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Low back pain

120 citationsUpdated Sep 2026

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Overview

Chronic low back pain is associated with significant disability driven by several factors [1]. In routine clinical settings, it is essential to provide patients with chronic non-specific low back pain adequate information regarding the prognosis of their complaint [2]. An inception cohort study design has been described to determine this prognosis in a representative cohort of patients sourced from primary care [3]. Current clinical practice guidelines provide recommendations for almost all major aspects of low back pain management, although marked heterogeneity exists between them [17]. Risk factors associated with pain severity in non-specific low back pain should be considered for early interventions to improve outcomes [12].

Surgical intervention may benefit patients with chronic low back pain, and a new classification based on injury patterns may be of interest [31]. However, the evidence for spinal fusion or disc replacement in non-specific low back pain is poor; spinal fusion should only be performed as part of a randomised controlled trial, and lumbar disc replacement should not be performed [55]. Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, despite its controversial validity and inconsistent postdiskography surgical outcomes [33]. No trials are yet available which have evaluated the cost-effectiveness of minimal interventional procedures in patients with chronic mechanical low back pain [62].

Nonoperative management strategies are under active investigation. Results from the OPTIMIZE study may inform referring providers and patients about the most effective nonoperative treatment and/or sequence of nonoperative treatments to treat chronic low back pain [6]. A trial of motor control exercise versus placebo will inform best practice for treating chronic low back pain and prevent its occurrence [10]. Additionally, a cluster randomized controlled trial will evaluate the effectiveness of screening for risk factors for chronic low back pain followed by a risk tailored intervention to prevent chronic low back pain [11]. The MATCH cluster randomized trial will provide the first randomized trial evidence of the clinical effectiveness of implementing risk stratification with matched treatment options for low back pain in a United States health care delivery system [29]. A randomised controlled trial is planned to determine if subgrouping and targeted treatment is better than best current care for reducing long-term disability from low back pain [19].

Anatomy & Pathophysiology

Bony Anatomy

The spinal column comprises 33 vertebrae divided into five distinct regions: 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 or 5 fused coccygeal vertebrae [74, 79, 82]. This configuration typically allows for 24 mobile segments [82]. The vertebral column averages 72 cm in length in men and is 7 to 10 cm shorter in women [82]. Each vertebra consists of an anterior vertebral body and a posterior arch formed by the pedicle, facet, lamina, and spinous process [79, 82]. The vertebral body is a cylindrical mass of bone composed of an inner region of cancellous bone surrounded by a thin shell of cortical bone [74, 79]. It connects to the posterior arch via the pedicles and functions primarily to bear weight and transfer forces to the pelvis and hips [74]. The posterior elements protect neural structures and function as a tension band [74]. The relative orientation of the articular processes determines the degree of flexion, extension, or rotation possible in each segment [82].

The thoracic spine exhibits the most variable anatomy, serving as a transitional zone between the mobile cervical and lumbar regions [76]. Its rigidity, combined with the ribs and sternum, forms a stable bony “cube” [76]. Thoracic vertebral bodies are larger than cervical but smaller than lumbar vertebrae [76]. Pedicles arise more superiorly from the posterior vertebral body and project obliquely from superodorsal to inferoventral [76]. Spinous processes project horizontally with slight inferior angulation in the upper four thoracic vertebrae, sharply obliquely in the midthoracic spine, and transition to a horizontal projection from T10 to T12 [76]. Rib heads articulate with the lateral vertebral bodies at the disk space via a demifacet [76]. Transverse processes project obliquely superolaterally, with the costotransverse joint located on their ventral aspect; however, no costotransverse articulation exists at T11 or T12, which feature shorter, laterally projecting transverse processes [76]. A decreased number of vertebrae has been associated with degenerative spondylolisthesis, suggesting numerical variants may be a clinical problem [174].

Intervertebral Disc

The intervertebral disc (IVD) separates successive vertebral bodies, providing compressive stiffness and flexibility for normal spine biomechanics [79]. It consists of an inner nucleus pulposus (NP) and an outer anulus fibrosus (AF) [79]. The NP acts as an osmotic pump, attracting water to generate hydraulic pressure under load [79]. The AF encapsulates the NP, providing mechanical support to contain pressure and constrain intervertebral rotations [79]. The outer AF integrates with the vertebral rim via a fibrocartilage enthesis containing a thin layer of calcified cartilage, or “tidemark” [79]. The end plate, a bilayer of cartilage and bone, separates the disk from adjacent vertebrae [79]. The cartilage end plate integrates with the inner AF to fully encapsulate the NP [79]. The end plate must be strong and thick to resist loads yet permeable to facilitate chemical transport and cellular vitality [79].

Intervertebral disc degeneration (IDD) is a multifactorial process characterized by altered loading biomechanics, extracellular matrix imbalance, increased proinflammatory cytokine secretion, and increased apoptosis and senescence in NP cells [116]. Mechanical progression and disk space narrowing lead to adjacent level pedicle approximation and narrowing of the superior-inferior dimensions of the intervertebral foraminal canal [116]. Ligamentous laxity and vertebral column translation alter loading mechanics and pressure relationships on bone and joint surfaces, influencing osteophyte formation and facet joint hypertrophy [116]. Altered biomechanics in IDD drive further degenerative changes and osteophyte formation, potentially causing lumbar central and foraminal stenosis, symptomatic nerve compression, and radiculopathy [116]. Preserved biomechanical behavior in upper lumbar segments underscores the particular vulnerability of the lumbosacral junction to mechanical deficits [108].

Ligaments and Soft Tissue

Successive vertebrae connect anteriorly via the IVD and posteriorly via facet joints [79]. Passive support is provided by the anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, facet joint capsule, interspinous ligament, and supraspinous ligaments [79]. The spinal column is stabilized by paraspinal muscles, including the erector spinae, which runs longitudinally on the dorsal surface to extend the spine [79]. The psoas muscle runs longitudinally on the ventrolateral surface, flexing the hip during bilateral contraction or laterally bending the trunk during unilateral contraction [79]. The multifidus muscle connects intersegmentally to stabilize the spine by acting like a bowstring to maintain lordosis [79]. Spinous and transverse processes act as lever arms, providing mechanical advantage for muscles inserting along their surfaces [78].

