What causes low back pain?

In approximately 85% of cases: no specific identifiable cause — non-specific LBP (mechanical LBP). Specific causes (~15%): herniated intervertebral disc with nerve root compression (sciatica — sharp, shooting leg pain in a dermatomal distribution); spinal stenosis (canal narrowing, often in older adults — causes neurogenic claudication: leg pain on walking, relieved by bending forward or sitting); vertebral fracture; spinal infection; inflammatory arthritis (ankylosing spondylitis — young men, morning stiffness, sacroiliac joint involvement); spinal tumour (primary or metastatic). Most LBP does NOT come from a specific structural problem identifiable on imaging.

Should I have an X-ray or MRI?

For most cases of acute or chronic LBP WITHOUT red flag features: NO — imaging is not recommended. Reasons: Over 90% of people over 50 have degenerative disc or facet changes on MRI that are incidental (unrelated to current pain). Seeing these findings on a report increases fear, anxiety and the perception that the back is "damaged" — which paradoxically increases disability, opioid use and willingness to have surgery. Imaging is indicated for: red flag symptoms (see above); progressive neurological signs; failure to improve with 4-6 weeks of conservative management; before surgery. If your back pain is not improving, discuss with a physiotherapist or GP first before requesting imaging.

Why is staying active important?

The evidence is very clear: bed rest for LBP is harmful. Rest leads to rapid muscle deconditioning, decreased physical fitness, increased fear of movement (kinesiophobia), depression and anxiety — all of which worsen pain and prolong recovery. Staying active: keeps muscles strong and flexible; prevents the psychological reinforcement of "the back is fragile and needs to be protected"; maintains normal daily function. Key advice: continue ordinary activity within the limits of pain; gradually increase activity as pain allows; avoid staying in one position too long; return to work as soon as possible.

What is the best treatment for chronic low back pain?

For chronic LBP (>12 weeks): Multi-component approaches work best — combining physical and psychological treatment. Exercise therapy: any form (walking, swimming, yoga, pilates, back-specific exercises) reduces pain and improves function — no single exercise type is proven superior. Cognitive behavioural therapy (CBT): addresses fear-avoidance, catastrophising, activity levels — evidence for reducing disability. Pain education: explaining the neuroscience of pain (explaining that pain does not mean damage) reduces fear and improves function. Multidisciplinary pain programmes: most effective for complex chronic LBP. Medications: NSAIDs have modest short-term benefit; duloxetine modest evidence. NOT recommended: opioids (short-term modest benefit; long-term harm — addiction, hyperalgesia); routine imaging; spinal surgery for non-specific LBP.

Sciatica (radiculopathy) is pain radiating from the lower back down the leg, following the distribution of the sciatic nerve — from the buttock, down the posterior thigh, into the calf and foot. It is caused by compression or irritation of lumbar nerve roots (usually L4, L5, S1) from a herniated disc, bone spur or spinal stenosis. True sciatica is DIFFERENT from referred low back pain (which is dull, aching pain in the buttock or thigh without nerve root distribution). Sciatica often includes: sharp, shooting or burning leg pain; leg numbness or tingling; leg weakness (in severe compression). Management: most resolve within 3 months with conservative treatment (analgesia, physiotherapy); epidural steroid injections for severe refractory cases; surgery for persistent neurological compromise or cauda equina signs.

How does GMJ News cover low back pain?

GMJ News covers WHO LBP burden (619M, #1 disability globally), non-specific LBP, the imaging harm, red flags (cauda equina emergency), the biopsychosocial model, fear-avoidance, CBT and exercise evidence, opioid avoidance, and the WHO 2023 factsheet. Low back pain — the number one cause of global disability — is directly relevant to PHIG's NCD and occupational health programme and Georgian clinical practice.

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Low Back Pain

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Low back pain — defined as pain below the costal margin and above the inferior gluteal folds — is the number one cause of disability globally (years lived with disability), affecting an estimated 619 million people worldwide in 2020 and projected to reach 843 million by 2050, causing enormous loss of productivity, quality of life and healthcare expenditure across all countries, income levels and occupations (WHO 2023). Despite its staggering burden, over 85% of low back pain episodes are non-specific — meaning no identifiable structural cause on imaging — and evidence consistently shows that active management (staying active, physiotherapy, cognitive behavioural therapy) outperforms bed rest, imaging and early surgical referral, with imaging in non-specific LBP potentially causing harm by identifying incidental degenerative changes that fuel unnecessary procedures and unhelpful catastrophising.

Key messages

#1 cause of global disability — 619M people

Low back pain is the single leading cause of years lived with disability (YLD) globally, affecting 619 million people in 2020 (projected 843 million by 2050). It causes more disability than any other condition worldwide (WHO 2023).

85% is non-specific — imaging usually unhelpful

Over 85% of low back pain has no identifiable structural cause on imaging. Routine X-ray/MRI for non-specific LBP is not recommended (NICE, WHO) — it identifies incidental degenerative changes unrelated to current symptoms, drives unnecessary procedures, and increases catastrophising and disability.

