Assessment and nonsurgical management of low back pain: a narrative review.

Park SC, Kang MS, Yang JH, Kim TH
The Korean journal of internal medicine · 2023 · doi:10.3904/kjim.2022.250 · PMID:36420562 · PMC9816685
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This narrative review assesses the complex etiology and diagnostic challenges of low back pain, advocating for non-pharmacologic management as first-line therapy while emphasizing multidisciplinary rehabilitation for patients unresponsive to initial treatments.

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This narrative review evaluates the diagnosis and nonsurgical management of low back pain, noting that distinguishing etiologies remains challenging despite evidence-based guidelines. The authors highlight that while most acute cases are self-limiting, chronic pain is influenced by psychological factors and often lacks a specific organic cause, making exact diagnoses rare. Management strategies emphasize patient education, lifestyle modifications, and tailored physiotherapy, as decisive evidence favoring one treatment modality over others is generally lacking. The paper does not explicitly discuss endometriosis or adenomyosis; it was included in the corpus via a keyword match in the upstream search index.

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Abstract

Low back pain (LBP) is a common condition that affects people of all ages and income levels worldwide. The etiology of LBP may be mechanical, neuropathic, systemic, referred visceral, or secondary to other causes. Despite numerous studies, the diagnosis and management of LBP remain challenging due to the complex biomechanics of the spine and confounding factors, such as trivial degenerative imaging findings irrelevant to symptoms and psychological and emotional factors. However, it is imperative to identify the crucial signs ("red flags") indicating a serious underlying condition. While many recent guidelines emphasize non-pharmacologic management approaches, such as education, reassurance, and physical and psychological care, as the first option, LBP patients in many countries, including South Korea, are prescribed medications. Multidisciplinary rehabilitation combined with prudent use of medications is required in patients unresponsive to first-line therapy. The development of practical guidelines apposite for South Korea is needed with multidisciplinary discussion.
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Intro

Despite considerable progress in the diagnosis and treatment of low back pain (LBP), distinguishing among its many possible etiologies, and thus determining the most appropriate management approach, remains challenging [ 1 – 3 ]. Therefore, while this review does not provide standards for the management of LBP, it does present evidence-based information on its diagnosis and nonsurgical treatment. Nonetheless, it should be noted that our review is based on studies with varying levels of evidence, some of which addressed highly specific aspects of LBP. Our findings should therefore be interpreted with caution.

Other

This review had several limitations. First, it was a narrative rather than systematic review or meta-analysis. Therefore, bias in the literature search or selection cannot be ruled out. In addition, the treatment modalities were not graded according to the level of evidence. Second, LBP is an extremely broad comprehensive category, such that its mechanisms, etiologies, examinations, and management protocols remain controversial. Third, given the lack of conclusive evidence supporting any one treatment option unconditionally, we cannot provide definitive recommendations for the management of LBP. Despite these limitations, this review provided an overview of the LBP management process and can thus act as a guide for physicians involved in the treatment of this common condition.

Conclusions

Despite a plethora of studies, trials, and clinical guidelines regarding the nonsurgical management of LBP, gaps remain between their recommendations and actual practice, depending on the health system and economic status of a given country, as well as patient behaviors and demographics. In South Korea, the lack of apposite guidelines often results in inappropriate imaging or drug prescriptions and subsequent substantial and unnecessary medical costs. Multidisciplinary discussions with clinicians from various departments, researchers, pharmaceutical companies, and lawmakers are required to devise practical guidelines. Ultimately, it is essential to comply with the basic principles of care, taking into account the benefits and potential risks of treatment.

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