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Chronic low back pain (cLBP)


Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain, partly because of a lack of agreement about definition.

Chronic back pain is sometimes defined as back pain that lasts for longer than 7-12 weeks. Others define it as pain that lasts beyond the expected period of healing, and acknowledge that chronic pain may not have well-defined underlying pathological causes. Others classify frequently recurring back pain as chronic pain since it intermittently affects an individual over a long period. Most national insurance and industrial sources of data include only those individuals in whom symptoms result in loss of days at work or other disability. Thus, even less is known about the epidemiology of chronic low-back pain with no associated work disability or compensation. Chronic low-back pain has also become a diagnosis of convenience for many people who are actually disabled for socioeconomic, work-related, or psychological reasons. In fact, some people argue that chronic disability in back pain is primarily related to a psychosocial dysfunction. Because the validity and reliability of some of the existing data are uncertain, caution is needed in an assessment of the information on this type of pain 1).

Disables millions of people across the world and generates a tremendous economic burden. Recent studies estimated the direct and indirect costs of back pain up to $624.8 billion 2) 3)

The socioeconomic toll of lumbar disc disorders is enormous, underscoring the critical importance of understanding the pathophysiology behind the degenerative process.

Pain catastrophizing, appraisals of pain control, styles of coping, and social support have been suggested to affect functioning in patients with low back pain.

Back pain characteristics, depressive mood, disability, and beliefs about personal control of pain are related to chronic LBP coping styles. Most of the variables related to advancement of degenerative changes were not associated with coping efforts 4).


The association between chronic low back pain and morphologic, structural changes of the lumbar paravertebral muscles has been widely acknowledged.

Mechanical alterations of the spine, which can cause chronic low back pain (LBP), are a frequent indication for spinal fusion.

Facetogenic chronic low back pain.

Ankylosing spondylitis.


Rarely can an anatomic diagnosis be made in patients with chronic LBP ≥ 3 months duration 5).

Patients with chronic pain syndromes (CPS) refer to their problems with affective or emotional terms with a higher frequency than those with acute pain. 6).

After 3 months, only ≈ 5% of patients with LBP will continue to have persistent symptoms. A structural diagnosis is possible in only ≈ 50% of these patients. These patients account for 85% of the cost in lost work and compensation 7).

The amount of time that a patient has been out of work due to low back problems is related to the chances of the patient getting back to work.

Differential diagnosis

Chronic low back pain differential diagnosis


see Chronic low back pain treatment.

Case series

28 patients with low back pain, with a duration > 6 months and a 50% pain reduction on the numeric analog scale (NAS) after a diagnostic block. All patients received endoscopic facet joint denervation of three facets on the left and right side using only one incision on each side with an exploration of the surrounding tissue. Telephone interviews were conducted with all patients. The outcome was determined with Odom's criteria, percentage reduction NAS, subjective assessment of the patient, and duration of the effect.

According to Odom's criteria, 68% of the patients showed “acceptable” to “excellent” results and confirmed that denervation helped them manage their daily lives better. The average pain reduction in the responder group was 47% with an average duration of 7.8 months.

In this retrospective study, Woiciechowsky and Richter from the Vivantes-Humboldt-Klinikum, Spine Clinic, Spine Center Berlin, Charité Medical Faculty Berlin, demonstrated the practicability and effectiveness of the endoscopic facet joint denervation procedure in the treatment of chronic low back pain using only one incision for three facets. Further studies should investigate if this procedure is more effective than percutaneous radiofrequency denervation 8).

Fourteen patients with CLBP, greater than 6 months, unresponsive to at least 4 months of conservative care were enrolled. All patients were treated successfully following screening using MRI findings of Modic type I or II changes and positive confirmatory provocative discography to determine the affected levels. All patients underwent ablation of the basivertebral nerve (BVN) using 1414 nm Nd:YAG laser-assisted energy guided in a transforaminal epiduroscopic approach. Macnab's criteria and visual analog scale (VAS) score were collected retrospectively at each follow-up interval.

The mean age was 46 ± 9.95 years. The mean symptoms duration was 21.21 ± 21.87 months. The mean follow-up was 15.3 ± 2.67 months. The preoperative VAS score of 7.79 ± 0.97 changed to 1.92 ± 1.38, postoperatively (P < 0.01). As per Macnab's criteria, seven patients (50%) had excellent, six patients (42.85%) had good, and one patient (7.14%) had fair outcomes.

The transforaminal epiduroscopic basivertebral nerve laser ablation (TEBLA) appears to be a promising option in carefully selected patients with CLBP associated with the Modic changes 9).

Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999 Aug 14;354(9178):581-5. Review. PubMed PMID: 10470716.
Wenig CM, Schmidt CO, Kohlmann T, Schweikert B (2009) Costs of back pain in Germany. Eur J Pain 13: 280–286.
Dagenais S, Caro J, Haldeman S (2008) A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 8: 8–20.
Misterska E, Jankowski R, Głowacki M. Chronic pain coping styles in patients with herniated lumbar discs and coexisting spondylotic changes treated surgically: Considering clinical pain characteristics, degenerative changes, disability, mood disturbances, and beliefs about pain control. Med Sci Monit. 2013 Dec 27;19:1211-20. doi: 10.12659/MSM.889729. PubMed PMID: 24370564; PubMed Central PMCID: PMC3891316.
Gatchel RJ, Mayer TG, Capra P, et al. Quantification of Lumbar Function, VI: The Use of Psychological Measures in Guiding Physical Functional Restoration. Spine. 1986; 11:36–42
Morley S, Pallin V. Scaling the Affective Domain of Pain: A Study of the Dimensionality of Verbal Descriptors. Pain. 1995; 62:39–49
Frymoyer JW. Back Pain and Sciatica. N Engl J Med. 1988; 318:291–300
Woiciechowsky C, Richter LM. Endoscopic 4-MHz Radiofrequency Treatment of Facet Joint Syndrome Is More Than Just Denervation: One Incision for Three Facets. J Neurol Surg A Cent Eur Neurosurg. 2020 Jan 14. doi: 10.1055/s-0039-1698397. [Epub ahead of print] PubMed PMID: 31935787.
Kim HS, Adsul N, Yudoyono F, Paudel B, Kim KJ, Choi SH, Kim JH, Chung SK, Choi JH, Jang JS, Jang IT, Oh SH. Transforaminal Epiduroscopic Basivertebral Nerve Laser Ablation for Chronic Low Back Pain Associated with Modic Changes: A Preliminary Open-Label Study. Pain Res Manag. 2018 Aug 14;2018:6857983. doi: 10.1155/2018/6857983. eCollection 2018. PubMed PMID: 30186540; PubMed Central PMCID: PMC6112211.
chronic_low_back_pain.txt · Last modified: 2020/02/26 15:54 by administrador