Chronic Low Back Pain

Tackling one of the most common reasons for physician visits, the panelists attempt to explain chronic low back pain, debate the usefulness of imaging for diagnosis, and discuss treatment approaches.

Tasked with defining the pervasive condition, Christopher Gharibo, MD, provides several different paradigms for low back pain, including acute pain versus chronic pain, pure low back pain versus back and leg pain, and positional pain versus non-positional pain where “even when you lie down, you still have the pain.”

Gharibo says it’s best to “go back to the basics” during diagnosis by checking the patient for fever, weight loss, abdominal issues, oncological concerns, or another medical illness that may present as low back pain, though he notes that most patients will “present with musculoskeletal with some degree of imprinted neuropathic pain, so the focus needs to be, ‘Is there a neurological compromise?’”

But according to Jeffrey A. Gudin, MD, instead of following that roadmap, most orthopedists “do what they know how to do, (which is) they get an X-ray” — despite the fact that studies have shown the films aren’t helpful in diagnosing common musculoskeletal pain.

Debating the usefulness of magnetic resonance imaging (MRI) tests, Joseph Pergolizzi, MD, says MRI results can be helpful when they detect moderate to severe stenosis, but he cautions that “I’ve seen some MRIs in patients that look “decent” and those patients are in a lot of pain, and then I’ve seen other patients where their MRIs aren’t all that great, and yet they’re not corresponding to the level and severity of pain.”

Regardless of a physician’s preferred pathway to chronic low back pain diagnoses, Pergolizzi recommends setting expectations for the patient upfront and then treating the condition with a “non-pharmacological and pharmacological intervention together that will address the intensity of their pain, as well as the mechanism that I think is causing their pain.”