LOW BACK PAIN (LBP)

• Low back pain, one of the most common complaints in primary care, affects up to 84% of people at some point in their lives and is chronic in 23% of the population. It is estimated that over 300 billion dollars is spent annually in the U.S. on LBP and neck pain, making spine disorders the number one healthcare expenditure. [1,75]

• Spine anatomy
• The spine is divided into six areas: cervical vertebrae, thoracic vertebrae, lumbar vertebrae, sacrum, and coccyx. Vertebrae are round bones separated by cartilage discs with extensions in the back that form a ring around the spinal cord. The intervertebral discs provide cushioning and allow the spine to bend.
• Spine anatomy
• Vertebra and disc anatomy

• Disc protrusion
• Disc protrusions (also called bulging discs, slipped discs, and herniated discs) occur when a cartilage disc protrudes from underneath a vertebra. The disc may touch or encroach on the spinal cord or a nerve root, sometimes producing pain. Protrusions may occur to one side or be broad-based, where the entire face of the disc is involved.
• Disc protrusion illustration

• Disc extrusion
• Disc extrusions (also called ruptured discs) occur when the annulus fibrosus tears and the gel-like nucleus pulposus extrudes through it
• Disc extrusion illustration

• Disc sequestration
• Disc sequestration occurs when a portion of the gel-like nucleus pulposus extrudes and then separates from the main disc
• Disc sequestration illustration

• Radiculopathy
• Radiculopathy is pain from nerve root compression, which may be caused by a herniated disc or vertebral bony malformations. Symptoms of radiculopathy include pain and/or weakness in the distribution of the affected nerve (see sciatica).

• Schmorl's node
• Schmorl's nodes are herniations of the nucleus pulposus into the vertebra above or below the discs. They are common, occurring in up to 70% of the population, and often found incidentally on spine imaging. Their association with back pain is unclear. [65]

• Sciatica
• The sciatic nerve, which contains sensory and motor fibers, originates from the L4 - S3 nerve roots and runs down the back of the leg. Herniated discs in the lower spine pressing on sciatic nerve roots can cause pain, weakness, tingling, and/or numbness in the leg, a condition called sciatica. Symptom distribution depends on the affected nerve, as described below.
• L4 nerve - the hip, thigh, inner knee, and calf
• L5 nerve - buttocks, outer thigh, anterior calf, and top of foot
• S1 nerve - buttocks, posterior leg and calf, and side of foot

• Spondylolysis
• Spondylolysis is stress fractures in the pars interarticularis, joints that articulate with the adjacent vertebral bodies. See spondylolysis review for more.
• Spondylolysis illustration

• Spondylosis
• Spondylosis is degenerative changes of the discs and vertebral bodies that occur with age. Radiologic signs of spondylosis include osteophyte formation (bone spurs), disc space narrowing, bulging or herniated discs, and bony sclerosis.

• Spondylolisthesis
• Spondylolisthesis is a condition where one vertebral body is displaced forward in relation to the one below it. There are two types of spondylolisthesis. Degenerative spondylolisthesis occurs when osteoarthritic changes in the pars interarticularis joint create laxity, allowing the vertebral body above to move forward. Spondylolytic spondylolisthesis is caused by stress fractures in the pars interarticularis, which allow slippage. See spondylolisthesis review for more.
• Spondylolisthesis illustration

• Spondylitis
• Spondylitis is vertebral body inflammation. Causes may be infectious or autoimmune (e.g., ankylosing spondylitis).

• Nonspecific LBP (70 - 80% of LBP cases)
• Overview
• Nonspecific LBP, also referred to as musculoskeletal back pain, mechanical low back pain, and lumbar strain, is by far the most common cause of LBP, accounting for 70 - 80% of cases
• Pathology
• Nonspecific LBP is back pain with no identifiable pathology (e.g., fracture, herniated disc)
• Symptoms
• Nonspecific low back pain often presents as a general aching across the lower back that is worsened by prolonged standing and/or physical activity
• Risk factors
• Family history
• Obesity
• Occupational factors (work-related lifting, carrying, pushing, pulling, walking, standing, etc.)
• Psychological factors
• Physical activity / Deconditioning
• Smoking [1,5-16]
• Treatment
• See nonspecific LBP treatment