Stay active — bed rest worsens outcomes

The most evidence-based message for acute non-specific LBP: stay active, avoid bed rest. Prolonged rest leads to deconditioning, muscle weakness and psychological fear-avoidance — all of which worsen outcomes. Most acute LBP (90%) resolves in 6-12 weeks regardless of treatment.

Red flags — must not miss

Cauda equina syndrome (bilateral leg weakness/numbness, bowel or bladder dysfunction, saddle anaesthesia) is a surgical emergency requiring immediate MRI and decompression. Other red flags: vertebral fracture (major trauma/osteoporosis + fall); spinal infection (fever, IV drug use, immunosuppression); cancer (unexplained weight loss, previous malignancy, age >50 with constant progressive pain).

CBT and physiotherapy — the evidence-based treatments

For chronic LBP (>12 weeks): cognitive behavioural therapy (CBT) is the most evidence-based treatment; physiotherapy (exercise-based); interdisciplinary pain programmes. Paracetamol has limited benefit; NSAIDs provide modest short-term relief; opioids should NOT be used for chronic non-specific LBP. Antidepressants (duloxetine) have modest evidence.

LBP is biopsychosocial — not just structural

The biopsychosocial model: LBP is driven by biological (structural), psychological (catastrophising, fear-avoidance, depression, anxiety) and social factors (workplace satisfaction, socioeconomic status, compensation claims). Psychological factors are stronger predictors of chronification than structural imaging findings.

Key statistics

619M

people with low back pain globally (GBD 2020)

GBD/WHO 2023

cause of years lived with disability (YLD) globally

WHO/GBD 2023

843M

projected LBP cases by 2050 without prevention

GBD 2023

>85%

of LBP episodes are non-specific (no identifiable structural cause)

WHO/NICE

90%

of acute LBP resolves within 6-12 weeks regardless of treatment

WHO

EMERGENCY

cauda equina syndrome = bilateral weakness/bowel/bladder → immediate MRI + surgery

WHO/NICE

Low back pain — burden by global region (years lived with disability, GBD 2020)

Source: GBD/WHO 2020. LBP burden is universal — no region spared; rising in LMICs with ageing and occupational change.

Glossary of key terms

Non-specific low back pain
WHO/NICELBP with no identifiable specific pathological cause (no herniated disc, fracture, infection, cancer, inflammatory arthritis — all of which together account for approximately 15% of LBP). Non-specific LBP is a symptom, not a diagnosis — the term is more accurate than "mechanical LBP" which implies a mechanical structure causing pain, which is often not demonstrated.

Cauda equina syndrome (CES)
WHO/SurgeryCompression of the cauda equina nerve roots — the bundle of nerves below the spinal cord — from massive disc herniation, tumour, haematoma or abscess. Medical/surgical emergency: treatment delay beyond 24-48 hours increases risk of permanent neurological deficit. Symptoms: bilateral leg weakness/numbness; bladder dysfunction (urinary retention — most sensitive sign); bowel incontinence; saddle anaesthesia (numbness in the perineum, inner thighs, genitalia). Immediate MRI + emergency surgical decompression.

Fear-avoidance model
WHO/Pain psychologyA key model explaining LBP chronification: acute pain → catastrophising (interpreting pain as highly threatening) → fear of movement (kinesiophobia) → avoidance of activity → disuse and deconditioning → disability and depression → maintains/worsens pain. Breaking the cycle: graded exposure, reassurance about safety of movement, CBT — rather than rest and passive treatments.

Yellow flags
WHO/NICEPsychosocial factors predicting chronification and disability in LBP (originally from New Zealand guidelines): catastrophising about pain; fear-avoidance beliefs; passive coping strategies; negative job satisfaction; expectation that pain won't improve; high anxiety or depression; social reinforcement of pain behaviour. Screening for yellow flags (STarT Back Tool) guides management — those with high psychosocial burden benefit most from CBT and psychologically-informed physiotherapy.

Imaging in non-specific LBP
WHO/RadiologyNICE and WHO recommend AGAINST routine imaging (X-ray, MRI) for non-specific LBP without red flag features. Evidence: 90% of people >50 years have degenerative changes on imaging without any back pain — these are incidental findings. Labelling incidental findings increases catastrophising, fear-avoidance and disability. Imaging is indicated for: red flags; failure to progress after 4-6 weeks; unexplained neurological signs; before surgery.

Spinal surgery for LBP
NICE/LancetEvidence for spinal surgery (discectomy, fusion, decompression) in non-specific LBP is generally poor — no better than intensive physiotherapy or cognitive behavioural therapy at 1-2 years, with surgical risks. Surgery has clear indications: cauda equina syndrome; progressive neurological deficit; radiculopathy (sciatica) unresponsive to conservative treatment for 6-8 weeks; spinal stenosis causing neurogenic claudication. NICE and WHO do not recommend spinal fusion for non-specific chronic LBP.