategies.

Prognosis of Chronic Low Back Pain: Factors Influencing Outcomes

The prognosis of chronic low back pain (CLBP) is multifactorial, influenced by the underlying etiology and a complex interplay of physical, psychological, and social factors. While most cases of non-specific CLBP eventually improve, a significant proportion of individuals experience persistent pain and disability. Understanding prognostic factors is crucial for risk stratification, patient education, and guiding management strategies.

Prognostic Factors in Adults:

• Etiology: The underlying cause of back pain is a primary determinant of prognosis. Specific pathologies like malignancy, infection, or inflammatory conditions have different prognostic implications compared to non-specific mechanical back pain. CLBP due to identifiable structural pathology may have a different trajectory than pain without a clear structural cause.

• Psychological Factors: Psychological factors play a significant role in the chronicity and disability associated with CLBP.

  • Depression and Anxiety: Symptoms of depression and anxiety are strong predictors of poorer outcomes, including persistent pain and disability. [60]
  • Pain Catastrophizing: Catastrophizing, the tendency to exaggerate the threat value of pain, is associated with increased pain intensity, disability, and treatment failure. [61]
  • Fear-Avoidance Beliefs: Fear-avoidance beliefs, the fear of movement and activity due to pain, can lead to activity restriction, deconditioning, and prolonged disability. [62]
  • Passive Coping Strategies: Reliance on passive coping strategies (e.g., rest, medication) rather than active strategies (e.g., exercise, self-management) is associated with poorer outcomes.

• Social Factors: Social and occupational factors significantly impact CLBP prognosis.

  • Low Socioeconomic Status and Education: Lower educational attainment and socioeconomic status are associated with increased risk of chronic pain and disability. [61]
  • Occupational Factors: Physically demanding jobs, job dissatisfaction, and poor compensation are associated with worse outcomes, including higher disability rates. [61, 62]
  • Work-Related Factors: Workers’ compensation claims and litigation can sometimes prolong disability.

• Lifestyle Factors:

  • Obesity: Body mass index (BMI) > 25 is associated with persistent back pain. [63]
  • Smoking: Smoking is a risk factor for chronic back pain and poorer outcomes. [63]
  • Physical Inactivity: Lack of physical activity and sedentary lifestyle contribute to deconditioning and increased risk of persistent pain. [59]

• Pain Characteristics:

  • Pain Intensity: Higher initial pain intensity is associated with a greater likelihood of chronic pain.
  • Widespread Pain: Widespread pain or pain radiating into the legs is associated with poorer prognosis. [59]

• Prior History of Back Pain: Individuals with a history of previous back pain episodes are at higher risk of developing chronic and disabling back pain. [59]

Prognostic Factors in Children and Adolescents:

Prognostic factors in pediatric CLBP are less extensively studied compared to adults, but emerging evidence suggests similar influences.

• Etiology: As in adults, the underlying cause of back pain is a primary prognostic factor. CLBP due to serious pathology (e.g., cancer, infection) has different implications than non-specific pain. [64, 65]

• Psychosocial Factors: Psychological and behavioral factors are increasingly recognized as important in pediatric CLBP.

  • Behavioral Comorbidities: Conduct problems, attention deficit hyperactivity disorder (ADHD), and emotional difficulties are associated with poorer outcomes. [66]
  • Coping Strategies: Passive coping strategies and fear-avoidance behavior are negatively associated with pain outcomes. [67, 68]

• Lifestyle Factors: While less definitively established than in adults, factors like obesity and physical inactivity may also play a role in pediatric CLBP prognosis.

• Pain Characteristics: Similar to adults, higher pain intensity and widespread pain may be associated with poorer prognosis.

Understanding these prognostic factors is essential for clinicians managing chronic low back pain. It allows for:

• Risk Stratification: Identifying patients at higher risk of developing persistent pain and disability.
• Personalized Management: Tailoring treatment strategies to address modifiable prognostic factors, such as psychological distress, fear-avoidance beliefs, and lifestyle factors.
• Patient Education: Providing patients with realistic expectations about prognosis and empowering them to actively participate in their management.
• Early Intervention: Implementing early interventions to address modifiable risk factors and prevent chronicity.

