Mechanisms of Low Back Pain: A Guide for Diagnosis and Therapy
Massimo Allegri, Silvana Montella, Fabiana Salici,
Adriana Valente, Maurizio Marchesini, Christian Compagnone,
Marco Baciarello, Maria Elena Manferdini, and Guido Fanelli
Department of Surgical Sciences,
University of Parma,
Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making.
Answering the question “what is the pain generator” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.
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KEYWORDS: CLBP; back; low back pain; spine
From the Full-Text Article:
Low back pain (LBP) is the most common musculoskeletal condition affecting the adult population, with a prevalence of up to 84%.  Chronic LBP (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 12 weeks.  Many authors suggest defining chronic pain as pain that lasts beyond the expected period of healing, avoiding this close time criterion. This definition is very important, as it underlines the concept that CLBP has well-defined underlying pathological causes and that it is a disease, not a symptom. CLBP represents the leading cause of disability worldwide and is a major welfare and economic problem.  Given this complexity, the diagnostic evaluation of patients with LBP can be very challenging and requires complex clinical decision-making. Answering the question, “what is the pain generator?” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a diagnosis not based on specific pain generator can lead to therapeutic mistakes. This article aims to provide a brief clinical guide that could help in the identification of pain generators through a careful anatomical description, thereby directing clinicians towards the correct diagnosis and therapeutic approach.
Low back pain epidemiology
LBP represents a major social and economic problem. The prevalence of CLBP is estimated to range from 15 to 45% in French healthcare workers ; the point prevalence of CLBP in US adults aged 20–69 years old was 13.1%.  The general population prevalence of CLBP is estimated to be 5.91% in Italy.  The prevalence of acute and CLBP in adults doubled in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups.  LBP has a significant impact on functional capacity, as pain restricts occupational activities and is a major cause of absenteeism. [7–9] Its economic burden is represented directly by the high costs of health care spending and indirectly by decreased productivity. [7, 9] These costs are expected to rise even more in the next few years. According to a 2006 review, the total costs associated with LBP in the United States exceed $100 billion per year, two-thirds of which are a result of lost wages and reduced productivity. 
Looking for the pain generator