Abstract
Dear Editor,
Non-specific low back pain (NSLBP) is defined as low back pain that cannot be determined by a specific nociceptive source. 1 Low back pain is a multidimensional presentation that may be caused by pain processing mechanisms, psychological factors, and biomechanical factors. 1 This multidimensional symptom accounts for billions of dollars of health care spending worldwide, creating an economic burden to patients and health care services. 2 The term “non-specific” or “unspecific” is defined as “not free from ambiguity”. 3 The word “ambiguity” is defined as “a word or expression that can be understood in 2 or more possible ways”. 3 Low back pain that has 2 or more potential causes can be determined as non-specific or unspecific. NSLBP can also arise idiopathically (i.e., without apparent cause). Patients suffering from low back pain may have serious and life-limiting consequences, including adverse effects on activities of daily living, employment and social interaction.1,2 The authors believe that determining a precise diagnosis may not be feasible with a presentation that may potentially have multiple causes. This conundrum is precisely what creates support for the term “non-specific”, as one cause may not be favored over another.
The ambiguity of a mechanism of injury also contributes to the complexity of low back pain. The comprehensive effort to conclude a diagnosis of low back pain or NSLBP is time consuming, expensive and rigorous for the patient. 2 The diagnosis of NSLBP is not derived because the clinician or practitioner would “rather not think any further” but because it is an appropriate diagnosis that aligns with the patient’s values. 4 A diagnosis of NSLBP does not mean the health care provider is unable to arrive at a likely cause but that there may be 2 or more possible causes. Yes, in some cases the clinician can assume that one factor is weighted more heavily than another but in other cases, the clinician cannot, which validates the NSLBP diagnosis, supported by the World Health Organization’s International Classification of Disease code (ME84.2Z Low back pain, unspecified). Eliminating NSLBP from the lexicon does not start and end with the clinician, it would take an alteration of the organizational, administrative and health recording realm, of which the authors are unaware of a proposed solution. 4
Despite the claim that “the whole arsenal” of imaging should be used to determine a specific cause of pain, 4 recommendations advise against imaging in most cases unless red flags are present. 5 Subjecting patients to imaging may lead to psychosocial impacts, pain catastrophizing, and alterations in activities of daily living. 6 Lumbar imaging findings, in the absence of serious pathology, generally do not influence long-term outcomes. 7 An emphasis on early imaging makes surgery more likely, with no systematic reported improvements in pain or disability. 8 Independent conservative interventions for the patients’ complaint aim to decrease the economic burden of the symptom. Clinicians relying on costly imaging results, contribute to negative consequences, and may reveal incidental findings unrelated to the cause of pain.
The authors believe NSLBP is an appropriate diagnosis due to its multidimensional presentation.