• Disc disease (4% of LBP cases)
• Pathology
• Disc disease is caused by spinal cord or nerve root compression from a herniated disc (see disc protrusion illustration)
• Symptoms
• Symptoms, which may occur suddenly or progress gradually, include pain, numbness, tingling, and/or weakness in the distribution of the affected nerve (see sciatica)
• Risk factors
• No definitive risk factors have been identified [17]
• Treatment
• See disc disease treatment

• Spinal stenosis (3% of LBP cases)
• Pathology
• Spinal stenosis is narrowing of the lumbar canal due to degenerative changes, including disc disease, ligamentum flavum thickening, osteoarthritic bone and joint disease, and spondylolisthesis. Collectively, these changes exert pressure on the spinal cord, producing symptoms (see spinal stenosis illustration)
• Symptoms
• Spinal stenosis causes pain and weakness in the buttocks, thighs, and lower legs that are worsened by prolonged walking or standing and relieved by leaning over or sitting (neurogenic claudication). [3]
• Risk factors
• Advanced age - age > 60 years is the most important risk factor
• History of chronic steroid use
• Paget's disease
• History of disc or spine disorders (e.g., disc disease, spondylolisthesis) [3]
• Treatment
• See spinal stenosis treatment

• Compression fractures (4% of LBP cases)
• Pathology
• Vertebral compression fractures are collapsed vertebrae, which may occur acutely from mild trauma (e.g., sneezing, lifting small objects) or develop gradually over time. In some cases, they are asymptomatic and discovered incidentally on imaging. The most common vertebrae affected are T8 through T12, L1, and L4. See vertebral compression fracture illustration.
• Symptoms
• Acute fractures may cause sudden back pain, while slowly progressive ones may be asymptomatic or present with gradually worsening pain. Compressed vertebrae can lead to kyphosis (hunched-over posture) and loss of height.
• Risk factors
• Advanced age - > 65 for men and 75 for women
• Females
• History of chronic steroid use
• Osteoporosis
• Trauma
• Very thin or frail
• White or Asian race [18]
• Treatment
• See vertebral compression fracture treatment

• Other causes
• Cancer - cancer, including bony metastasis, should be considered in patients with a history of malignancy or concerning symptoms (e.g., unexplained weight loss)
• Infection - risk factors for infectious spondylitis include IV drug abuse, recent bacterial infection, surgery, organ transplant recipient, and immunosuppression
• Cauda equina syndrome - cauda equina syndrome is a rare but serious condition involving severe compression of the nerves leaving the bottom of the spinal cord. Symptoms include inability to urinate or control bowel movements, loss of sensation around the rectum, and leg weakness. Causes include lower spine tumors and massive midline disc herniation. It is a medical emergency requiring prompt surgery to prevent permanent disability. [4]
• Ankylosing spondylitis - ankylosing spondylitis is a chronic inflammatory spine condition marked by vertebral body fusion and reduced flexibility. It typically presents in younger patients (< 30 years old) and is more common in men. More than 90% of affected patients have the HLA-B27 haplotype. Bony growth within spinal ligaments (syndesmophytes) and sacroiliitis are typical X-ray findings. [2]

• History
• Most LBP etiologies can be determined from the medical history. General aching and soreness across the lower back that is worse with prolonged standing or activity is typical of nonspecific LBP. Pain, numbness, and/or tingling that radiates into the lower extremities is consistent with disc disease. Spinal stenosis should be considered in older patients with buttocks, hip, thigh, and/or leg symptoms. Frail elderly patients with sudden or gradual pain in a specific region of the back should be evaluated for vertebral compression fractures. In certain cases (e.g., fever, IV drug abuser, history of cancer, trauma), other etiologies should be considered.