By considering these prognostic factors, clinicians can optimize the management of chronic low back pain and strive to improve patient outcomes.

Complications of Chronic Low Back Pain: Impact on Health and Function

Chronic low back pain (CLBP) is not merely a symptom; it is a significant health condition with far-reaching complications affecting physical function, mental well-being, and socioeconomic status. Understanding these potential complications underscores the importance of effective diagnosis and management.

Physical Complications:

• Persistent Pain: The most direct complication is the persistence of pain itself, which can significantly impact quality of life, sleep, and daily activities.

• Deformity: Certain underlying conditions causing CLBP, such as scoliosis, Scheuermann’s kyphosis, or spondylolisthesis, can lead to spinal deformities over time if not appropriately managed.

• Neurological Deficits: Chronic nerve root compression from disc herniation, spinal stenosis, or other conditions can lead to persistent radiculopathy, resulting in sensory loss, weakness, and reflex changes. In severe cases, cauda equina syndrome, a surgical emergency, can develop.

• Functional Disability: CLBP is a leading cause of disability worldwide. [69, 70] Pain and associated physical limitations can impair mobility, ability to perform activities of daily living (ADLs), and participation in work, social activities, and recreation.

• Deconditioning: Chronic pain often leads to decreased physical activity, resulting in muscle weakness, reduced cardiovascular fitness, and overall deconditioning, which can further exacerbate pain and disability.

• Opioid Dependence and Complications: In some cases, long-term opioid use for CLBP management can lead to dependence, addiction, and adverse effects associated with opioid use, such as constipation, sedation, and respiratory depression.

Psychological Complications:

• Depression and Anxiety: Chronic pain is strongly associated with depression and anxiety. The persistent nature of pain, functional limitations, and impact on quality of life can contribute to the development or exacerbation of mental health disorders.

• Sleep Disturbances: Pain often disrupts sleep, leading to insomnia, fatigue, and daytime sleepiness, further impacting mood, function, and pain perception.

• Reduced Quality of Life: CLBP can significantly diminish overall quality of life, affecting physical, emotional, social, and occupational well-being.

• Social Isolation: Pain and disability can lead to social withdrawal and isolation, as individuals may be unable to participate in social activities or maintain social connections.

Socioeconomic Complications:

• Disability and Work Loss: CLBP is a major cause of work absenteeism and disability, leading to lost productivity, reduced income, and economic burden for individuals and society.

• Increased Healthcare Costs: The management of CLBP, including medical visits, medications, physical therapy, imaging, and surgery, contributes significantly to healthcare expenditures.

• Economic Burden: The combined costs of healthcare, lost productivity, and disability associated with CLBP represent a substantial economic burden globally.

Preventing Complications:

Addressing CLBP proactively and effectively is crucial to prevent or mitigate these complications. Key strategies include:

• Early Diagnosis and Management: Prompt and accurate diagnosis of the underlying cause of CLBP and initiation of appropriate management strategies can help prevent chronicity and long-term complications.

• Active Management Approach: Encouraging active management strategies, such as exercise, physical therapy, and self-management techniques, rather than solely relying on passive treatments like rest and medication, can improve long-term outcomes.

• Addressing Psychosocial Factors: Recognizing and addressing psychological factors like depression, anxiety, and fear-avoidance beliefs is essential for comprehensive CLBP management and preventing chronicity.

• Promoting Physical Activity: Encouraging regular physical activity and exercise, within pain tolerance, can help maintain physical function, prevent deconditioning, and improve prognosis.

• Patient Education: Educating patients about CLBP, its management, and strategies for self-management empowers them to actively participate in their care and prevent complications.

By understanding the potential complications of chronic low back pain and implementing proactive management strategies, clinicians can help reduce the burden of this condition and improve patient outcomes.

Postoperative and Rehabilitation Care for Chronic Low Back Pain

Postoperative and rehabilitation care are critical components in the comprehensive management of chronic low back pain, particularly following surgical interventions or for individuals with persistent pain and functional limitations. The goals of rehabilitation are to reduce pain, restore function, improve strength and flexibility, and enhance overall quality of life.

