The Nonsurgical Treatment of Back Pain

Abstract

Each spinal motion segment is a three-joint complex comprised of the intervertebral disc, two facet joints, and a host of ligamentous and muscular attachments. This complex allows for multiaxial movement and loading of the spine while maintaining an upright posture and protection of the neural elements. The anatomic complexity of this articulation has complicated the search for a specific pathoanatomic cause for low back pain. The most common etiologies can be broadly categorized as neural, muscular, osseous, disc-related, and facet-related and have been the subject of much debate (Lutz et al. 2003). In the early decades of the twentieth century, nerve dysfunction, including neuritis and neuralgia, as well as muscular dysfunction were proposed as the leading causes of back pain. As the use of radiographs became more widespread, the classic bony changes associated with disc degeneration and spondylosis were found in many patients complaining of low back pain; hence, osseous etiologies became a popular theory. Initially, an inflammatory etiology for these bony changes was assumed; however, when no consistent marker of inflammation was found, it was then seen as a degenerative disorder. In the late 1930s and early 1940s, intervertebral disc pathology began to be recognized as a major low back pain generator (Barr 1938; Key 1945) and became the dominant theory for several decades. This resulted in an increase in the number and variety of surgical procedures directed at the intervertebral disc. By the end of the twentieth century, evidence emerged that anatomic abnormalities, as visualized by diagnostic imaging tests, often did not correlate with clinical symptoms (Boden et al. 1990). As a result, most modern treatments for low back pain are pragmatic in approach rather than searching for a specific anatomic directed cause (Lutz et al. 2003), with nonsurgical intervention taking center stage.