Biomechanics and Alignment

Normal cervical alignment is approximately 15° of lordosis, thoracic kyphosis ranges from 20° to 40°, and lumbar lordosis is approximately 40° to 50° [78]. Kyphotic segments (thoracic, sacral) are “primary” curvatures present in utero and at birth, while cervical and lumbar lordotic curvatures develop secondarily to allow upright posture [78]. The center of gravity runs from the odontoid process proximally through the sacral promontory caudally [78]. Changes in sagittal balance that shift the center of gravity too far ventrally can result in significant pain and disability [78].

The basic motion segment is the “functional spinal unit,” comprising two vertebrae, the intervening disk, and the facet joints with their capsules [78]. This unit limits spinal motion within the confines of protecting neural structures [78]. Vertebral bodies are loaded in series, with caudal levels supporting more weight than cranial segments [78]. Vertebral bodies bear 70% to 90% of the static axial load of the spine [78]. Facet joints support 10% to 20% of axial load in standing, neutral alignment [78]. In extension, facet joints may bear up to 30% of the axial load, whereas in flexion, they may be burdened with up to 50% of the anterior shear load [78]. The IVD absorbs axial loads by deforming the NP to redistribute forces radially, resisted by the tensile properties of the AF fibers [78].

Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, affecting the interpretation of spinal posture, motion, and loading measures [93]. Bending speed imposes different levels of demand on lumbo-pelvic movement kinematics and patterns [107]. A low individual physiologic maximum of lower segment lumbar extension mobility may cause overloading of the low back among athletes involved in sports with frequent maximal lumbar extension and predicts future low back pain [169]. The inverse association of trunk flexion with chronic low back pain and lumbar osteoarthritis may indicate a role for a flexible spine in avoiding or managing these conditions [188].

Vascular Anatomy

Thoracic and lumbar levels are supplied by paired segmental arteries originating directly from the aorta’s posterior surface, running posteriorly along the midportion of the vertebral body [83]. Branches supply the vertebral body, paraspinal musculature, and spinal cord [83]. The cervical spine derives circulation primarily from the vertebral arteries, which arise from the subclavian arteries and typically enter the transverse foramen at C6 [83]. These arteries run proximally through the transverse foramina to C1, course posteriorly over the superior aspect of the C1 ring, then turn proximally to enter the foramen magnum, where they merge to form the basilar artery [83]. Vertebral artery anatomy is variable, with one side typically dominant and occasional entry through the C7 transverse foramen [83].

Spinal cord vascular supply is primarily from medullary branches of segmental spinal arteries, which merge to feed the anterior spinal artery, responsible for approximately 80% of the spinal cord’s vascular supply [83]. The arteria medullaris magna (AMM), also known as the arteria radicularis magna or artery of Adamkiewicz, is the largest anterior segmental artery, typically arising on the left side between T8 and L1 [83]. Ligation or injury to the AMM could have disastrous consequences for planned anterior procedures at the thoracolumbar junction [83].

Neural Anatomy

A typical mixed spinal nerve contains motor, sensory, and sympathetic components [84]. Motor rootlets leave the anterolateral sulcus of the spinal cord to form motor roots, with fibers arising from anterior horn cells to innervate skeletal muscles [84]. Sensory fibers arise from pain, thermal, tactile, and stretch receptors, with cell bodies in the dorsal root ganglia and axons entering the posterolateral sulcus via rootlets [84]. Fibers conveying joint or position sensibility and some tactile fibers turn cephalad in the dorsal columns, synapsing at the gracile and cuneate nuclei at the cervicomedullary junction [84]. Pain and temperature fibers synapse in the substantia gelatinosa and cross to ascend in the dorsal spinothalamic tract [84]. Tactile fibers enter, synapse, and cross to ascend in the ventral spinothalamic tract [84].

The sympathetic component of all 31 mixed spinal nerves leaves the spinal cord along only 14 motor roots, with cells of origin in the intermediolateral cell column extending throughout the thoracic and upper lumbar cord segments [84]. Sympathetic fibers exit with the 12 thoracic and first two lumbar motor roots, enter the respective mixed spinal nerve, and promptly emerge as white rami [84]. Mixed spinal nerves, after leaving the intervertebral foramina, receive their sympathetic component and branch into anterior and posterior primary rami [84]. Posterior primary rami supply the paraspinal musculature and skin along the posterior trunk, neck, and head [84]. Anterior primary rami of all cervical, the first thoracic, and all lumbosacral nerves join to form plexuses [84]. The area of skin supplied by a single spinal root is a dermatome [84]. Segmental dermatomal patterns are well preserved in the thoracic region but not in the limbs due to the migration of dermatomes and myotomes into limb buds [84].

Spinal Stenosis Anatomy

Spinal stenosis is categorized by the anatomic area, vertebral segment region, and specific pathologic entity involved [89]. Central spinal stenosis involves the area between the facet joints occupied by the dura and its contents [89]. It is usually caused by disc protrusion, bulging anulus, osteophyte formation, or buckled or thickened ligamentum flavum [89]. Symptomatic central stenosis results in neurogenic claudication with generalized leg pain [89].

The lateral canal contains nerve roots, and compression here results in radiculopathy [89]. The lateral recess, or “Lee’s entrance zone,” begins at the medial border of the superior articular process and extends to the medial border of the pedicle [89]. Its borders are the pedicle laterally, the superior articular facet dorsally, the posterior ligamentous complex to disc and floor of the canal, and the central canal medially [89]. Facet arthritis most frequently causes stenosis in this zone, along with vertebral body spurring and disc or anulus pathology [89].

“Lee’s midzone” describes the foraminal region, which lies ventral to the pars [89]. The borders of the foraminal region are the lateral recess medially, the posterior vertebral body and disc ventrally, the pars and intertransverse ligament dorsally, and the lateral border of the pedicle laterally [89]. The dorsal root ganglion and ventral motor root occupy 30% of the foraminal space [89]. Causes of foraminal stenosis include pars fracture with proliferative fibrocartilage or lateral disc herniation [89]. The exit zone is lateral to the facet joint, where nerve roots can be compressed by a “far lateral” disc, spondylolisthesis with associated subluxation, or facet arthritis [89].

