Lower Back Pain (LBP)

Epidemiology

Classification

Etiologies

1. Myofascial / Mechanical Pain

2. Discogenic Pain

3. Facet Joint Pain

4. Sacroiliac (SI) Joint Pain

5. Radiculopathy (Disc Herniation / Nerve Root Compression)

6. Lumbar Spinal Stenosis

7. Spondylolisthesis / Spondylolysis

8. Inflammatory (e.g., Ankylosing Spondylitis)

9. Referred / Visceral Pain

Red Flags (Require Urgent Evaluation)

Diagnosis

• Plain X-rays: first-line for suspected fracture, malignancy, or spondylolisthesis
• MRI: preferred for suspected disc herniation, radiculopathy, infection, malignancy, or spinal stenosis - should not be routine for non-specific LBP
• CT myelography: if MRI contraindicated
• Note: MRI findings of disc degeneration are present in >50% of asymptomatic adults by age 40 and do not reliably correlate with symptoms

Management

Acute Non-specific LBP (< 6 weeks)

• Staying active (bed rest is harmful and delays recovery)
• Heat application
• Physical therapy / targeted exercises
• Patient education and reassurance

• NSAIDs (e.g., ibuprofen, naproxen) - first-line analgesic
• Muscle relaxants (non-benzodiazepine, e.g., cyclobenzaprine, tizanidine) - short-term for spasm
• Acetaminophen - no longer recommended as first-line (insufficient evidence for back pain)
• Opioids - only for severe debilitating pain, lowest dose, shortest duration; avoid with benzodiazepines (respiratory depression risk)
• Gabapentinoids (gabapentin, pregabalin) - insufficient evidence; not recommended

Chronic LBP (> 3 months)

• Exercise therapy (core strengthening, aerobics) - strong evidence
• Cognitive-behavioral therapy (CBT) - addresses catastrophizing, fear-avoidance
• Mindfulness-based stress reduction
• Pilates (recent meta-analysis, PMID 37632387 confirms effectiveness)
• Cognitive Functional Therapy - 2024 systematic review supports benefit in chronic LBP
• Massage, acupuncture, TENS

• NSAIDs (continued as needed)
• Duloxetine (SNRI) - approved for chronic musculoskeletal pain
• Tricyclic antidepressants (e.g., amitriptyline, low-dose) - some evidence

• Fluoroscopic epidural steroid injections (radiculopathy/stenosis)
• Facet joint injections or medial branch blocks
• Radiofrequency ablation of medial branch nerves (facet pain)
• SI joint injections

• Microdiscectomy - for disc herniation with persistent radiculopathy after 6-12 weeks of conservative therapy
• Laminectomy/decompression - for symptomatic spinal stenosis
• Spinal fusion - selected cases; evidence is modest for non-specific LBP

Psychological Co-morbidities

• Depression: 33-67%
• Anxiety: 10-30%
• Substance misuse: 13-40%
• Personality disorders: >50% in some studies

Sleep Posture

Clinical Review: Chronic LBP Prescription (6 months duration)

Prescription Analysis

1. Tab Gabapentin GRS 300 mg BD (Gabapentin Gastric Retentive System, twice daily)

• Gabapentin is licensed for neuropathic pain - it works by binding alpha-2-delta subunits of voltage-gated calcium channels, reducing neuronal excitability.
• For pure non-specific chronic LBP without radiculopathy or neuropathic features, evidence is weak. The Maudsley Deprescribing Guidelines state: "Systematic reviews have found no benefit of gabapentinoids over placebo in low back pain, sciatica, spinal stenosis."
• A 2023 systematic review (PMID 37379868) of gabapentin/pregabalin for chronic LBP without radiculopathy found only 5 qualifying trials with 242 participants - evidence quality was very low to moderate, and the conclusion was that quality information to support routine use is lacking.
• However, if this patient has a neuropathic/radicular component (shooting leg pain, dermatomal distribution, burning/tingling) - gabapentin is a reasonable and indicated choice.
• Textbook of Family Medicine states: "Anticonvulsant medications such as gabapentin may be indicated for neuropathic pain but do not have evidence of effectiveness in more general musculoskeletal pain."

