Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists W. Michael Hooten, MD, and Steven P. Cohen, MD CME Activity Target Audience: The target audience for Mayo Clinic Proceedings is primar- ily internal medicine physicians and other clinicians who wish to advance their current knowledge of clinical medicine and who wish to stay abreast of advances in medical research. Statement of Need: General internists and primary care physicians must main- tain an extensive knowledge base on a wide variety of topics covering all body sys- tems as well as common and uncommon disorders. Mayo Clinic Proceedings aims to leverage the expertise of its authors to help physicians understand best practices in diagnosis and management of conditions encountered in the clinical setting. Accreditation: Mayo Clinic College of Medicine is accredited by the Accred- itation Council for Continuing Medical Education to provide continuing med- ical education for physicians. Credit Statement: Mayo Clinic College of Medicine designates this journal- based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).ä Physicians should claim only the credit commensurate with the extent of their participation in the activity. Learning Objectives: On completion of this article, you should be able to: (1) distinguish the key anatomical structures implicated in the pathogenesis of low back pain; (2) identify the clinical characteristics that differentiate axial and radicular low back pain; and (3) formulate an evidence-based treatment plan for low back pain. Disclosures: As a provider accredited by ACCME, Mayo Clinic College of Medicine (Mayo School of Continuous Professional Development) must ensure balance, independence, objectivity, and scientific rigor in its educa- tional activities. Course Director(s), Planning Committee members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off-label and/or investigational use of pharmaceuticals or instru- ments discussed in their presentation. Disclosure of this information will be published in course materials so that those participants in the activity may formulate their own judgments regarding the presentation. In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L. Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of the content of this program but have no relevant financial relationship(s) with industry. The authors report no competing interests. Method of Participation: In order to claim credit, participants must com- plete the following: 1. Read the activity. 2. Complete the online CME Test and Evaluation. Participants must achieve a score of 80% on the CME Test. One retake is allowed. Visit www.mayoclinicproceedings.org, select CME, and then select CME arti- cles to locate this article online to access the online process. On successful completion of the online test and evaluation, you can instantly download and print your certificate of credit. Estimated Time: The estimated time to complete each article is approxi- mately 1 hour. Hardware/Software: PC or MAC with Internet access. Date of Release: 12/1/2015 Expiration Date: 11/30/2017 (Credit can no longer be offered after it has passed the expiration date.) Privacy Policy: http://www.mayoclinic.org/global/privacy.html Questions? Contact dletcsupport@mayo.edu. Abstract Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis. The accuracy of historical and physical examination findings has been established for sacroiliac joint pain, radiculopathy, and lumbar spinal stenosis. However, the accuracy of similar data, so-called red flags, for identifying the underlying medical sources of LBP has been overstated. Diagnostic imaging studies can be useful, and adherence to established guidelines can protect against overuse. Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related in- dications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence. ª 2015 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2015;90(12):1699-1718 From the Mayo Clinic College of Medicine and Department of Anesthesi- ology, Division of Pain Medicine, Mayo Clinic, Rochester, MN (W.M.H.); Department of Anesthesi- ology and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, Johns Hop- kins School of Medicine, Baltimore, MD (S.P.C.); and Department of Anes- thesiology, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD (S.P.C.). SYMPOSIUM ON PAIN MEDICINE Mayo Clin Proc. n December 2015;90(12):1699-1718 n http://dx.doi.org/10.1016/j.mayocp.2015.10.009 www.mayoclinicproceedings.org n ª 2015 Mayo Foundation for Medical Education and Research 1699