• Physical exam
• The most useful exam is the straight leg raise (straight leg raise video), which can help distinguish between nonspecific LBP and disc disease. In studies, it has a sensitivity of 92% and a specificity of 28%, which means a negative test is helpful in ruling out disc disease but a positive test doesn't mean it is likely. Other exam findings, including lower extremity reflexes and motor strength, are mostly nonspecific, highlighting the importance of the medical history. [21]

• Imaging
• Imaging for LBP is controversial, as it accounts for considerable healthcare expenditures and oftentimes has little impact on treatment decisions. Regardless of the etiology, LBP often improves, and early imaging has not been found to affect outcomes. Furthermore, many abnormalities found on imaging, including herniated discs, spondylolisthesis, spondylolysis, and canal stenosis, are present in people without back or leg pain, making it difficult at times to know if findings are incidental or causal (see MRI findings in patients without pain). [25,66]
• LBP imaging recommendations from the ACP and APS are provided below. ACR red flag findings that may indicate a serious underlying condition favoring imaging are also listed, although, in studies, they perform poorly as predictors of serious etiologies.

• ACP/APS recommendations for LBP imaging
• Clinicians should not routinely order radiological studies for nonspecific low back pain
• Clinicians should order radiological studies when severe or progressive neurological deficits are present or when serious underlying conditions are suspected
• Clinicians should order an MRI (preferred) or CT scan in patients with persistent (> 4 weeks) low back pain and signs and symptoms of disc disease only if they are potential candidates for surgery or epidural spinal injections [20]


• ACR LBP "red flag" findings that may indicate a serious underlying condition
• History of cancer
• Unexplained weight loss
• Immunosuppression
• Urinary infection
• Intravenous drug use
• Prolonged use of corticosteroids
• Back pain not improved with conservative management
• History of significant trauma
• Minor fall or heavy lift in a potentially osteoporotic or elderly individual
• Prolonged use of steroids
• Acute onset of urinary retention or overflow incontinence
• Loss of anal sphincter tone or fecal incontinence
• Saddle anesthesia
• Global or progressive motor weakness in the lower limbs
• Prior back surgery [24]

• Imaging studies
• X-ray - X-rays are useful for identifying bony abnormalities, including vertebral compression fractures, degenerative changes, spondylolysis, and spondylolisthesis
• MRI - MRI provides images of the bones, ligaments, nerve roots, and spinal cord, making it the preferred study for evaluating disc disease and spinal stenosis
• CT scan - CT scans allow visualization of the bones, spinal cord, and discs. Bone images are superior to MRI, while disc and spinal cord images are inferior.
• CT myelogram - CT myelogram is a CT scan where contrast is infused around the spinal cord to improve visualization of the canal. It is sometimes ordered when metallic hardware, which can distort MRI images, is present from previous surgeries.
• Nerve conduction studies (NCS) and electromyography (EMG) - NCS and EMG measure nerve and muscle electrical activity in the arms and legs. Rarely, they are used to detect disc disease in the lower extremities.

• Nonspecific LBP
• Most people with acute nonspecific LBP will improve within a few weeks to several months. Recurrence within a year is seen in up to 73% of patients, while chronic LBP (> 3 months) develops in 10 - 15%. [1,4,26]
• Factors associated with continued pain and/or disability
• Worrying and health anxiety
• Claims for compensation/disability
• Minimal or no exercise in leisure time
• More intense pain
• Longer duration of pain
• Fear/avoidance of physical activity
• Doubt over returning to work [27]

• Disc disease
• Most people who experience disc disease symptoms recover in 3 - 5 months. In one review, 60% of patients with disc disease had a marked decrease in leg and back pain by 2 months. At one year, pain persisted in 20 - 30% of patients. [30] In another study, 36% of patients with sciatica showed major improvement in 2 weeks, and 73% showed reasonable to major improvement after 12 weeks. [29]
• Disc abnormalities on imaging also improve in most patients. The table below shows the natural course of disc disease on MRI in 154 patients (average age 45 years) with sciatica who were followed for 14 months. All patients were treated conservatively (i.e., no surgery).