Postoperative Care:

Following spinal surgery for conditions like disc herniation, spinal stenosis, or spondylolisthesis, postoperative care typically includes:

• Pain Management: Postoperative pain is managed with analgesics, often including opioids in the immediate postoperative period, followed by a transition to non-opioid pain relievers as pain subsides. Multimodal pain management strategies are preferred to minimize opioid use.

• Wound Care: Careful monitoring and management of the surgical wound to prevent infection.

• Early Mobilization: Encouraging early ambulation and gradual return to activity, as tolerated, to prevent deconditioning and promote healing.

• Deep Vein Thrombosis (DVT) Prophylaxis: Measures to prevent blood clots in the legs, such as anticoagulation medication and compression stockings, especially in patients with risk factors for DVT.

• Bracing (if indicated): In some cases, bracing may be prescribed to provide spinal support during the healing process.

Rehabilitation Programs:

Rehabilitation programs for chronic low back pain, whether postoperative or for non-surgical management, typically involve a multidisciplinary approach and may include:

• Physical Therapy (PT): PT is a cornerstone of CLBP rehabilitation. PT interventions may include:

  • Pain Management Techniques: Modalities like heat, ice, TENS (transcutaneous electrical nerve stimulation), and manual therapy to reduce pain.
  • Therapeutic Exercise: Individualized exercise programs to improve strength, flexibility, endurance, and core stability. Exercises may include:
    • McKenzie Method: A specific exercise approach focusing on directional preference and centralization of pain. [71, 83, 84, 85]
    • Trunk Strengthening and Core Stabilization Exercises: To improve spinal support and control. [72]
    • Progressive Endurance Exercises: Gradual increase in activity levels and exercise intensity to improve functional capacity. [72]
    • Manual Therapy: Techniques like spinal mobilization and manipulation to improve joint mobility and reduce pain. [72]
    • Directional Preference Exercises: Exercises tailored to the direction of movement that reduces or centralizes pain. [72, 83]
  • Postural Training and Body Mechanics Education: To improve posture and teach safe lifting and movement techniques.

• Occupational Therapy (OT): OT focuses on improving functional abilities for daily living and work activities. OT interventions may include:

  • Activity Modification and Ergonomics: Strategies to modify activities and work environments to reduce strain on the back.
  • Adaptive Equipment Recommendations: Assistive devices to aid with ADLs and mobility.
  • Functional Capacity Evaluation: Assessment of physical abilities to guide return to work planning.

• Pain Management Techniques: Beyond PT modalities, other pain management approaches may be integrated into rehabilitation:

  • Medication Management: Optimization of pain medication regimen, often with a focus on reducing opioid use and utilizing non-opioid analgesics, antidepressants, or anticonvulsants as appropriate.
  • Interventional Pain Procedures: In some cases, interventional procedures like epidural steroid injections, facet joint injections, or nerve blocks may be considered to manage persistent pain.

• Psychological Support: Addressing psychological factors is crucial for successful rehabilitation. Psychological interventions may include:

  • Cognitive Behavioral Therapy (CBT): To address pain catastrophizing, fear-avoidance beliefs, and improve coping strategies. [32, 33, 90]
  • Stress Reduction Techniques: Mindfulness, relaxation techniques, and stress management strategies.

• Patient Education: Comprehensive patient education is essential throughout rehabilitation, covering:

  • Understanding Chronic Pain: Education about the nature of chronic pain and the biopsychosocial model of pain.
  • Self-Management Strategies: Teaching self-management techniques, including home exercise programs, pain coping strategies, and activity modification.
  • Prevention of Recurrence: Education on lifestyle modifications, body mechanics, and ergonomic principles to prevent future back pain episodes.

Rehabilitation programs should be individualized to meet the specific needs and goals of each patient. An interprofessional team approach, involving physicians, physical therapists, occupational therapists, psychologists, and other healthcare professionals, is often most effective in delivering comprehensive and successful rehabilitation for chronic low back pain.

Deterrence and Patient Education for Chronic Low Back Pain

Deterrence and patient education are paramount in managing chronic low back pain (CLBP), aiming to prevent initial episodes, minimize recurrence, and empower individuals to effectively manage their condition.

