Cited by 1,345Musculoskeletal pain and rehabilitationSpine and Intervertebral Disc PathologyPain Management and Treatment

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Low back pain

Open access

Knezevic, Nebojsa Nick, Candido, Kenneth D, Vlaeyen, Johan W S, Van Zundert, Jan, Cohen, Steven P·2021·The Lancet

DOI 10.1016/s0140-6736(21)00733-9

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Abstract

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

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Authors: Knezevic, N. N., Candido, K. D., Vlaeyen, J. W. S., Van Zundert, J., & Cohen, S. P.
Affiliations: University of Illinois Chicago (US)
Maastricht University (NL)
Johns Hopkins University (US)
ORCID: Vlaeyen, Johan W S
Cohen, Steven P
Venue: The Lancet
Publisher: Elsevier BV
Published: 2021-07
Volume: 398
Issue: 10294
Pages: 78-92
ISSN: 0099-5355 (ISSN-L)
0140-6736
DOI: 10.1016/s0140-6736(21)00733-9
OpenAlex: W4211136641
Cited by: 1,345
References: 145
Citations by year: 2026: 274 · 2025: 380 · 2024: 317 · 2023: 239 · 2022: 113 · 2021: 22
FWCI: 21.91
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: public-domain
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
doi.org/10.15223/policy-017 (stm-asf)
doi.org/10.15223/policy-037 (stm-asf)
doi.org/10.15223/policy-012 (stm-asf)
doi.org/10.15223/policy-029 (stm-asf)
doi.org/10.15223/policy-004 (stm-asf)
Locations: The Lancet (publishedVersion, public-domain)
PubMed (publishedVersion)
Lirias (KU Leuven) (acceptedVersion)
Research Publications (Maastricht University) (submittedVersion, public-domain)
Lirias (submittedVersion, public-domain)
Research Publications (Maastricht University) (submittedVersion, other-oa)
Topics: Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Orthopedics and Sports Medicine › Spine and Intervertebral Disc Pathology
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Keywords: low back pain, pain classification, biopsychosocial model, diagnostic imaging, diagnostic injection, epidural steroid injection, spinal cord stimulation, radiofrequency ablation, intervertebral disc degeneration, sacroiliac joint, facet joints, neuropathic pain, nociplastic pain, non-specific low back pain, pain prevention, interdisciplinary treatment, pharmacotherapy, physiotherapy, psychological intervention, spinal decompression, disc replacement, spinal fusion, treatment algorithm, comparative effectiveness
MeSH terms: Humans, Risk Factors, Low Back Pain

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