Introduction

Chronic low back pain (CLBP) is defined as pain localized between the lower rib margin and the gluteal folds that persists for more than 6 weeks. It may occur with or without leg pain (sciatica) and represents one of the leading causes of long-term disability worldwide. Unlike acute low back pain, chronic pain often involves a combination of structural pathology, persistent inflammation, central pain sensitization, psychological factors, and functional impairment. Although most cases remain non-specific, persistent symptoms require careful evaluation to identify spinal instability, neurological compromise, infection, inflammatory disorders, malignancy, or other specific causes.

Management is multidisciplinary and focuses on improving function, reducing pain, preventing disability, and restoring quality of life rather than complete pain elimination.

Epidemiology

• One of the leading causes of years lived with disability worldwide.

• Approximately 10–20% of patients with acute low back pain develop chronic symptoms.

• Most common between 40 and 70 years of age.

• More frequent among manual workers, obese individuals, smokers, and patients with sedentary lifestyles.

• Recurrence is common.

Etiology

Non-specific chronic low back pain (most common)

• Degenerative disc disease

• Facet joint arthropathy

• Chronic muscular or ligamentous strain

• Lumbar spondylosis

Specific spinal causes

• Lumbar disc herniation

• Lumbar spinal stenosis

• Degenerative spondylolisthesis

• Vertebral compression fractures

• Osteoporosis

• Spondyloarthritis

• Vertebral osteomyelitis

• Spinal tuberculosis

• Primary or metastatic spinal tumours

• Failed back surgery syndrome

Risk factors

• Previous episodes of low back pain

• Increasing age

• Obesity

• Smoking

• Heavy manual labour

• Repetitive lifting

• Poor posture

• Sedentary lifestyle

• Depression and anxiety

• Occupational dissatisfaction

• Osteoporosis

• Degenerative spinal disease

Pathophysiology

Chronic low back pain develops when acute mechanical injury fails to resolve completely or when degenerative, inflammatory, or structural spinal disorders produce ongoing nociceptive stimulation. Progressive degeneration of the intervertebral discs reduces disc height and alters spinal biomechanics, increasing stress on the facet joints, ligaments, and paraspinal muscles. Chronic inflammation and repetitive mechanical loading contribute to cartilage degeneration, osteophyte formation, and ligament hypertrophy, which may narrow the spinal canal or neural foramina and compress nerve roots, resulting in radicular symptoms. Persistent pain also induces changes within the central nervous system (central sensitization), whereby pain-processing pathways become hypersensitive, allowing pain to persist even after the original tissue injury has healed. Psychological factors such as anxiety, depression, fear-avoidance behaviour, and physical deconditioning further perpetuate pain and disability.

Classification

According to symptom duration:

• Acute: less than 6 weeks

• Subacute: 6–12 weeks

• Chronic: more than 6 weeks (according to this guideline)

According to pain pattern:

• Chronic non-specific low back pain

• Chronic low back pain with radiculopathy (sciatica)

• Chronic low back pain secondary to structural spinal disease

Clinical presentation

Patients commonly present with:

• Persistent low back pain lasting more than 6 weeks

• Lumbar stiffness

• Pain aggravated by prolonged standing, sitting, bending, or lifting

• Reduced spinal mobility

• Muscle spasm

• Functional limitation

• Sleep disturbance

• Reduced work capacity

Patients with radiculopathy may have:

• Pain radiating below the knee

• Buttock pain

• Numbness

• Tingling

• Lower limb weakness

• Positive straight-leg raise test

• Sensory deficits

• Reduced reflexes

Red flag signs

Urgent specialist assessment is required if any of the following are present:

• Progressive neurological deficit

• Saddle anaesthesia

• Bladder or bowel dysfunction

• Suspected cauda equina syndrome

• Fever

• History of malignancy

• Significant unexplained weight loss

• Persistent night pain

• Intravenous drug use

• Immunosuppression

• Suspected spinal infection

• Significant spinal trauma

• Osteoporosis with suspected vertebral fracture

Diagnostic criteria

Chronic low back pain is diagnosed when all of the following are present:

• Pain localized between the lower rib margin and gluteal folds

• Symptoms persisting for more than 6 weeks

• Functional limitation or persistent pain despite appropriate conservative management

• Clinical assessment excluding serious spinal pathology

• Imaging findings correlated with symptoms where indicated

Investigations

Imaging

Plain spine X-rays

Initial imaging for suspected degenerative disease, deformity, or instability.