Degeneration of the disc occurs with narrowing and subsequent ligamentous redundancy, compromising the spinal canal area [89]. Instability from disc degeneration may precipitate facet overgrowth and ligamentous hypertrophy [89]. The ligamentum flavum may be markedly thickened into the lateral recess where it attaches to the facet capsule, causing nerve root compression [89]. The most common type of spinal stenosis is caused by degenerative arthritis, including Forestier disease, characterized by hyperostosis and spinal rigidity in elderly patients [89]. Acquired forms are usually degenerative and most commonly localized to the facet joints and ligamentum flavum [89]. The L4-5 level is most commonly involved in acquired spinal stenosis, followed by L5-S1 and L3-4 [89]. Congenital spinal stenosis is usually central and evident on imaging [89]. In idiopathic congenital narrowing, the anteroposterior canal dimension is narrowed due to short pedicles, while the posterior is otherwise normal [89]. In achondroplasia, the canal is narrowed in the anteroposterior plane owing to shortened pedicles and in lateral diameter because of diminished interpedicular distance [89].

Pathophysiology of Low Back Pain

Low back pain (LBP) is a complicated disorder and a leading cause of disability worldwide [116]. Lumbar spine spondylosis can be an associated cause of LBP and is a common condition with an estimated prevalence ranging from 40% to 85% [116].

Classification

The chronic low back pain syndrome is highly multifactorial, comprising many more dimensions of health and quality of life than merely back-related functioning [15]. The heterogeneity of patients with low back pain (LBP) is more complex than that which can be explained by leg pain patterns alone [136]. Aggregation of different locations or intensities of pain into one binary classification of LBP may result in loss of information potentially useful in prevention or treatment [131]. The prevalence of LBP varies with the definition of LBP and the emergency setting [37].

Treatment-Based Classification: This approach focuses on identifying clusters of findings from history and clinical examination that predict a more favorable outcome with a specific treatment approach [16]. It may assist clinicians in predicting which intervention is likely to be most effective for individual patients with LBP [16]. Sub-classification based specific movement control exercises are superior to general exercise in sub-acute LBP when both are combined with manual therapy [133].

STarT Back Tool: This patient self-reported questionnaire calculates three subgroups based on the risk of persistent LBP disability: low, medium, and high risk [158]. In a primary care population with strictly defined acute LBP, a risk classification schema using items similar to STarT-Back had limited ability to identify persons who progressed to chronic pain [38]. The Kappa value for agreement between risk group classification using STarT Back and ÖMPSQ was 0.35 [178]. In a cohort of 123 patients, STarT Back Tool change categories were Improved (48.8%), Stable (40.6%), and Worsened (10.6%) [183]. The intake ODI score was significantly higher in the "Improved" group (32.7 ± 16.6) compared to the "Stable" group (25.6 ± 16.4) and "Worsened" group (35.5 ± 13.3) [183]. The 6-month ODI score was significantly lower in the "Improved" group (20.5 ± 16.7) compared to the "Worsened" group (33.8 ± 14.0) [183].

Quebec Task Force Classification: This simple measure is based on the clinician’s clinical assessment with categories including local LBP only, LBP + leg pain above the knee, LBP + leg pain below the knee, and LBP + leg pain and neurological signs [158]. The findings regarding the heterogeneity of patients with LBP underpin the concurrent validity of this classification [136].

Latent Class Analysis Subgroups: Derived subgroups include single-stage categories such as "Mildly affected: mild intermittent LBP", "Recent onset severe LBP, activity limitations", and "Persistent LBP, psychological issues, activity limitations and comorbidity" [158]. In a cohort of 928 patients, the prevalence of the "Mildly affected: mild intermittent LBP" subgroup was 17% (N=154) [158]. The prevalence of the "Recent onset severe LBP, activity limitations" subgroup was 21% (N=192) [158]. The prevalence of the "Pain- and work-related concerns, high physical workload" subgroup was 14% (N=130) [158]. The prevalence of the "Nerve root involvement" subgroup was 8% (N=75) [158]. The prevalence of the "Severely affected: very recent onset severe LBP, social participation and activity limitations" subgroup was 15% (N=136) [158]. The prevalence of the "Persistent LBP, psychological issues, activity limitations and comorbidity" subgroup was 14% (N=132) [158]. The prevalence of the "Severely affected: recent onset LBP with several consequences" subgroup was 12% (N=109) [158].

Other Considerations: A new classification based on the injury pattern may be of interest for patients with chronic LBP [31]. Textural features from T2-weighted magnetic resonance images can be applied in LBP classification [50]. A novel classification of the course of LBP based on repetitive measurements over a year was presented in a working population [152]. The distribution of low back disability in school teachers in Botswana was 67% minimal, 28% moderate, 4% severe, and 1% crippled [156]. Multiple and severe lumbar MRI findings of advanced disc degeneration and vertebral endplate signal changes in the lower lumbar spine have a stronger association with pain than milder stages of degeneration [64]. Latent Class Analysis of MRI data detected clinically meaningful subgroups of MRI findings that could be arranged into biologically plausible hypothetical degenerative pathways [64]. The clinical importance of identifying subgroups in LBP is limited due to small subgroup sizes and small additional effect sizes [128]. There is no evidence to support the use of sub-grouping for people with LBP based on individual participant data meta-analysis of randomised controlled trials [128].

Clinical Presentation

Epidemiology and Prevalence

Low back pain is a leading presenting complaint in emergency settings, with prevalence varying according to the specific definition used and the clinical environment [37]. In the Charles V. Keating Emergency and Trauma Centre, most patients present with non-specific or mechanical low back pain without potential nerve root involvement [13]. Globally, low back pain remains a leading cause of disability in the Middle East and North Africa region, exhibiting significant variation in burden across countries and sexes [40]. In the general South Korean population, chronic low back pain is most prevalent among the elderly and women [111]. Recurrence is frequent; a study of physically demanding college academic programs reported a 77% recurrence rate among lower back pain sufferers, indicating warning signs of a chronic state [106].