• Spinal stenosis
• A study in the journal Spine followed 49 patients with spinal stenosis for 3 years. Patients were given aggressive nonsurgical treatment (e.g., steroid injections, physical therapy, medications). After an average follow-up of 33 months, the following was seen:
• Nine patients (18%) received surgery because they did not improve. Of these patients, 78% had severe stenosis on MRI versus 38% in those not receiving surgery.
• In patients who did not receive surgery, 65% had improvement in their pain, 18% were worse, and 17% were the same. For functional outcomes, 40% had improvement, 25% were worse, and 35% were the same. [34]

• Vertebral compression fractures
• Vertebral compression fractures typically cause acute back pain that improves over a period of 3 months. Chronic pain will develop in 40% of patients. [37]

• Overview
• Nonspecific LBP is treated with exercises, stretching, medications like NSAIDs, acetaminophen, muscle relaxers, and perhaps, most importantly, time, as most nonspecific LBP improves within a month. Long-term prevention involves core muscle strengthening since weak abdominal and lower back muscles play a significant role. Many patients are referred for physical therapy, which may benefit patients with poor exercise habits. However, evaluating the effects of physical therapy in trials is difficult since the control group is unblinded, preventing correction for a placebo effect.
• A study comparing early physical therapy to usual care is reviewed below. Studies enrolling patients with nonspecific LBP evaluating TENS units and duloxetine are also reviewed. Core strengthening exercises for LBP are available here - low back pain workout

• Overview
• Disc disease may be treated conservatively (e.g., physical therapy, medications, spine injections) or surgically. Three studies comparing conservative therapy to surgery are reviewed below, along with a study evaluating the effects of epidural injections.

• RCT
  Microdiskectomy vs Conservative Treatment for Sciatica Lasting 4 - 12 Months, NEJM (2020) [PubMed abstract]
• Design: Randomized controlled trial (N=128 | length = 6 months) in patients with unilateral radiculopathy for 4 to 12 months and findings on MRI of posterolateral herniation of the disk between L4 and L5 or L5 and S1 on the appropriate side, with compression of the corresponding nerve root
• Treatment: Microdiskectomy vs Conservative treatment for a minimum of 6 months
• Primary outcome: Leg pain intensity score on the visual analogue scale (ranging from 0 to 10, with higher scores indicating a greater intensity of pain) at 6 months after randomization
• Results:
• Baseline leg pain intensity score: Microdiskectomy - 7.7, Conservative therapy - 8.0
• Primary outcome: Microdiskectomy - 2.8, Conservative therapy - 5.2 (p<0.001)
• In the Microdiskectomy group, 12.5% of patients did not receive surgery. In the Conservative therapy group, 97% of patients were continuing to receive nonsurgical care at 6 months.
• Findings: In this single-center trial involving patients with sciatica lasting more than 4 months and caused by lumbar disk herniation, microdiskectomy was superior to nonsurgical care with respect to pain intensity at 6 months of follow-up.

• Summary
• Surgical studies for disc disease are hampered by high crossover rates, which bias the study towards the null, and a lack of sham procedure in the control group, leaving participants unblinded and susceptible to a placebo effect. It is difficult to draw meaningful conclusions from the three studies above, as they all suffered from these weaknesses.
• Steroid injections were not superior to saline or sham injections in the epidural injection trial. A study in patients with spinal stenosis (see LESS trial) also found they offer no real benefit. The BMJ 2025 spine procedure guidelines do not recommend epidural injections for radiculopathy.
• Patients with disc disease should consider its natural course before undergoing surgical treatment.

• Overview
• Spinal stenosis may be treated surgically or conservatively (e.g., physical therapy, medications, injection). Surgical treatment starts with a laminectomy, which relieves pressure in the spinal canal (laminectomy illustration). Other decompressive procedures, including discectomy and foraminotomy, may also be performed. Lastly, spinal fusion, binding two vertebral bodies together with rods, screws, and a bone graft (spinal fusion illustration), is often performed. Theoretically, spinal fusion stabilizes the anatomy and reduces the risk of nerve impingement, particularly in patients with spondylolisthesis.
• Studies evaluating spinal stenosis therapies, including surgery vs. conservative therapy, laminectomy with and without fusion, epidural steroids, and spinal cord stimulators, are reviewed below.

