Management of chronic low back pain

Treatment for chronic low back pain (pain persisting for over 3 months) falls into three broad categories: monotherapies, mulitidisciplinary therapy, and reductionism. Most monotherapies either do not work or have limited efficacy (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery). Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on pain. The reductionist approach (pursuit of a pathoanatomical diagnosis with the view to target-specific treatment) should be implemented when a specific diagnosis is needed. While conventional investigations do not reveal the cause of pain, joint blocks and discography can identify zygapophysial joint pain (in 15%-40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%). Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.