Clinical Course and Prognosis

The clinical course of low back pain symptoms follows a pattern similar in both randomized clinical trials and cohort observational studies [18]. Both the presence and absence of low back pain serve as predictors for the future course of the condition [8]. However, risk classification schemas using items similar to the STarT-Back in primary care populations with strictly defined acute low back pain have demonstrated limited ability to identify individuals who progress to chronic pain [38].

Diagnostic Assessment and Classification

Clinicians are recommended to assess factors beyond pain intensity, including physical, psychological, social, and health-related quality of life measures [21]. Treatment-based classification focuses on identifying clusters of findings from history and clinical examination that predict a more favorable outcome with a specific treatment approach [16]. The differential diagnosis of extravertebral low back pain is extensive, with relatively low prevalence rates dependent on the clinical setting [100]. Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in patients with positive disc findings but without neurological deficits [41]. Most low back pain diagnoses were categorized as specific according to the German guideline on specific low back pain, contrary to common international assumptions [28]. The high prevalence of asymptomatic degeneration emphasizes the importance of distinguishing spinal from extraspinal causes in lumbar degenerative disease and low back pain [7]. Differences in characteristics of nonspecific low back pain between elderly and young patients were successfully detected using a new detailed visual analogue scale scoring system [22]. Serum protein profiling findings benefit the diagnosis of chronic low back pain and the understanding of differences between different forms of discogenic low back pain [14].

Risk Factors and Associated Conditions

Significant risk factors for developing low back pain include a previous history of low back pain and the presence of low back pain symptoms at the start of work [9]. Low back pain is strongly associated with sleep disturbance, with the association being stronger in participants with more frequent low back pain [113]. The presence of comorbidities is associated with poorer care for low back pain [36]. Lower back pain in patients with liver cirrhosis is a problem that requires attention [114]. Musculoskeletal pain frequently co-occurs with persistent low back pain, with studies including 34,492 individuals across general, working, and clinical populations [23].

Investigations

Clinical Assessment and Prognosis

The clinical course of low back pain symptoms follows a pattern similar in randomised clinical trials and cohort observational studies [18]. Both the presence and absence of low back pain are predictive for the future course [8]. Significant risk factors for developing low back pain include a previous history of low back pain and the presence of low back pain symptoms at the start of work [9]. Back pain is a common presenting complaint in emergency departments, with most persons receiving a diagnosis of non-specific or mechanical low back pain with no potential nerve root involvement [13]. A systematic review of diagnostic accuracy studies evaluated clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine [20].

Imaging: Magnetic Resonance Imaging (MRI)

MRI is the standard for advanced imaging of the spine and is superior to CT in most circumstances, particularly for identification of infections, tumors, and degenerative changes within the discs [105, 112]. MRI is superior for imaging the disc and directly imaging neural structures [105, 112]. It provides excellent assessment of the spinal cord and allows ideal evaluation of intervertebral discs, nerve roots, posterior longitudinal ligament, and intervertebral foramen [104]. The ability to image the nerve root in the foramen is of particular value with MRI, as it is difficult even with postmyelography CT because the subarachnoid space and contrast agent do not extend fully through the foramen [105, 112].

MRI evidence of lumbar disc degeneration was found in 35% of patients aged 20 to 39 years and in 100% of patients older than 50 years [105, 112]. MRI evidence of cervical disc degeneration has been reported in 25% of patients younger than 40 years and in 60% of patients 60 years and older [105, 112]. The best way to obtain meaningful clinical information from MRI is to have a specific question derived from the patient’s history and physical examination, posed using the parameters of neural compression, instability, and deformity [105, 112]. Failure to interpret an imaging study by correlating findings with specific clinical questions (neural compression, instability, deformity) would inevitably lead to poor clinical choices and outcomes [105, 112].

A positive MRI T2-weighted image of the lumbar disc with a high-intensity zone indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain [171]. However, MRI abnormalities examined in a longitudinal study were not major predictors of outcome in patients with low back pain [153]. Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes [203]. No statistically significant differences were observed in current back pain intensity, leg pain intensity, low back pain duration, physical function, or mental health between groups with 0–3 and ≥4 MRI findings [191]. Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels [215]. Severe lumbar spondylosis at the middle or lower level may contribute to low back pain [210]. Lumbar spondylolisthesis is associated with severity of disability in patients with chronic mechanical low back pain [73].

Imaging: Computed Tomography (CT)

CT myelography is invasive and more costly than MRI and is reserved for patients who have contraindications to MRI or who have equivocal MRI examinations [104]. CT is particularly useful in differentiating compression fractures from burst fractures and in identifying subtle features such as the presence of facet widening [109]. The primary disadvantage of CT imaging in comparison to magnetic resonance imaging is that it does not provide as good a visualization of the soft tissues [109].

Invasive Diagnostic Procedures

Structural measures, including MRI findings and provocative discography results, showed no statistical association with adverse outcomes in subjects with benign persistent back pain [32]. Negative discography in patients with probable symptoms of discogenic low back pain cannot absolutely exclude the diagnosis of discogenic pain [180].

Other Diagnostic Considerations

The high prevalence of asymptomatic degeneration emphasizes the importance of distinguishing spinal from extraspinal causes in the evaluation of lumbar degenerative disease and low back pain [7].

Treatment

Non-Operative Management

The management of nonspecific chronic low back pain is heterogeneous and not well codified, with residual symptoms remaining common [26]. Nonsurgical treatment is directed at reducing pain and increasing function irrespective of cause when no specific pathoanatomic underlying cause is identifiable [56]. Clinicians must identify contraindications to nonsurgical treatment via "red flags" that require further work-up [56]. Patients should understand the prognosis and purpose of each recommended treatment [56]. Given the uncertainty of evidence, non-specific low back pain should be managed with non-pharmacological treatments that mitigate pain and disability at immediate-term [135]. Pharmacological management serves as a co-adjuvant to non-pharmacological therapy and is not a substitute for it [26].

