A critical evidence review of the common causes of low back pain by one of spine medicine's most rigorous voices. Nachemson applies strict scientific standards to diagnosis, natural history, and treatment of idiopathic LBP, sciatica, spondylolisthesis, and spinal stenosis. The recurring question: which diagnoses and operations are actually proven?
Treat the natural history as your baseline. Since 90% of nonspecific LBP resolves in six weeks and sciatica outcomes converge with or without surgery, the burden of proof falls on intervention, not on watchful waiting.
Build a mental model for imaging: a herniation on MRI in a patient without matching symptoms is background noise, present in a third of asymptomatic people. Correlate imaging with the clinical exam before attributing pain to it.
Be skeptical of unvalidated diagnostic labels. Facet syndrome, SI dysfunction, degenerative disk disease, and segmental instability lack tests that reliably distinguish pain from no pain. Recognize the psychosocial driver. In chronic disability, illness behavior and compensation systems weigh more than the presumed structural lesion, so do not read pain behavior as physical disease.
When you do operate, hold to real evidence: the Herkowitz and Kurz RCT showing decompression plus fusion beats decompression alone for degenerative spondylolisthesis is the kind of proof this paper demands.
A critical evidence review of the common causes of low back pain by one of spine medicine's most rigorous voices. Nachemson applies strict scientific standards to diagnosis, natural history, and treatment of idiopathic LBP, sciatica, spondylolisthesis, and spinal stenosis. The recurring question: which diagnoses and operations are actually proven?
Treat the natural history as your baseline. Since 90% of nonspecific LBP resolves in six weeks and sciatica outcomes converge with or without surgery, the burden of proof falls on intervention, not on watchful waiting.
Build a mental model for imaging: a herniation on MRI in a patient without matching symptoms is background noise, present in a third of asymptomatic people. Correlate imaging with the clinical exam before attributing pain to it.
Be skeptical of unvalidated diagnostic labels. Facet syndrome, SI dysfunction, degenerative disk disease, and segmental instability lack tests that reliably distinguish pain from no pain. Recognize the psychosocial driver. In chronic disability, illness behavior and compensation systems weigh more than the presumed structural lesion, so do not read pain behavior as physical disease.
When you do operate, hold to real evidence: the Herkowitz and Kurz RCT showing decompression plus fusion beats decompression alone for degenerative spondylolisthesis is the kind of proof this paper demands.