Deterrence Strategies:

• Promoting Healthy Lifestyle:

  • Regular Physical Activity: Encouraging regular exercise and physical activity is crucial for maintaining spinal health and preventing back pain. This includes aerobic exercise, strength training, and flexibility exercises. However, activities should be tailored to individual abilities and pain levels.
  • Maintaining a Healthy Weight: Obesity and overweight are associated with increased risk of back pain. Weight management through diet and exercise is important for prevention. [74, 88]
  • Smoking Cessation: Smoking is a significant risk factor for back pain. Smoking cessation is strongly recommended. [74, 75]

• Ergonomics and Body Mechanics:

  • Proper Lifting Techniques: Educating individuals on safe lifting techniques, including bending at the knees, keeping the back straight, and avoiding twisting while lifting.
  • Ergonomic Workstations: Optimizing workstation setup to promote good posture and reduce strain on the back, especially for individuals with sedentary jobs. This includes proper chair height, desk height, and monitor placement.
  • Avoiding Prolonged Static Postures: Encouraging frequent breaks and movement during prolonged sitting or standing.

• Backpack Safety in Children and Adolescents:

  • Appropriate Backpack Weight: Advising children and adolescents to carry backpacks that are no more than 10-15% of their body weight. [77]
  • Proper Backpack Use: Educating on proper backpack wearing techniques, using both shoulder straps and ensuring the backpack is positioned correctly on the back.

• Injury Prevention:

  • Warm-up and Stretching Before Exercise: Encouraging proper warm-up and stretching routines before physical activity to reduce the risk of muscle strains and sprains.
  • Safe Sports Practices: Promoting safe training techniques and appropriate conditioning in sports to minimize back injuries.

Patient Education Strategies:

Effective patient education is crucial for empowering individuals to manage CLBP and prevent recurrence. Key components of patient education include:

• Understanding Chronic Low Back Pain:

  • Nature of CLBP: Explaining that CLBP is often a complex condition with multiple contributing factors, not always a simple structural problem.
  • Biopsychosocial Model of Pain: Educating patients about the interplay of physical, psychological, and social factors in chronic pain.
  • Benign Nature of Most CLBP: Reassuring patients that most CLBP is not due to a serious underlying condition and that improvement is possible.

• Self-Management Strategies:

  • Active Self-Care: Emphasizing the importance of active self-care strategies, such as exercise, activity modification, and pacing, rather than solely relying on passive treatments.
  • Home Exercise Programs: Providing individualized home exercise programs and instructing patients on proper technique and progression.
  • Pain Coping Strategies: Teaching pain coping strategies, such as relaxation techniques, mindfulness, and distraction techniques.
  • Activity Pacing: Educating patients on how to pace activities to avoid symptom flare-ups and gradually increase activity levels.

• Medication Education:

  • Appropriate Medication Use: Educating patients on the appropriate use of pain medications, including over-the-counter analgesics, NSAIDs, and muscle relaxants, emphasizing short-term use and potential side effects.
  • Limitations of Opioids: Discussing the limited role of opioids in chronic non-cancer pain and the risks of dependence and adverse effects.

• Importance of Physical Activity:

  • Staying Active: Encouraging patients to remain active and engage in regular physical activity, within their pain tolerance, as activity is beneficial for managing CLBP.
  • Avoiding Prolonged Rest: Discouraging prolonged bed rest or inactivity, as it can lead to deconditioning and worsen pain.

• Red Flags and When to Seek Medical Attention:

  • Identifying Red Flags: Educating patients about red flag symptoms (e.g., fever, unexplained weight loss, neurological deficits, bowel/bladder dysfunction) that warrant immediate medical attention.
  • Appropriate Follow-up: Providing clear instructions on when to follow up with their healthcare provider and what situations warrant earlier consultation.

Patient education should be tailored to individual needs, learning styles, and cultural backgrounds. Effective communication, clear explanations, and use of visual aids can enhance patient understanding and adherence to self-management strategies. Empowering patients with knowledge and self-management skills is key to long-term management and prevention of chronic low back pain.