Exercise and Physical Therapy: The effect of various exercise types on pain and disability varies, with no major difference between types [46]. All six exercise therapies evaluated in a systematic review and meta-analysis effectively alleviated low back pain, with yoga showing the best results [120]. Physiotherapy provides strong support for the improvement of back care and prevention of non-specific low back pain in children and adolescents [137]. Assessing personal control at baseline as a moderator for the outcome prognosis of successful physiotherapy management of persistent low back pain should be further explored [68].

Manual and Alternative Therapies: Spinal manipulative therapy provides some short-term benefit, especially with acute low back pain [48]. Osteopathic manipulative treatment significantly reduces low back pain [126]. Verum acupuncture is more effective than sham treatment for the non-pharmacological management of low back pain [161]. Extracorporeal shockwave therapy is effective and safe for treating chronic low back pain [122].

Multidisciplinary and Psychological Approaches: Both exercise therapy and multidisciplinary biopsychosocial rehabilitation (MBR) modalities were effective in alleviating chronic low back pain [115]. Education-oriented MBR emerged as the most efficacious for pain mitigation, while behavior-focused MBR was the most efficacious for disability reduction [115]. Targeting self-efficacy is more important than dysfunctional behavioral cognitions in patients with longstanding chronic low back pain [27]. A multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible and suggested overall beneficial effects on patients' health [117]. The PAINDOC multidisciplinary program is a feasible treatment for patients with non-specific chronic low-back pain [138].

Prognosis and Patient Factors: Recovery from low back pain at 6 months was low (12.6%) [30]. Clinicians should assess factors beyond pain intensity, including physical, psychological, social, and health-related quality of life measures, when evaluating treatment effectiveness [21]. Individualized administration route preference-matched treatment in acute low back pain improves therapeutic outcomes [47]. A low level of formal education and high level of self-reported back disability may be associated with a poor response to non-surgical multidisciplinary management in tertiary care [130]. In severely obese patients with low back pain, the rate of meaningful important change was lowest, indicating the least treatment response compared to other groups [123].

Research Considerations: The variability in inclusion and exclusion criteria used in non-specific low back pain trials may impact the generalizability of trial results [49]. The disappointing results of clinical research in chronic non-specific low back pain are commonly explained by the failure of researchers to adequately attend to sub-grouping of the population [143]. Alternatively, current approaches may be ineffective, and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed [143].

Operative Management

Indications: The evidence for spinal fusion or disc replacement in non-specific low back pain is poor [55]. Spinal fusion for non-specific low back pain should only be performed as part of a randomised controlled trial [55]. Lumbar disc replacement should not be performed for non-specific low back pain [55]. A multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain could play a role in changing a patient's status from candidate to non-candidate for surgery [117].

Surgical Approach / Technique: The treatment of chronic, nonradicular, discogenic low back pain remains controversial [124]. Intradiskal electrothermal therapy for chronic, nonradicular, discogenic low back pain shows reported therapeutic success rates of 60% to 80% [124]. A more precise quantification of clinical benefits for intradiskal electrothermal therapy in chronic, nonradicular, discogenic low back pain remains to be proved in randomized prospective trials [124].

Other Considerations: Patients with chronic low back pain who had surgical stabilization of the spine showed slightly better scores on a disability index than did those managed with an intensive rehabilitation program [163].

Complications

Chronic Pain and Disability: Low back pain remains a leading cause of disability in the Middle East and North Africa region [40]. It was a common complication following oblique lateral interbody fusion, with an incidence rate of 18.1% [132]. A subset of low back conditions involves disorders of the cauda equina and/or lumbar nerve roots, distinguished from the more common type of back pain by the presence of radicular symptoms with or without neurologic changes [56].

Risk Factors: Past work-related low back injury may be an important risk factor for future episodes of low back pain and disability in the general population [69]. A previous history of LBP was the most consistent risk factor for transition to LBP from a baseline of a pain-free state [44]. Past history of LBP is a major risk factor for the development of new episodes of disabling back pain among Japanese workers [43]. Additionally, a large training volume in the past year and previous episodes with LBP are risk factors for LBP [190].

Psychosocial Comorbidities: The relationship between chronic low back pain and the future development of depression or anxiety symptoms is not causal [129].

Other Considerations: The clinical course of LBP symptoms followed a pattern that was similar in RCTs and cohort observational studies [18]. Structural measures, including MRI findings and provocative discography results, showed no statistical association with adverse outcomes [32]. Few individuals with neck or low back pain were on sick leave or were granted a disability pension owing to neck or low back problems during 12 years of follow up [54]. Over a 13-year period, 40% of participants improved with a clinically important change in self-reported activity related to chronic low back pain [53]. Among those completing long-term follow up visits, 50% experienced substantial clinically significant reductions (≥50%) in pain intensity which were sustained at 12 months following percutaneous peripheral nerve stimulation [57]. Patients with concomitant low back pain and lumbar spine pathology showed comparable patient-reported outcome measures to those without back concerns at a minimum of 5-year follow-up after hip arthroscopy [4].

Recovery

Prognosis and Natural Course: The presence or absence of low back pain serves as a predictor for the future course of the condition [8]. Recovery rates at 6 months are low, with a reported rate of 12.6% [30]. In patients from the secondary care sector with chronic low back pain, there is considerable variation in weekly symptom persistence over one year, ranging from bothersome pain every day of the week to no weeks with seven days of pain [214]. In a prospective longitudinal cohort study in primary healthcare, all outcome measurements except hand grip force showed small improvements or remained stable over a 13-year period [53]. Clinically meaningful clusters of patients can be defined based on their individual course of low back pain over time [208].

Prognostic Factors and Predictors: A previous history of low back pain is the most consistent risk factor for transitioning from a pain-free state to low back pain [44]. It is also a major risk factor for the development of new episodes of disabling back pain among Japanese workers [43]. Treatment-based classification, which identifies clusters of findings from history and clinical examination that predict favorable outcomes with specific treatments, may assist clinicians in predicting the most effective intervention for individual patients [16]. Patient-physiotherapist agreement impacts short-term outcomes [58]. At a population level, back beliefs are generally positive and relatively constant over time, though misconceptions about a poor prognosis are common [185].

