This 2021 Lancet Seminar by Knežević et al. surveys the full clinical landscape of low back pain. It covers epidemiology, pain classification, pathogenesis across lumbar structures, diagnostic evaluation, and the full treatment spectrum from self-care to surgery. The central question: how do you classify, evaluate, and manage a condition where nociceptive, neuropathic, and nociplastic contributors almost always overlap?
When your chronic LBP patient has had three injections, two courses of PT, and multiple imaging studies pointing at a disc — and is still disabled. The diagnosis is almost certainly not a single structural problem.
This paper establishes that overlapping nociceptive, neuropathic, and nociplastic mechanisms are the norm in chronic LBP. The practical rule: when single-modality treatments fail, it means you're treating only one contributor. A multimodal, interdisciplinary approach combining pharmacotherapy, physical therapy, and cognitive behavioral therapy is the standard of care, not a last resort.
Imaging findings are unreliable guides to surgical decision-making: herniated discs appear in nearly a third of asymptomatic 20-year-olds, and spinal stenosis is present in up to 56% of asymptomatic individuals in some reviews. Surgery for herniated disc is faster, not better at 1–2 years. Reserve it for progressive neurological deficits or failure of adequate conservative care.
Screen every chronic LBP patient for fear-avoidance beliefs and negative expectations. These predict disability as reliably as structural findings, and treating them changes outcomes.
This 2021 Lancet Seminar by Knežević et al. surveys the full clinical landscape of low back pain. It covers epidemiology, pain classification, pathogenesis across lumbar structures, diagnostic evaluation, and the full treatment spectrum from self-care to surgery. The central question: how do you classify, evaluate, and manage a condition where nociceptive, neuropathic, and nociplastic contributors almost always overlap?
When your chronic LBP patient has had three injections, two courses of PT, and multiple imaging studies pointing at a disc — and is still disabled. The diagnosis is almost certainly not a single structural problem.
This paper establishes that overlapping nociceptive, neuropathic, and nociplastic mechanisms are the norm in chronic LBP. The practical rule: when single-modality treatments fail, it means you're treating only one contributor. A multimodal, interdisciplinary approach combining pharmacotherapy, physical therapy, and cognitive behavioral therapy is the standard of care, not a last resort.
Imaging findings are unreliable guides to surgical decision-making: herniated discs appear in nearly a third of asymptomatic 20-year-olds, and spinal stenosis is present in up to 56% of asymptomatic individuals in some reviews. Surgery for herniated disc is faster, not better at 1–2 years. Reserve it for progressive neurological deficits or failure of adequate conservative care.
Screen every chronic LBP patient for fear-avoidance beliefs and negative expectations. These predict disability as reliably as structural findings, and treating them changes outcomes.