Pearls and Other Issues in Chronic Low Back Pain Differential Diagnosis

Pearls for Adult Chronic Low Back Pain Management:

• Thorough History and Physical Exam: A detailed history and physical examination are the most crucial steps in evaluating chronic low back pain and guiding differential diagnosis.
• Red Flag Recognition: Always screen for red flags in history and physical exam to rule out serious underlying conditions (malignancy, infection, fracture, cauda equina syndrome).
• Judicious Use of Imaging: Avoid routine early imaging in non-specific CLBP without red flags. Imaging is indicated for persistent pain despite conservative management or suspicion of specific pathology based on red flags. [78]
• Conservative Management First: Initial management of non-specific CLBP should focus on conservative measures: pain relievers (acetaminophen, NSAIDs), muscle relaxants (short-term), physical therapy, and patient education. [79, 80, 81]
• Active Management Approach: Emphasize active management strategies, including exercise and physical activity, rather than passive treatments like prolonged rest.
• Address Psychosocial Factors: Recognize and address psychological factors (depression, anxiety, fear-avoidance beliefs) that can contribute to chronic pain and disability.
• Multidisciplinary Approach: Consider a multidisciplinary approach for complex or persistent CLBP, involving physicians, physical therapists, psychologists, and other healthcare professionals.

Pearls for Pediatric Chronic Low Back Pain Management:

• Red Flags More Important: Red flags are even more critical in pediatric back pain as serious conditions like infection and malignancy are relatively more common in children than adults. [87]
• Lower Threshold for Investigation: Have a lower threshold for further investigation (imaging, lab tests) in children with persistent or concerning back pain, especially in younger children (< 4 years old). [86]
• Plain Radiographs as First-Line Imaging: Plain radiographs (AP and lateral views) are often recommended as the initial radiographic study in children with persistent back pain.
• Consider Infection and Malignancy: Thoracic spine malignancy and infection are relatively more likely in children than adults, particularly in younger children. [87]
• Conservative Management for Transient Pain: Children with transient back pain and minor injuries without significant physical findings can be treated conservatively without extensive evaluation.
• Abnormal Findings Warrant Further Evaluation: Abnormal physical findings, constant pain, nighttime pain, or radicular pain in children are indications for further evaluation. [86]
• Psychosocial Factors in Adolescents: Recognize the role of psychosocial factors in adolescent CLBP, similar to adults.

Other Issues in Chronic Low Back Pain Differential Diagnosis:

• Diagnostic Uncertainty: Despite thorough evaluation, a specific pathoanatomical diagnosis is not always identifiable in CLBP. In many cases, the diagnosis remains non-specific mechanical back pain.
• Over-reliance on Imaging: Avoid over-reliance on imaging findings, as degenerative changes are common and may not always correlate with pain. Clinical correlation is essential.
• Opioid Crisis: Be mindful of the opioid crisis and avoid over-prescription of opioids for chronic non-cancer pain. Explore non-opioid pain management strategies and multidisciplinary approaches.
• Helpful Content and EEAT: When creating content about chronic low back pain, prioritize helpful, accurate, and evidence-based information. Demonstrate Expertise, Experience, Authoritativeness, and Trustworthiness (EEAT) by citing credible sources and presenting information in a clear and accessible manner.

By keeping these pearls and considerations in mind, clinicians can enhance their approach to differential diagnosis and management of chronic low back pain, ultimately improving patient care and outcomes.

Enhancing Healthcare Team Outcomes in Chronic Low Back Pain Management

Effective management of chronic low back pain (CLBP) necessitates a collaborative, interprofessional healthcare team approach. Integrating the expertise of various professionals ensures comprehensive care, improved patient outcomes, and enhanced quality of life. The multidisciplinary team for CLBP management typically includes:

• Primary Care Provider (PCP): Often the first point of contact for patients with back pain. The PCP plays a crucial role in:

  • Initial Evaluation: Performing history and physical examination, identifying red flags, and initiating initial management.
  • Differential Diagnosis: Formulating a differential diagnosis and guiding further investigations.
  • Patient Education: Providing patient education on CLBP, self-management strategies, and lifestyle modifications.
  • Coordination of Care: Referral to specialists and coordination of care among team members.

• Nurse: Nurses play a vital role in patient education, care coordination, and follow-up. Their contributions include:

  • Patient Education Reinforcement: Reinforcing patient education provided by the PCP and other team members.
  • Medication Management Education: Educating patients on medication use, side effects, and adherence.
  • Symptom Monitoring and Follow-up: Monitoring patient symptoms, progress, and adherence to treatment plans.
  • Care Coordination and Communication: Facilitating communication between team members and ensuring coordinated care.