Multidimensional Assessment and Disability: Clinicians are recommended to assess factors beyond pain intensity, including physical, psychological, social, and health-related quality of life measures for chronic non-specific low back pain [21]. Fear-avoidance beliefs and distress are associated with disability in both chronic low back pain and patients at an early stage of acute low back pain [213].

Management and Intervention Outcomes: Among those completing long-term follow-up visits for percutaneous peripheral nerve stimulation, 50% experienced substantial clinically significant reductions (≥50%) in pain intensity sustained at 12 months [57]. Most participants of a 10-week low back pain programme attended almost all sessions [211]. An effective, appropriately targeted, and well-implemented exercise program for long-term management can minimize the burden of the condition on patients, the health care system, and society [61].

Key Evidence

• [L4] Chronic low back pain is associated with significant disability driven by several factors. [1] (10.1186/s12891-019-2403-9)
• [L2] In a routine clinical setting it is important to provide patients suffering from chronic non-specific low back pain with adequate information about the prognosis of their complaint. [2] (10.1186/1471-2474-12-252)
• [L2] This study protocol describes the design of an inception cohort study to determine the prognosis of chronic non-specific low back pain in a representative cohort of patients sourced from primary care. [3] (10.1186/1471-2474-8-11)
• [L3] Patients with concomitant low back pain and lumbar spine pathology showed comparable patient-reported outcome measures to those without back concerns at a minimum of 5-year follow-up. [4] (10.1002/arj.70191)
• [L2] If proven to be effective, this approach will constitute a major advance in the management of low back pain. [5] (10.1186/s12891-015-0852-3)
• [L2] Results of this study may inform referring providers and patients about the most effective nonoperative treatment and/or sequence of nonoperative treatments to treat chronic low back pain. [6] (10.1186/s12891-020-03324-z)
• [L4] Both presence and absence of low back pain seem to be predictive for the future course. [8] (10.1186/1471-2474-14-270)
• [L2] Significant risk factors for developing low back pain were a previous history of low back pain and presence of low back pain symptoms at the start of work. [9] (10.1186/s12891-018-2037-3)
• [L2] The results will inform best practice for treating chronic low back pain and prevent its occurrence. [10] (10.1186/1471-2474-6-54)
• [L2] This trial will evaluate the effectiveness of screening for risk factors for chronic low back pain followed by a risk tailored intervention to prevent chronic low back pain. [11] (10.1186/1471-2474-11-5)
• [L4] These factors should be considered for early interventions to improve outcomes in non-specific low back pain. [12] (10.1186/s12891-024-07828-w)
• [L4] Back pain is a common presenting complaint in our local emergency department, with most of these persons receiving a diagnosis of non-specific/mechanical low back pain with no potential nerve root involvement. [13] (10.1186/s12891-018-2237-x)
• [L4] The findings benefit the diagnosis of chronic low back pain and the understanding of differences between different forms of discogenic low back pain. [14] (10.1186/1471-2474-15-193)
• [L3] The chronic low back pain syndrome is highly multifactorial and comprises many more dimensions of health and quality of life than merely back-related functioning. [15] (10.1186/s12891-021-04130-x)
• [Paper] Treatment-based classification, which focuses on identifying clusters of findings from the history and clinical examination that predict a more favorable outcome with a specific treatment approach, may assist clinicians in predicting which intervention is likely to be most effective for individual patients with low back pain. [16] (10.1016/j.csm.2008.03.002)
• [L2] Current CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. [17] (10.1186/s12891-024-07468-0)
• [L1] The clinical course of LBP symptoms followed a pattern that was similar in RCTs and cohort observational studies. [18] (10.1186/1471-2474-15-68)
• [L2] This paper presents the rationale, design, methods, and operational aspects of a planned randomised controlled trial to determine if subgrouping and targeted treatment is better than best current care for reducing long-term disability from low back pain. [19] (10.1186/1471-2474-9-58)
• [L1] This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. [20] (10.1186/s12891-017-1549-6)
• [L5] This review discusses the multidimensional nature of chronic non-specific low back pain and recommends that clinicians assess factors beyond pain intensity, including physical, psychological, social, and health-related quality of life measures. [21] (10.1111/papr.12846)
• [L4] Differences in characteristics of nonspecific low back pain between elderly and young patients were successfully detected using the new detailed VAS scoring system. [22] (10.1155/2012/680496)
• [L1] [23] (10.1186/s12891-020-03893-z)
• [L4] Approaches to primary outcome assessment in back pain need re-assessment. [24] (10.1186/s12891-015-0534-1)
• [L5] The management of nonspecific chronic low back pain is not well codified and extremely heterogeneous, with residual symptoms common; pharmacological management should be considered as co-adjuvant to non-pharmacological therapy and is not a substitute for it. [26] (10.1186/s13018-022-03426-5)
• [L3] [27] (10.1186/s12891-021-04637-3)
• [L4] Most LBP diagnoses were categorized as specific according to the German guideline on specific LBP, contrary to common international assumptions. [28] (10.1186/s12891-025-08514-1)
• [L2] This trial will provide the first randomized trial evidence of the clinical effectiveness of implementing risk stratification with matched treatment options for low back pain in a United States health care delivery system. [29] (10.1186/s12891-016-1219-0)
• [L2] Recovery from low back pain at 6 months was low (12.6%). [30] (10.1186/s12891-015-0509-2)
• [L2] Surgery may benefit patients with chronic low back pain, and a new classification based on the injury pattern may be of interest. [31] (10.1016/j.otsr.2018.11.021)
• [L2] Structural measures, including MRI findings and provocative discography results, showed no statistical association with adverse outcomes. [32] (10.1016/j.spinee.2004.05.250)
• [L5] Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, despite its controversial validity and inconsistent postdiskography surgical outcomes. [33] (10.5435/00124635-200601000-00008)
• [L3] The presence of comorbidities is associated with poorer care for low back pain. [36] (10.1186/s12891-018-2316-z)
