Why Is My Low Back Pain Not Getting Better—Is It Serious?

Low back pain can be complicated. In approximately 85% of patients, no specific cause for low back pain is identified. Typically, the pain resolves spontaneously, and in 95% of patients, it improves within about three months. In some cases, the pain may be multifactorial or non-organic in origin. The pain may also be referred from other areas such as the hip joint, buttock, or sacroiliac joint. MRI may show false positives; therefore, images must be interpreted carefully and always correlated with the patient's history and physical examination. Patients may present with red flags that require further investigation. These include a history of significant trauma, prior malignancy, or severe progressive neurological deficits. Patients may exhibit loss of bladder or bowel control, or may have systemic signs such as fever, chills, and weight loss. Pain can also be referred from non-spinal sources including aortic aneurysm, renal calculi, pancreatitis, pelvic pathology, duodenal ulcer, or acute myocardial infarction. These possibilities must be excluded before attributing the pain to spinal origin. If the source is spinal, yet the presentation is not straightforward, then the low back pain is considered complicated. So what are these scenarios? Number one is cauda equina syndrome. The patient typically has more back pain than leg pain, accompanied by bladder or bowel dysfunction, incontinence, urinary frequency, and perianal numbness. This condition can be easily missed, and the consequences may be catastrophic. Always ask patients about bladder or bowel symptoms. If such symptoms are present, obtain an emergency MRI and perform urgent surgery. This provides the best chance of symptom resolution, especially for bladder function. Another complicated case is low back pain with progressive neurological deficits. Investigate the cause of the neurological deficit. If no cause is found in the lumbar spine, evaluate the thoracic spine or cervical spine. Obtain MRIs as needed. If the patient has a pacemaker and cannot undergo MRI, proceed with myelogram and CT scan. A complicated scenario also includes low back pain with gait disturbance. In such cases, obtain a cervical spine MRI to evaluate for concomitant cervical myelopathy caused by spinal cord compression. Careful patient selection is crucial for achieving successful outcomes, particularly in patients with nonspecific low back pain. Low back pain is the most common worker's compensation claim in the United States, accounting for 25% of all claims and one-third of total compensation costs. Worker’s compensation is an independent risk factor for poor surgical outcomes. Patients receiving worker’s compensation and undergoing surgery generally have worse outcomes compared to the general population. Smoking is another complicating factor. Smoking impairs disc nutrition and negatively affects the healing process after spinal fusion surgery. A further complication is low back pain in patients with ankylosing spondylitis. These patients are at risk for occult spinal fractures, which may not be readily apparent but are associated with increased neurological deficits and higher postoperative mortality. If such a patient presents with significant back pain, obtain an MRI or CT scan to detect undiagnosed fractures. Surgery is typically indicated if a fracture is identified. Low back pain associated with osteoporotic fractures is another complex condition. Perform a DEXA scan and initiate appropriate medical treatment. In acute fractures, consider bracing or surgical intervention. In elderly patients with significant pain, obtain X-rays to check for osteoporotic compression fractures. Depression is another complicating factor, as it adversely affects surgical outcomes. Postoperative anticoagulation is also a concern. Evaluate the risk-benefit ratio. In certain situations, an inferior vena cava (IVC) filter may be considered. If the patient presents with neurogenic claudication—characterized by low back pain accompanied by leg heaviness and cramping, relieved by sitting—then lumbar spinal stenosis is likely. Obtain an MRI to confirm the diagnosis. These patients often benefit from spinal surgery. Neurogenic claudication manifests as pain and heaviness in one or both legs, worsens with standing upright, and improves with sitting or leaning forward. If vascular claudication is also suspected, a vascular consultation is necessary and vascular imaging may be required.