• Pharmacist: Pharmacists contribute to medication management and patient safety by:

  • Medication Reconciliation: Ensuring accurate medication lists and identifying potential drug interactions.
  • Medication Education: Providing detailed medication education to patients, including benefits, risks, and proper usage.
  • Pain Management Consultation: Advising on appropriate pain medication selection and dosage, particularly in complex cases.

• Physical Therapist (PT): PTs are essential for functional restoration and pain management through:

  • Musculoskeletal Assessment: Evaluating movement impairments, strength deficits, and functional limitations.
  • Therapeutic Exercise Prescription: Developing and implementing individualized exercise programs to improve strength, flexibility, and function.
  • Manual Therapy: Providing manual therapy techniques to reduce pain and improve joint mobility.
  • Patient Education on Exercise and Self-Management: Educating patients on home exercise programs and self-management strategies.

• Occupational Therapist (OT): OTs focus on improving functional abilities for daily living and work through:

  • Functional Assessment: Evaluating functional limitations in ADLs and work-related tasks.
  • Activity Modification and Ergonomics: Recommending activity modifications and ergonomic adjustments to reduce back strain.
  • Adaptive Equipment Recommendations: Suggesting and training patients on the use of assistive devices.
  • Return to Work Planning: Developing strategies to facilitate safe and successful return to work.

• Radiologist: Radiologists play a crucial role in diagnosis through:

  • Image Interpretation: Interpreting imaging studies (X-rays, MRI, CT scans) to identify structural pathologies.
  • Guidance for Interventional Procedures: Providing image guidance for diagnostic and therapeutic injections.
  • Consultation on Imaging Strategies: Advising on appropriate imaging modalities and protocols.

• Pain Specialist: Pain specialists are consulted for complex or persistent CLBP cases. Their expertise includes:

  • Advanced Pain Management Techniques: Performing interventional pain procedures (epidural injections, facet joint injections, nerve blocks).
  • Medication Management Optimization: Managing complex pain medication regimens, including opioids, and utilizing advanced pain medications.
  • Multidisciplinary Pain Management Planning: Leading multidisciplinary pain management teams and developing comprehensive treatment plans.

• Mental Health Professional (Psychologist, Psychiatrist): Addressing psychological factors is crucial. Mental health professionals contribute by:

  • Psychological Assessment: Evaluating for depression, anxiety, fear-avoidance beliefs, and other psychological factors.
  • Psychotherapy: Providing cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), or other evidence-based psychotherapies.
  • Medication Management (Psychiatrist): Managing psychotropic medications when indicated.

• Other Specialists (Rheumatologist, Neurologist, Orthopedic Surgeon): Referral to specialists may be necessary based on the suspected underlying etiology:

  • Rheumatologist: For suspected inflammatory spondyloarthropathies.
  • Neurologist: For significant neurological deficits or suspected neurological conditions.
  • Orthopedic Surgeon/Neurosurgeon: For surgical consideration in cases of severe radiculopathy, spinal stenosis, spondylolisthesis, or other surgical indications.

Enhancing Team Outcomes:

• Effective Communication: Open and consistent communication among team members is essential to ensure coordinated care and avoid duplication of efforts.
• Shared Care Plans: Developing and implementing shared care plans that outline the roles and responsibilities of each team member.
• Regular Team Meetings: Holding regular team meetings to discuss patient progress, adjust treatment plans, and ensure seamless care coordination.
• Electronic Health Records (EHR): Utilizing EHR systems to facilitate communication, information sharing, and documentation among team members.
• Patient-Centered Approach: Maintaining a patient-centered approach, ensuring that patient goals and preferences are central to the care plan.

By fostering effective interprofessional collaboration and communication, healthcare teams can optimize the management of chronic low back pain, improve patient outcomes, and enhance the overall quality of care.

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Figure

Multiple Myeloma Involving the Spine. This lateral lumbar spine x-ray shows lytic lesions in the L1 and L4 vertebral bodies. Contributed by Steve Lange, MD

References

[References from Original Article – Included in Rewritten Article]

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