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Subacute and chronic low back pain: Nonsurgical interventional treatment

Roger Chou, MD
Section Editor
Steven J Atlas, MD, MPH
Deputy Editor
Howard Libman, MD, FACP


Up to 84 percent of adults have low back pain at some time in their lives [1,2]. The long-term outcome of low back pain is generally favorable [3], but, given how common low back pain is, persistent symptoms affect millions of individuals. Subacute low back pain is commonly defined as back pain lasting between 4 and 12 weeks and chronic low back pain as pain that persists for 12 or more weeks.

Most patients (>85 percent) who are seen in primary care have "nonspecific low back pain," which is low back pain that cannot reliably be attributed to a specific disease or spinal pathology [4]. Rapid improvement in pain and disability, and return to work, are the norm in the first month [5]. Further improvement generally occurs over three months, after which pain, level of disability, and rates of return to work remain relatively constant. Approximately 5 percent of people with back pain disability account for 75 percent of the costs associated with low back pain [6].

Multiple treatment options for subacute and chronic low back pain are available. Broadly, these are divided into pharmacologic and noninterventional treatments, nonsurgical interventional treatments, and surgical treatments (table 1 and table 2 and table 3 and table 4). This topic will address nonsurgical interventional options for patients with subacute and chronic low back pain who have failed conservative management. Several of these involve the injection of medications, commonly glucocorticoids, into the spinal structures. Others involve the destruction of nerves or other tissues in the back presumed to be the source of pain through the application of various types of energy.

In general, patients with subacute nonspecific low back pain would not be considered candidates for interventional therapies, as they could still improve with noninvasive therapies and there is little evidence on efficacy of invasive therapies in this circumstance [7]. For patients with subacute or chronic radiculopathy, or severe disabling chronic nonspecific low back pain, it is difficult to categorically advise when nonsurgical interventional therapies should be considered. It may be reasonable to consider some nonsurgical interventional therapies for patients who have not responded to noninvasive therapies and who are not interested in surgery or are not considered appropriate candidates for surgery. Relatively few randomized trials have evaluated patients specifically with spinal stenosis [8,9], although a number of trials have evaluated mixed populations.

Treatment of acute low back pain is discussed separately (see "Treatment of acute low back pain"). Noninterventional treatment of subacute and chronic low back pain, and surgical options are also discussed separately. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment" and "Subacute and chronic low back pain: Surgical treatment".)

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Literature review current through: Nov 2017. | This topic last updated: Oct 18, 2017.
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