• RCT
  Spinal Cord Burst Stimulation vs Placebo Stimulation for Chronic Radicular Pain, JAMA (2022) [PubMed abstract]
• Design: Randomized, placebo-controlled, crossover trial (N=50 | length = 12 months) in patients with ≥ 6 months of radicular pain (average ≥ 5 on 10 point scale) after ≥ 1 decompressive or fusion procedure(s) for degenerative lumbar spine disease
• Treatment: All patients were implanted with a pulse generator connected to electrodes with leads that travel into the epidural space posterior to the spinal cord dorsal columns. Patients then received two 3-month periods of spinal cord burst stimulation and two 3-month periods of placebo stimulation in random order.
• Primary outcome: Change from baseline in the self-reported Oswestry Disability Index (ODI; range, 0 points [no disability] to 100 points [maximum disability]; the minimal clinically important difference was 10 points) score between periods with burst stimulation and placebo stimulation.
• Results:
• Mean baseline ODI score was 44.7
• Primary outcome (change in ODI): Stimulation periods -10.6, Placebo periods -9.3 (p=0.32)
• Findings: Among patients with chronic radicular pain after lumbar spine surgery, spinal cord burst stimulation, compared with placebo stimulation, after placement of a spinal cord stimulator resulted in no significant difference in the change from baseline in self-reported back pain–related disability.

• Summary
• Surgery vs conservative treatment - the SPORT trial had too many crossovers to draw meaningful conclusions. The much smaller Spine study, which had few crossovers, found that surgery was superior to conservative therapy for pain and disability over two years.
• Laminectomy/decompression +/- fusion - the SLIP trial (N=66) found a small improvement with the addition of spinal fusion to decompressive surgery. The larger SSS Study and NORDSTEN-DS trial found no additional benefit with fusion. Overall, spinal fusion does not appear to enhance decompressive surgery, even in patients with significant spondylolisthesis.
• Epidural steroids - after six weeks, epidural injection of steroid and lidocaine was not superior to lidocaine only in the LESS trial. Steroid was significantly better at three weeks, which may be related to systemic absorption and unrelated to placement around the spinal cord; suppressed cortisol levels, which were observed in the steroid group, support this assumption. Given the cost and potential risk of such procedures (e.g., the deadly meningitis outbreak of 2012), steroid epidural injections should not be given for spinal stenosis. The BMJ 2025 spine procedure guidelines do not recommend epidural injections for radicular or axial spine pain.
• Spinal cord stimulators - spinal cord stimulators have become more popular in recent years, and pain management doctors often promote them. The stimulator study found they did not improve radicular pain after spinal decompression surgery.

• Overview
• Most vertebral compression fractures are treated conservatively with pain medications and short periods of bed rest. Rarely, fractures may cause focal neurologic symptoms and spinal instability requiring surgery. Vertebroplasty, a procedure where an acrylic cement is injected through a needle into the compressed vertebra to stabilize the fracture, is sometimes performed for pain control. A variant of vertebroplasty called balloon kyphoplasty uses an inflatable balloon to heighten the vertebrae before the cement is injected. Early on, many unblinded studies comparing vertebroplasty to conservative treatment found it improved pain. However, blinded studies comparing it to a sham procedure, including the three reviewed below, have not shown a definitive benefit.

• Bracing
• Hard and soft bracing are sometimes used to treat compression fractures. A small study (N=60) found hard and soft bracing did not improve outcomes in patients with osteoporotic compression fractures. [PMID 25471910]

• Summary
• The VAPOUR trial found a benefit with vertebroplasty, while the other two did not. One hypothesis for the conflicting results is that most subjects in the VAPOUR trial were treated within three weeks of fracture diagnosis, while the length between fracture and treatment was longer in the negative trials. The authors of the VERTOS trial also note that more than 80% of participants in the VERTOS sham group believed they had received the intervention compared to 54% in the VAPOUR trial. These differences in placebo effect may have contributed to the contradictory results.
• In conclusion, vertebroplasty may be of some benefit in patients with acute fractures (< 3 weeks), but its effects are not overwhelming

• Overview
• Transcutaneous electrical nerve stimulation (TENS) units are placed over the lower back where they deliver a mild electrical current via skin electrodes. A study comparing TENS units to sham units in people with chronic LBP (see below) found they had no effect on functional status. Another study published in 1990 found they did not improve back pain. [PMID 2140432]

• Overview
• It is hypothesized that nonspecific back pain may originate from irritated nerves surrounding intervertebral discs and facet and sacroiliac joints. Radiofrequency denervation (RD) is a procedure where a needle is placed using fluoroscopic or ultrasound guidance in the area of nerve endings thought to be causing pain. The needle is then heated, theorectically killing the pain-conducting nerve. Treatment areas are determined from lidocaine injections that elicit a positive response. The study below found no effect of RD in patients with chronic LBP thought to be related to RD-treatable nerve endings. The study was unblinded, allowing for a placebo effect in the RD group. Even so, RD had no meaningful effect.