• [L1] Our results indicate that low back pain is consistently a top presenting complaint and that the prevalence of low back pain varies with definition of low back pain and emergency setting. [37] (10.1186/s12891-017-1511-7)
• [L2] A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. [38] (10.1002/ejp.615)
• [L4] Low back pain remains a leading cause of disability in the Middle East and North Africa region, with significant variation in burden across countries and sexes, and strong associations with socio-demographic factors. [40] (10.1186/s12891-023-06178-3)
• [L4] Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in patients with positive disc findings but without neurological deficits. [41] (10.1007/s00402-007-0420-x)
• [L2] Past history of LBP is a major risk factor for the development of new episodes of disabling back pain among Japanese workers. [43] (10.1186/s12891-017-1686-y)
• [L1] A previous history of LBP was the most consistent risk factor for transition to LBP from a baseline of a pain-free state. [44] (10.1016/j.spinee.2014.01.026)
• [L1] The effect of various exercise types used in chronic low back pain on pain and disability varies with no major difference between exercise types. [46] (10.1186/s12891-022-05722-x)
• [L2] Individualized administration route preference-matched treatment in acute low back pain improves therapeutic outcomes, although further studies with larger cohorts are needed. [47] (10.1186/s13018-020-01594-w)
• [L1] Most reviews of randomized clinical trials indicate that spinal manipulative therapy provides some short-term benefit to patients, especially with acute low back pain. [48] (10.5435/00124635-200307000-00002)
• [L2] This review highlights the variability in inclusion and exclusion criteria used in non-specific low back pain trials, which may impact the generalizability of trial results. [49] (10.1186/s12891-018-2034-6)
• [L4] Textural features from T2-weighted magnetic resonance images can be applied in low back pain classification. [50] (10.1002/jor.24973)
• [L2] All outcome measurements, except for hand grip force, showed small improvements or remained stable over a period of 13 years. 40% of participants improved with a clinically important change in self-reported activity related to chronic low back pain over the 13-year period. [53] (10.1186/s12891-025-09371-8)
• [L2] Few individuals with neck or low back pain were on sick leave or were granted a disability pension owing to neck or low back problems during 12 years of follow up. [54] (10.1186/1471-2474-7-66)
• [L5] The evidence for spinal fusion or disc replacement in non-specific low back pain is poor; spinal fusion should only be performed as part of a randomised controlled trial, and lumbar disc replacement should not be performed. [55] (10.1302/0301-620x.99b8.bjj-2017-0199.r1)
• [L5] [56] (10.5435/00124635-200608000-00005)
• [L4] Among those completing long-term follow up visits, 50% experienced substantial clinically significant reductions (≥50%) in pain intensity which were sustained at 12 months. [57] (10.1111/papr.12856)
• [L2] The results of this study indicate that patient-physiotherapist agreement has some impacts on the short-term outcomes of low back pain. [58] (10.1186/1471-2474-7-76)
• [L3] An effective, appropriately targeted, and well implemented exercise program for the long-term management of LBP could minimize the burden of the condition on patients, the health care system and society. [61] (10.1186/s12891-024-07712-7)
• [L2] No trials are yet available which have evaluated the cost-effectiveness of minimal interventional procedures in patients with chronic mechanical low back pain, which emphasizes the importance of this study. [62] (10.1186/1471-2474-13-260)
• [L3] Among patients with low back pain before total hip arthroplasty, 62.9% had improved low back pain. [63] (10.1016/j.arth.2021.08.025)
• [L3] [64] (10.1186/s12891-018-1978-x)
• [L4] Assessing Personal control at baseline as a relevant moderator for the outcome prognosis of successful physiotherapy management of persistent low back pain should be further explored. [68] (10.1186/s12891-022-05031-3)
• [L3] These results suggest that past work-related low back injury may be an important risk factor for future episodes of low back pain and disability in the general population. [69] (10.1186/1471-2474-9-22)
• [L4] Lumbar spondylolisthesis is associated with severity of disability in patients with chronic mechanical low back pain. [73] (10.1186/s12891-017-1562-9)
• [L3] Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture, motion and loading. [93] (10.1186/1471-2474-9-152)
• [L5] The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. [100] (10.1186/s12891-024-07435-9)
• [L4] The study revealed a high prevalence of lower back pain consistent with literature, with a 77% recurrence rate among sufferers, indicating warning signs of a chronic state. [106] (10.1186/1471-2474-8-67)
• [L3] The present findings show that bending speed imposes different levels of demand on the kinematics and pattern of the lumbo-pelvic movement. [107] (10.1186/s12891-017-1515-3)
• [L3] The preserved biomechanical behavior in the upper lumbar segments underscores the particular vulnerability of the lumbosacral junction to mechanical deficits. [108] (10.1186/s12891-025-09238-y)
• [L3] Chronic low back pain was most common in the elderly and women in the general South Korean population. [111] (10.1186/s13018-023-03509-x)
• [L2] Low back pain is strongly associated with sleep disturbance, with the association being stronger in participants with more frequent low back pain. [113] (10.1186/s12891-022-06106-x)
• [L4] Lower back pain in patients with liver cirrhosis is a problem that requires attention. [114] (10.1186/s12891-023-06424-8)
• [L1] Both exercise therapy and MBR modalities were effective in alleviating chronic low back pain, with education-oriented MBR emerging as the most efficacious for pain mitigation and behavior-focused MBR being the most efficacious for disability reduction. [115] (10.3390/jcm12237489)
• [L2] The multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible, suggesting overall beneficial effects on patients' health and could play a role in changing a patient's status from candidate to non-candidate for surgery. [117] (10.1186/s12891-023-06763-6)
• [L1] All six exercise therapies effectively alleviated low back pain, with yoga showing the best results. [120] (10.1186/s12891-025-08658-0)
• [L1] The authors suggest that ESWT is effective and safe for treating chronic low back pain. [122] (10.1186/s13018-023-03943-x)
• [L3] In severely obese patients with low back pain, the rate of meaningful important change was lowest, indicating the least treatment response compared to other groups. [123] (10.1186/s12891-016-0992-0)
