© 2005 World Institute of Pain, 1530-7085/05/$15.00 Pain Practice, Volume 5, Issue 3, 2005 179–189 Blackwell Science, LtdOxford, UKPPRPain Practice1530-70852005 World Institute of Pain 2005 53179189Original ArticleLow Back PainVAN ZUNDERT AND VAN KLEEF Address correspondence and reprint requests to: J. Van Zundert, MD, Huisdriesstraat 3, 3600 Genk, Belgium. Tel: 32-89-32-52-40; Fax: 32-89-50- 27-69; E-mail: janvanzundert@pandora.be SPECIAL ARTICLE Low Back Pain: From Algorithm to Cost-Effectiveness? Jan van Zundert, MD*; Maarten van Kleef, MD, PhD † *Department of Anesthesiology and Multidisciplinary Pain Center—Ziekenhuis Oost-Limburg, Genk, Belgium; † Department of Anesthesiology and Pain Management, University Hospital Maastricht, Maastricht, the Netherlands  Abstract: Low back pain is one of the most important burdens for the patient, the health-care provider, and society. Treatment selection should target the appropriate use of the available health-care resources with the highest probability of success. When conventional treatment fails to provide satisfactory pain reduction and improvement of the quality of life, more interventional techniques can be envisioned. The degree of invasiveness of the different treatment modal- ities varies as well as the costs. A stepwise approach to chronic low back pain may reduce the economic burden with optimal use of the less invasive treatments. In this review, we discuss the treatment algorithm with special attention to the interventional pain management techniques. We also describe the results of a cost evaluation for the management of low back pain in Belgium compared with that in the Netherlands, two neighboring countries with different social security systems.  Key Words: low back pain, treatment algorithm, cost- effectiveness, interventional pain management INTRODUCTION In Low Back Pain: A Twentieth Century Health Care Enigma, Waddell highlighted in 1996 the growing dis- satisfaction with health care for low back pain in the U.S.A., which he described as specialist oriented, and in the U.K., where health care is underfunded. 1 Almost 10 years later, we still struggle with the appropriate use of the available health-care resources for adminis- tering the treatment that has the highest probability for success. Nearly everyone at some point experiences back pain that interferes with work, daily routine activities, or recreation, but only a portion of the population will suffer chronic low back pain. Spitzer 2 estimated that 8% of the patients who have an acute episode of low back pain will develop chronic low back pain. However, these figures, suggesting a spontaneous resolution of the prob- lem, have been questioned. The considerable variation found in the literature regarding the incidence of chronic low back pain may be attributed to variation in its definition. An extensive literature review indicates that at 6 months, 16% are still sick listed, while 62% of the patients continued to experience pain at 12 months fol- lowing initial diagnosis. The mean reported prevalence of low back pain in cases with previous back pain episodes was 56% compared to 22% for those without a prior history of low back pain. 3 The available treatment options can be subdivided in four major categories: conservative (pharmacological and physical treatment), cognitive rehabilitation pro- grams, interventional, and surgical management tech- niques. Interventional and surgical techniques should only be considered when pharmacological treatment supplemented with physical exercise failed to provide adequate relief or induced unacceptable side effects. In the present era of evidence-based medicine, the best available level of evidence should guide our therapeutic choices.