• The British Medical Journal (BMJ) published recommendations in 2025 on procedures for chronic (≥ 3 months) spine pain not caused by cancer or an inflammatory arthropathy. [PMID 39971339] The authors included four people living with chronic spine pain, 10 clinicians with experience managing chronic spine pain, and eight methodologists. The evidence reviewed encompassed studies comparing interventions to usual care or sham procedures. Based on their review, the following recommendations were made.


• Axial spine pain: For cervical, lumbar, or sacroiliac axial spine pain, the panel strongly recommends AGAINST the following procedures:
• Joint radiofrequency ablation with or without joint targeted injection of local anesthetic plus steroid
• Epidural injection of local anesthetic, steroids, or their combination
• Joint-targeted injection of local anesthetic, steroids, or their combination
• Intramuscular injection of local anesthetic with or without steroids


• Radicular pain: For cervical or lumbar radicular pain, the panel strongly recommends AGAINST the following procedures:
• Dorsal root ganglion radiofrequency with or without epidural injection of local anesthetic or local anesthetic plus steroids
• Epidural injection of local anesthetic, steroids, or their combination

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• NSAIDs are widely prescribed to help alleviate LBP. In trials, they have been found to be effective. [51]

• Opioids
• Opioids are not generally recommended for acute low back pain, while their use in chronic pain is controversial. A trial (N=347) in patients with acute neck and/or low back pain found that oxycodone was no better than placebo for pain relief at 6 weeks. [PMID 37392748] Another study in patients given naproxen for acute nonspecific LBP found that the addition of oxycodone was no better than placebo or cyclobenzaprine for functional status at one week. [PMID 26501533]

• Acetaminophen (Tylenol®)
• Acetaminophen is widely available and often used to treat LBP. A large trial (N=1652) in patients with acute LBP found that it did not shorten recovery time compared to placebo. [PMID 25064594]

• Muscle relaxants
• Carisoprodol (Soma®)
• Carisoprodol, a controlled substance that has abuse potential, has been shown to be effective for LBP in trials [54]
• Cyclobenzaprine (Flexeril®)
• In trials, cyclobenzaprine's effects on LBP have been mixed. A meta-analysis found that it had a modest short-term benefit compared to placebo. [PMID 11434793] A study in patients given naproxen for acute nonspecific LBP found that the addition of cyclobenzaprine was no better than placebo or oxycodone for functional status at one week. [PMID 26501533]
• Metaxalone (Skelaxin®)
• A study comparing the addition of metaxalone, baclofen, tizanidine, or placebo to ibuprofen in patients presenting to the ER with acute nonspecific LBP found none of the drugs were significantly better than placebo. See muscle relaxer study for more.
• Methocarbamol (Robaxin®)
• A study comparing the addition of methocarbamol, orphenadrine, or placebo to naprosyn in patients presenting to the ER with nonspecific LBP found that neither muscle relaxer improved outcomes compared to placebo. See orphenadrine vs methocarbamol for LBP for more.
• Tizanidine (Zanaflex®)
• A study comparing the addition of tizanidine, metaxalone, baclofen, or placebo to ibuprofen in patients presenting to the ER with acute nonspecific LBP found none of the drugs were significantly better than placebo. See muscle relaxer study for more.

• Benzodiazepines
• A study comparing the addition of valium or placebo to naproxen in patients presenting to the ER with acute nonspecific LBP found that valium was no better than placebo at improving pain and function over 3 months of follow-up. [PMID 28187918]

• RCT
  Pregabalin vs Placebo for Acute and Chronic Sciatica, NEJM (2017) [PubMed abstract]
• Design: Randomized placebo-controlled trial (N=209 | length = 8 weeks) in patients with sciatica for at least 1 week and less than 1 year
• Treatment: Pregabalin titrated to a maximum of 600 mg/day vs Placebo for 8 weeks
• Primary outcome: Leg-pain intensity score on a 10-point scale (with 0 indicating no pain and 10 the worst possible pain) at 8 weeks
• Results:
• Primary outcome: Pregabalin - 3.7, Placebo - 3.1 (p=0.19)
• Findings: Treatment with pregabalin did not significantly reduce the intensity of leg pain associated with sciatica and did not significantly improve other outcomes, as compared with placebo, over the course of 8 weeks. The incidence of adverse events was significantly higher in the pregabalin group than in the placebo group.