• Both gabapentin and tramadol/opioid combinations carry additive CNS depression risk
• The Maudsley guidelines explicitly warn: "Co-prescription [of gabapentinoids with opioids] should usually be avoided because of increased risk of respiratory depression, accidental overdose and death."
• The MHRA has issued warnings on this combination. You should counsel the patient about sedation, dizziness, and avoid driving/operating machinery.

2. Tab Ultracet BD (Tramadol 37.5 mg + Paracetamol/Acetaminophen 325 mg)

• Ultracet = Tramadol 37.5 mg + Acetaminophen 325 mg per tablet
• Tramadol is a weak opioid agonist + serotonin-norepinephrine reuptake inhibitor (SNRI), giving it a dual mechanism useful in pain with a neuropathic component
• The combination with acetaminophen provides synergistic analgesia
• Textbook of Family Medicine confirms: "Combination analgesic therapy with acetaminophen and tramadol was found to decrease pain significantly"
• Tramadol is a good choice for chronic LBP as it provides moderate analgesia with lower addiction potential than stronger opioids

• Tramadol + Gabapentin = additive sedation risk (as above)
• Tramadol lowers seizure threshold - of note if patient has any seizure history
• Tramadol is a serotonergic drug - avoid combination with SSRIs/SNRIs (serotonin syndrome risk)
• BD dosing of Ultracet is appropriate for chronic use; monitor for tolerance and dependence with long-term use
• Tramadol is not ideal as a long-term standalone strategy without a plan to introduce stronger disease-modifying therapies (physiotherapy, exercise)

3. Cap B-Complex (Vitamin B Complex)

• B vitamins (B1, B6, B12) support peripheral nerve health and are commonly used as adjuncts in back pain, especially when there is a neuropathic/radicular component
• B12 deficiency can itself cause neuropathic pain and should be excluded
• Low risk, reasonable add-on, especially with the neuropathic pain medication on board
• No major interactions

4. Tab Pantocid DSR OD (Pantoprazole 40 mg + Domperidone 30 mg SR, once daily)

• Tramadol can cause nausea/vomiting and GI upset; domperidone component helps with this
• Pantoprazole (PPI) provides gastric protection - particularly relevant if the patient is also taking NSAIDs or has GI risk factors
• Domperidone SR component is particularly helpful for tramadol-induced nausea, which is one of the most common reasons for discontinuation
• Good choice as a cover for this prescription

Summary Scorecard

Suggestions to Strengthen Management

1. Await MRI results before finalising pharmacotherapy - if there is disc herniation with nerve root compression (L4-L5, L5-S1), gabapentin is strongly justified and dose can be optimised.
2. Add an NSAID (e.g., Tab Etoricoxib 60 mg OD or Tab Aceclofenac 100 mg BD with food) if not contraindicated - NSAIDs remain first-line for chronic LBP with inflammatory/mechanical component and are more evidence-based than gabapentin for non-neuropathic pain.
3. Physiotherapy referral is mandatory - Exercise therapy (core strengthening, stretching) has the strongest long-term evidence for chronic LBP. Medication alone without physiotherapy rarely leads to lasting improvement.
4. Counsel on gabapentin + tramadol CNS interaction - warn patient about dizziness, sedation, avoid driving, no alcohol.
5. Set a 4-6 week review - Reassess pain scores, functional improvement, and side effects. If no meaningful improvement with gabapentin, consider tapering it, especially if MRI shows no radiculopathy.
6. Consider Duloxetine 30-60 mg OD as an alternative/add-on - it has FDA approval for chronic musculoskeletal pain and addresses any co-morbid depression/anxiety (which is highly prevalent in chronic LBP).
7. Screen for psychological co-morbidities - Depression and anxiety co-occur in 33-67% of chronic LBP patients and worsen outcomes. Brief PHQ-9 / GAD-7 screening is worthwhile.