Dynamic spine X-rays (flexion-extension views)

Assess:

• Segmental instability

• Spondylolisthesis

• Abnormal spinal motion

CT scan

Useful for:

• Bony abnormalities

• Fractures

• Facet arthropathy

• Surgical planning

MRI (preferred investigation)

Indicated for:

• Persistent radiculopathy

• Neurological deficit

• Suspected disc prolapse

• Spinal stenosis

• Infection

• Malignancy

• Failure of conservative management

Electromyography (EMG)

May be considered when:

• Diagnosis remains uncertain after MRI

• Peripheral neuropathy requires differentiation from lumbar radiculopathy

Laboratory investigations

Performed when inflammatory disease, infection, or malignancy is suspected.

• Complete blood count

• Erythrocyte sedimentation rate

• C-reactive protein

• Renal function tests

• Serum calcium

• Vitamin D level where appropriate

Differential diagnosis

• Lumbar disc herniation

• Lumbar spinal stenosis

• Degenerative disc disease

• Facet arthropathy

• Sacroiliitis

• Ankylosing spondylitis

• Vertebral compression fracture

• Vertebral osteomyelitis

• Spinal tuberculosis

• Metastatic spinal disease

• Hip osteoarthritis

• Fibromyalgia

• Peripheral neuropathy

Management

The goals of treatment are to:

• Reduce pain

• Improve functional capacity

• Restore quality of life

• Prevent disability

• Maintain independence

• Avoid unnecessary surgery

Non-pharmacological management

Self-management

Provide education regarding:

• The nature of chronic low back pain

• Realistic expectations of treatment

• Self-management strategies

• Gradual return to normal activities

• Importance of remaining physically active

Exercise therapy

Exercise programmes should be individualized and may include:

• Core stabilization exercises

• Aerobic exercise

• Stretching

• Strengthening programmes

• Biomechanical rehabilitation

• Physiotherapy-supervised exercise

Manual therapy

May be considered as part of a comprehensive rehabilitation programme and may include:

• Spinal manipulation

• Mobilization

• Soft tissue techniques

• Massage

Orthotics

Selected patients may benefit from:

• Lumbar support belts

• Corsets

• Temporary spinal orthoses

Psychological therapy

Consider cognitive behavioural therapy (CBT) as part of a multidisciplinary programme, particularly in patients with persistent disability, fear-avoidance behaviour, anxiety, or depression.

Pharmacological treatment

Conservative treatment principles

Conservative management includes:

• External spinal immobilization where appropriate

• Supportive analgesia

• Muscle relaxants

• Bisphosphonates when indicated for underlying osteoporosis

• Short periods of bed rest only when absolutely necessary

• Monitoring for neurological deterioration or spinal instability

NSAIDs

Ibuprofen

• 400 mg orally as an initial dose, then 200 mg every 8 hours

OR

Diclofenac sodium

• 50 mg orally every 8 hours for 7–14 days

OR

Meloxicam

• 7.5–15 mg orally every 12–24 hours for 7–14 days

Severe pain

Diclofenac

• 75 mg intramuscularly every 12 hours by deep IM injection for 1–3 days

±

Tramadol

• 100 mg intramuscularly every 12 hours by deep IM injection for 1–3 days

THEN

Diclofenac

• 50 mg orally every 8 hours for 14 days

±

Tramadol

• 50 mg orally every 8 hours for up to 14 days

Topical analgesics

May be added for localized pain.