• RCT
  Pregabalin vs Diphenhydramine for Neurogenic Claudication in Spinal Stenosis, Neurology (2015) [PubMed abstract]
• Design: Randomized controlled crossover trial (N=29 | length = 33 days) in patients with spinal stenosis and neurogenic claudication
• Treatment: Pregabalin 150 mg twice daily vs Diphenhydramine 12.5 mg twice daily. Patients received each treatment for 13 days before crossing over to the other treatment with a 7 day washout period in between.
• Primary outcome: Time to first moderate pain symptom (Numeric Rating Scale (0 - 10) score ≥ 4) during a 15-minute treadmill test
• Results:
• Primary outcome: No significant difference was found between pregabalin and active placebo for the time to first moderate pain symptom (p=0.61)
• Findings: Pregabalin was not more effective than active placebo in reducing painful symptoms or functional limitations in patients with neurogenic claudication associated with lumbar spinal stenosis

• Pathology
• Spondylolysis
• Spondylolysis is a fracture(s) in the pars interarticularis, joints that articulate with the adjacent vertebral bodies. In children and young adults, it is believed to be caused by repetitive stress and is seen more frequently in athletes who engage in sports requiring frequent and extensive spine motion (e.g., gymnasts, figure skaters, dancers, divers).
• Spondylolysis illustration


• Spondylolisthesis
• Spondylolisthesis is a condition where one vertebral body is displaced forward in relation to the one below it. There are two types of spondylolisthesis. Degenerative spondylolisthesis occurs when osteoarthritic changes in the pars interarticularis joint create laxity, allowing the vertebral body above to move forward. Spondylolytic spondylolisthesis is caused by stress fractures in the pars interarticularis, which allow slippage (see spondylolisthesis illustration). Younger patients are affected by spondylolytic spondylolisthesis, while older patients typically have degenerative spondylolisthesis. [72,74]
• Spondylolisthesis is expressed as a percentage using the Meyerding method, which takes the anterior-posterior length of the upper vertebra's overhanging part and divides it by the anterior-posterior diameter of the lower vertebra's top surface. The ratio is then multiplied by 100 and expressed as a percent, which can be used to assign a grade as below. [72,74]
• Grade I: ≤ 25%
• Grade II: 26 - 50%
• Grade III: 51 - 75%
• Grade IV: 76 - 100%
• Grade V: 100% (spondyloptosis)
• Spondylolisthesis in children and young adults typically occurs at the L5 - S1 level, and slippage is usually mild, with 79% being Grade I, 20% being Grade II, and 1% being Grade III. Degenerative spondylolisthesis most often affects the L4 - L5 level, with an average slippage of 14%.

• Prevalence
• Children and young adults
• Spondylolysis is present in 4% of 6-year-olds and 6% of 14-year-olds. Spondylolisthesis is not seen in unilateral spondylolysis but is present to some degree in 50 - 74% of patients with bilateral defects.
• Older patients
• A study that reviewed CT scans (N=188) from an unselected population of U.S. adults (average age 52 years) found the following:
• Lumbar spondylolysis was present in 16.5% of males and 5% of females
• Spondylolisthesis was present in 20.7% of patients
• Spondylolytic spondylolisthesis was present in 8.2% of patients
• Degenerative spondylolisthesis was present in 7.7% of men and 21.3% of women
• Prevalence of degenerative spondylolisthesis by age was as follows:
• < 40 years: 0%
• 40 - 49 years: 2.1%
• 50 - 59 years: 10.8%
• 60 - 69 years: 41.7%
• ≥ 70 years: 16.7% [72,73,76]

• Symptoms
• Children and young adults
• Most patients are asymptomatic, while 10% may develop LBP worsened by activity, particularly lumbar hyperextension.
• Older patients
• Most patients are asymptomatic, unless they develop significant spinal stenosis