• [L5] The treatment of chronic, nonradicular, discogenic low back pain remains controversial, and while intradiskal electrothermal therapy shows reported therapeutic success rates of 60% to 80%, a more precise quantification of clinical benefits remains to be proved in randomized prospective trials. [124] (10.5435/00124635-200301000-00003)
• [L1] OMT significantly reduces low back pain. [126] (10.1186/1471-2474-6-43)
• [L1] Despite this, the clinical importance of identifying these subgroups is limited due to small subgroup sizes and small additional effect sizes, providing no evidence to support the use of sub-grouping for people with low back pain. [128] (10.1186/s12891-021-04028-8)
• [L2] The relationship between chronic low back pain and the future development of depression or anxiety symptoms is not causal. [129] (10.1016/j.spinee.2017.02.009)
• [L2] A low level of formal education and high level of self-reported back disability may be associated with a poor response to non-surgical multidisciplinary management of LBP in tertiary care. [130] (10.1186/s12891-020-03839-5)
• [L4] Aggregation of different locations of pain or different intensities of pain into one binary classification of LBP may result in loss of information which may potentially be useful in prevention or treatment of LBP. [131] (10.1186/1471-2474-15-283)
• [L3] Low back pain was a common complication following OLIF with an incidence rate of 18.1%. [132] (10.1186/s13018-025-05584-8)
• [L1] Sub-classification based specific movement control exercises are superior to general exercise in sub-acute low back pain when both are combined with manual therapy. [133] (10.1186/s12891-016-0986-y)
• [L1] With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. [135] (10.1136/bjsports-2020-103596)
• [L4] These findings underpin the concurrent validity of the Quebec Task Force Classification, though the heterogeneity of patients with LBP is more complex than that which can be explained by leg pain patterns alone. [136] (10.1186/1471-2474-13-236)
• [L1] Recent studies provide strong support for the use of physiotherapy in the improvement of back care and prevention of non-specific low back pain in children and adolescents. [137] (10.1186/s12891-022-05270-4)
• [L2] This study showed that the PAINDOC multidisciplinary program is a feasible treatment for patients with non-specific chronic low-back pain. [138] (10.1186/s12891-025-08294-8)
• [L5] The disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population; alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed. [143] (10.1186/1471-2474-9-11)
• [L2] This trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder. [146] (10.1186/1471-2474-12-104)
• [L2] This study presents a novel classification of the course of LBP based on repetitive measurements over a year, and revealed the predicting factors for chronic LBP based on repetitive measurements in a working population. [152] (10.1186/s12891-016-1307-1)
• [L2] Our findings suggest that the MRI abnormalities examined are not major predictors of outcome in patients with LBP. [153] (10.1186/1471-2474-12-234)
• [Paper] The distribution of low back disability was 67% minimal, 28% moderate, 4% severe, and 1% crippled. [156] (10.1186/1471-2474-15-359)
• [L2] [158] (10.1186/s12891-017-1708-9)
• [L1] Verum acupuncture is more effective than sham treatment for the non-pharmacological management of LBP. [161] (10.1186/s13018-022-03212-3)
• [L1] Patients with chronic low back pain who had surgical stabilization of the spine showed slightly better scores on a disability index than did those managed with an intensive rehabilitation program. [163] (10.2106/jbjs.8802.ebo2)
• [L2] The low individual physiologic maximum of lower segment lumbar extension mobility may cause overloading of the low back among athletes involved in sports with frequent maximal lumbar extension and that it predicts future low back pain. [169] (10.1177/036354659702500316)
• [L1] A positive MRI T2-weighted image of the lumbar disc with HIZ indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain. [171] (10.1186/s13018-023-04187-5)
• [L3] A decreased number of vertebrae was associated with degenerative spondylolisthesis, suggesting numerical variants may potentially be a clinical problem. [174] (10.1302/0301-620x.103b7.bjj-2020-1760.r1)
• [L4] [178] (10.1186/s12891-018-2082-y)
• [L2] Negative discography in patients with probable symptoms of discogenic low back pain cannot absolutely exclude the diagnosis of discogenic pain. [180] (10.1007/s00402-011-1448-5)
• [L2] [183] (10.2519/jospt.2014.5178)
• [L3] At a population level, back beliefs were generally positive and relatively constant over time, but misconceptions about a poor prognosis were common. [185] (10.1186/s12891-019-2925-1)
• [L3] The inverse association of trunk flexion with chronic low back pain and lumbar osteoarthritis may indicate a role for a flexible spine in avoiding or managing these conditions. [188] (10.1186/s12891-019-2523-2)
• [L2] However, a large training volume in the past year and previous episodes with LBP are risk factors for LBP. [190] (10.1177/0363546512458413)
• [L4] No statistically significant differences were observed in current back pain intensity, leg pain intensity, LBP duration, physical function, or mental health between the groups with 0-3 and ≥4 MRI findings. [191] (10.1186/s12891-026-09614-2)
• [L2] Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. [203] (10.1186/1471-2474-15-152)
• [L3] It is possible to define clinically meaningful clusters of patients based on their individual course of LBP over time. [208] (10.1186/1471-2474-12-99)
• [L4] Severe lumbar spondylosis at the middle or lower level may contribute to low back pain. [210] (10.1186/s12891-016-1343-x)
• [L3] Most participants of a 10-week low back pain programme attended almost all sessions. [211] (10.1186/s12891-021-04329-y)
• [L3] The results replicate previous reports on the association between pain experience, fear-avoidance beliefs, distress, and disability in chronic low back pain, and extend the findings to patients at an early stage of acute low back pain. [213] (10.1016/j.pain.2004.09.020)
• [L2] This study revealed there to be considerable variation in weekly persistence of symptoms during 1 year in patients from the secondary care sector with chronic LBP, ranging from bothersome pain each day of the week every week of the year to no weeks at all with 7 days of pain. [214] (10.1186/s12891-015-0754-4)
• [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. [215] (10.1186/s12891-025-09182-x)

See Also

• Degenerative spondylolisthesis

References

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