Abstract
Perhaps 1 of the great misunderstandings of these times in highly specialized spine care is the term „non-specific low back pain”. The existence of back pain and the fact that it has a myriad of causes has been known since BC.
The term gained widespread use with the introduction of imaging modalities and is based on the conception that imaging does not provide the information necessary to identify the cause of back or neck pain beyond any doubt. In contrary to the undisputedly painful nature of eg a vertebral fracture, results of the imaging studies frequently show structural changes which can or can not cause low back pain or neck pain. Most frequently, degenerative changes are found and their clinical presentation may differ. Even the physical examination is usually a battery of tests, increasing their validity when conducted together.
Due to the multifactorial and multidimensional nature of pain, several medical specialties as well as other professions address the field of spine care and back pain treatment.
So by coining the term “non-specific low back pain”, the implications are much more widespread than originally intended. “Unspecific” implies, no known reason for the patients symptoms exist. This is an overly simplistic and nowadays unacceptable approach: “If I cannot see the reason for the patients pain on my imaging studies, it must be non-specific and I’d rather not think any further”!
A multitude of guidelines around the globe accept this flawed reasoning. Tim Germon wrote a very worthwhile editorial on this, titled “Return to the dark ages”. 1
While everyone agrees that pain exists without structural correlation, I would like to take this thought further. A muscular component may play a huge role in generation of back pain, functional imbalance, lack of strength, coordination, etc. So is the resulting painful condition “non-specific”? Not at all, well defined and published concepts exist to diagnose and treat these muscular und functional deficiencies successfully.
Psychological components of back pain are another field. The significance of psychosocial factors leading to chronic spinal pain has been known for decades. So precisely assessing these is mandatory (and requested by many guidelines on low back or neck pain) and their diagnosis and treatment is anything but unspecific.
From a purely structural anatomical concept of back pain, we take significant lengths in establishing a diagnosis. Functional imaging, numerous modalities, combination of several imaging studies, etc. The whole arsenal of xray or ultrasound guided diagnostic injections is employed to solve the missing pieces of the puzzle and label a structure painful or not, with some uncertainties remaining.
But especially from the nonsurgical specialties perspective, similar efforts are rather the exception than the norm. It takes a comprehensive troublesome and costly approach to establishing a clear diagnosis for a condition which has a generally good prognosis within weeks to months and is therefore just not worth the hassle. The pain is “non-specific”. Period.
Looking back at the 60+ years this unfortunate term has made it into the everyday life of spine care practioners around the globe, medical curriculums, guidelines and recommendations and even the medicolegal environment and the desks of health policy makers.
With the well published understanding of multifactorial origins of back pain, now would be the perfect time to take the next step and precisely defining the “most likely predominant cause” of the patients pain. Instead of just labelling it“non-specific” and accept a flawed concept of medicine which would not be acceptable in numerous other areas.
If you look at a comparable discussion with the medical specialties, “Essential hypertension” comes up frequently. The thorough workup of the precise reason for a patients high blood pressure can consume time and resources just not available to many primary care providers and so the terms “Essential” or “non-specific” might be just so convenient to leave it as it is. With the difference that a hypertensive disorder might have serious, even life-limiting consequences. Low back pain does not have these but the global burden of disease is similar, the impact on patients wellbeing is similar and the socioeconomic consequences are even higher.
So should the spine community take that practical approach and just omit a precise diagnosis (read: precise and effective treatment) for a substantial percentage of our patients? Certainly not since the knowledge and the capabilities are well established. The just need to be linked together.
So lets not accept “non-specific” back or neck pain any longer, evolve to a precise diagnosis and move on from the dark ages!