Diclofenac gel

• Apply every 12 hours

OR

Ketoprofen gel

• Apply every 12 hours

Gastroprotection

For patients with previous peptic ulcer disease or prolonged NSAID use.

Omeprazole

• 20 mg orally once daily for 2–4 weeks

OR

Pantoprazole

• 40 mg orally once daily for 2–4 weeks

OR

Esomeprazole

• 40 mg orally once daily for 2–4 weeks

OR

Lansoprazole

• 30 mg orally once daily for 2–4 weeks

Patients with radicular symptoms

Neuromodulator

Pregabalin

• 75–150 mg orally once daily for 4 weeks

• Dose may be increased according to clinical response.

AND

Neurovitamins

Vitamin B1 + Vitamin B6 + Vitamin B12

• Orally once daily for 4 weeks

AND

Muscle relaxant

Baclofen

• Initially 5 mg orally every 8 hours

• Increase by 5 mg per dose every 3 days

• Maximum 20 mg every 8 hours

• Continue for up to 2 weeks

OR

Tizanidine

• Initially 2 mg orally every 8 hours

• Increase gradually to 4 mg daily every 1–4 days according to response

• Treatment may continue for 4 weeks or longer

• Gradually taper before discontinuation by reducing 2–4 mg daily

Interventional management

Non-surgical interventions

For carefully selected patients with persistent pain despite optimal conservative treatment:

• Epidural injection of local anaesthetic with corticosteroid for severe refractory radicular pain

• Radiofrequency medial branch denervation for confirmed facet-mediated pain when conservative treatment has failed and surgery is unsuitable

Surgical management

Surgery should only be considered when clinical findings correlate with radiological abnormalities and adequate non-operative treatment has failed.

Spinal decompression

Indications include:

• Persistent sciatica

• Lumbar spinal stenosis

• Nerve root compression with neurological symptoms

Procedures may be performed using open or minimally invasive techniques depending on patient factors and available expertise.

Spinal fusion

Consider decompression with instrumented fusion using pedicle screws, rods, or interbody devices in patients with:

• Segmental spinal instability

• Degenerative spondylolisthesis

• Recurrent instability following decompression

The choice of open or minimally invasive surgery depends on patient characteristics, pathology, available resources, and surgeon expertise.

Rehabilitation

Long-term rehabilitation should include:

• Progressive physiotherapy

• Core muscle strengthening

• Flexibility exercises

• Gait and balance training

• Occupational rehabilitation

• Weight reduction where appropriate

• Smoking cessation

• Ergonomic education

• Long-term home exercise programme

Monitoring and follow-up

Patients should be reassessed every 4–8 weeks to evaluate:

• Pain severity

• Functional status

• Neurological examination

• Medication effectiveness

• Adverse drug effects

• Need for imaging or specialist referral

• Progress with rehabilitation

Complications

• Persistent disability

• Chronic radiculopathy

• Lumbar spinal stenosis

• Progressive neurological deficits

• Muscle deconditioning

• Depression and anxiety

• Opioid dependence

• Reduced quality of life

• Work absenteeism

Prevention

• Regular exercise

• Core muscle strengthening

• Maintenance of healthy body weight

• Smoking cessation

• Ergonomic workplace modifications

• Safe lifting techniques

• Early treatment of acute low back pain

• Regular physical activity

• Management of osteoporosis and other underlying spinal disorders

Prognosis

The prognosis depends on the underlying cause, patient adherence to rehabilitation, psychosocial factors, and the presence of neurological deficits. Many patients experience significant improvement with a multidisciplinary approach combining exercise, education, pharmacological therapy, and psychological support. Persistent pain is more likely in individuals with obesity, smoking, depression, occupational risk factors, or significant degenerative spinal disease. Carefully selected patients with structural spinal pathology may achieve substantial symptom relief following appropriate surgical intervention.