• Natural course
• Children and young adults
• Most cases of isolated spondylolysis heal spontaneously. Bilateral defects are less likely to heal than unilateral ones, and concomitant spondylolisthesis makes fracture resolution unlikely. Over time, spondylolytic spondylolisthesis rarely progresses, with only 4 - 5% of patients experiencing worsening in longitudinal studies. [72,76]
• Older patients (> 40 years)
• Spondylolisthesis progression is more common in older patients. A study following 145 patients with degenerative spondylolisthesis for 10 years found that the condition progressed in 34% of patients. However, progression did not correlate with increased symptoms, and only 15% of patients were ever treated surgically. [74]

• Treatment
• Children and young adults
• Most patients can be managed conservatively, and those who are asymptomatic (i.e., spondylolysis is discovered incidentally) can continue their current level of physical activity. There is no consensus on how to manage symptomatic patients, with a mix of bracing, activity modification, and physical therapy often being used. Regardless of treatment, prognosis is good, with more than 90% of patients returning to athletic competition. Rarely, surgery may be required for severe cases (e.g., grade 3 or 4 spondylolisthesis, progressive neurologic symptoms). [76]
• Older patients (> 40 years)
• Degenerative spondylolisthesis can cause and/or worsen spinal stenosis. See spinal stenosis treatment for more. [74]

• 1 - PMID 21982256
• 2 - PMID 17448825
• 3 - PMID 18287604
• 4 - PMID 11172169
• 5 - PMID 20537959
• 6 - PMID 20447872
• 7 - PMID 20494816
• 8 - PMID 20494815
• 9 - PMID 20207335
• 10 - PMID 20097618
• 11 - PMID 19910263
• 12 - PMID 19631589
• 13 - PMID 20228714
• 14 - PMID 10423792
• 15 - PMID 21221663
• 16 - PMID 10954644
• 17 - PMID 17525856
• 18 - PMID 14727827
• 19 - PMID 21156951
• 20 - PMID 17909209
• 21 - PMID 20166095
• 22 - PMID 8208267
• 23 - PMID 2312537
• 24 - ACR Appropriateness Criteria in Low Back Pain (2015)
• 25 - PMID 19790051
• 26 - PMID 12907487
• 27 - PMID 20447871
• 28 - PMID 15867409
• 29 - PMID 11887877
• 30 - PMID 12027305
• 31 - PMID 17119140
• 32 - PMID 17538084
• 33 - PMID 21914755
• 34 - PMID 10685483
• 35 - PMID 18287602
• 36 - PMID 17202885
• 37 - PMID 22116114
• 38 - PMID 19657121
• 39 - PMID 21750078
• 40 - PMID 16778696
• 41 - PMID 19934813
• 42 - PMID 10635527
• 43 - PMID 19447684
• 44 - PMID 18026865
• 45 - PMID 6373773
• 46 - PMID 20381432
• 47 - PMID 17538085
• 48 - PMID 21328304
• 49 - PMID 2140432
• 50 - PMID 22337531
• 51 - PMID 18253976
• 52 - PMID 11434793
• 53 - PMID 18711953
• 54 - PMID 12804507
• 55 - PMID 16788338
• 56 - PMID 18253994
• 57 - Cymbalta PI
• 58 - PMID 20472510
• 59 - PMID 17909211
• 60 - PMID 18665021
• 61 - PMID 17046475
• 62 - PMID 16481946
• 63 - PMID 18772303
• 64 - PMID 20606148
• 65 - PMID 20012754
• 66 - PMID 25781443
• 67 - PMID 25883095
• 68 - PMID 25988461
• 69 - PMID 26461996 - Early PT in LBP
• 70 - PMID 19934813 Spondylolysis incidence
• 71 - PMID 20381432 Spondylolysis incidence
• 72 - PMID 10635527 Spondylolisthesis incidence
• 73 - PMID 19139672 Spondylolisthesis incidence in Framingham study
• 74 - PMID 18026865 Spondylolisthesis review
• 75 - PMID 32125402 US Health Care Spending by Payer and Health Condition, 1996-2016, JAMA (2020)
• 76 - McDonald BT, Hanna A, Lucas JA. Spondylolysis. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513333/