Primary care physicians (PCPs) have a group of patients who are difficult to treat effectively, namely patients with low back pain (LBP). These patients have high expectations for pain relief and want immediate results. These patients vary in size, weight, and age, and have complex causes of pain and varying lesions. Low back pain is only a symptom and the cause and associated lesions may not be identified. Because back pain can severely limit a patient’s mobility, patients often experience a very strong sense of loss when the pain does not diminish or is expected to take a long time to resolve. Chen Ye, Department of Pain, Fujian Provincial Hospital South About 50% to 80% of adults have developed LBP, and more than two-thirds of Americans have had the condition at some point in their lives. Therefore, PCPs will spend a lot of time with patients with LBP. Of all the structures in the human body, the spine seems to be experiencing particular problems. Although the spine primarily serves as a scaffold for the body, keeping it upright, this does not mean that he is able to support the obese body of the modern patient or accommodate the physiological need to lift heavy objects or overuse it (in cases where the back muscles are not strong enough). Causes of LBP Low back pain may be caused by skeletal muscle tension, while the latter may be caused by strain and spinal lesions due to aging, infection or malignancy. Patients at risk of LBP are as follows: – those with poor physiological condition and unable to participate in regular physical exercise; – those older than 55 years of age; – workers who have participated in intense physical labor for a considerable period of time (e.g. construction workers); – obese people; – people with reduced spinal canal and spinal stenosis; – smokers or drug users; – people with low socioeconomic status. There are a number of warning signs that must be heeded when evaluating a patient with LBP. Malignancy may be the cause of pain if the patient has lost significant weight or complains of pain that worsens at night and does not resolve at rest in a flat position. Neurological symptoms such as sudden onset of incontinence or worsening foot drop may indicate spinal cord injury or progression of neurological disease. Another alarming sign is severe or progressive neurological dysfunction and weakness of important muscles in the lower extremities. Other causes of LBP are kidney or urinary tract infections, and gynecological conditions such as ovarian cysts can also cause low back pain. Evaluation When LBP is acute, most physicians are fairly confident in the pain diagnosis. However, when the pain becomes chronic, the physician will feel that the patient is all the same, regardless of the degree of pain. Patients with chronic pain have learned to cope with the pain and often appear to be pain free, making the identification of pain level difficult. In addition, patients with chronic LBP may have vague or multi-site complaints, and it may be difficult to identify the site of pain. Constantly talking about their pain with family and friends may strain their relationship with each other, and chronic pain patients learn when and to whom they can let go of talking about their pain. In performing a basic pain assessment, we must ask the patient the following questions: – the patient’s pain intensity level as determined by a validated pain rating scale (0 to 1010 numbered scale) and all changes in the patient’s pain with activity or movement; – the area of pain and all areas where the pain radiates; – the duration of pain and any events that may cause pain, such as lifting heavy objects; – the nature of the pain (e.g., sharp, dull, or shooting pain); – any functional impairment such as inability to walk up and down stairs, pain that interferes with sleep, eating, social relationships, etc. Chronic pain is difficult to manage and control. When pain persists without relief, patients often report an inability to concentrate, sleep well, participate in hobby activities, help with household chores, or participate in physical activity and work. Chronic pain can have a significant impact on the patient and their family. Patients often feel crazy and irritable, unable to manage things well, feel worthless and depressed. Treatment options Treatment options for acute LBP are fairly simple and straightforward. The current recommendations are: – Stay active. There is no indication for bed rest in acute LBP. If the patient has a clear indication and no history of cardiovascular disease or gastrointestinal bleeding, a short course of non-steroidal anti-inflammatory drugs (NSAIDs), i.e., non-selective anti-inflammatory drugs (e.g., ibuprofen or naproxen) or COX-2 inhibitors (celecoxib), may be useful for acute back pain. They may be useful for acute back pain. When using these medications, keep the duration of use as short as possible, use the lowest effective dose possible, and try to use them in patients who do have a clear indication and low risk factors; – Give the patient medications appropriate to the patient’s reported pain level; – Try heat therapy, cold packs, pain creams, or massage if the patient is willing to Heat therapy, cold compresses, pain creams, or massage can be tried if the patient is willing to accept these therapies. Chronic LBP is a complex condition to treat because it is persistent and symptomatic on a daily basis. Many patients with chronic LBP have a physical injury, but the injury does not progress. In treating these patients, we must use a multidisciplinary approach. – Injured patients can benefit from receiving physical therapy programs that focus on improving motor skills; – NSAIDs do not make a difference in chronic LBP. These drugs can be beneficial when used for a short period of time in acute LBP at the lowest possible dose. The inflammatory response in people with chronic LBP is different from that in people with acute LBP. Acute injuries produce swelling and an inflammatory response. When the pain becomes chronic, the body has adapted and the inflammatory response has disappeared and stopped. Only the soft tissue injury or spinal injury persists, causing the patient motor impairment and persistent pain. – Many patients with chronic LBP continue to take opioids, but addiction does not occur. When a patient takes an opioid daily for pain relief, the patient is considered drug dependent. Addiction is a chronic neurobiological disorder in which a patient abuses prescription pain medications or uses addictive drugs. Addicts cannot control their own drug choices. On the other hand, chronic pain patients are constantly searching for pain relief and using opioid prescription drugs under the guidance of a prescribing physician to improve their functioning. The physician must distinguish between opioid dependence and addiction. – Add sleep-promoting and antidepressant medications such as selective 5-hydroxytryptamine norepinephrine reuptake inhibitors (SSNRIs), selective reuptake inhibitors (SSRIs), or tricyclic antidepressants (TCAs). – Referral of patients to treatment programs that help patients build coping skills and positive images – Use non-pharmacologic interventions such as heat therapy, cold compresses, acupuncture, or pain creams if the patient is interested. – Consider referring the patient to a pain intervention clinic to be evaluated for direct epidural corticosteroid injections at the site of disc compression of the nerve root. If the patient is suitable for treatment with this therapy, the pain therapist may perform 3 consecutive injections, and this treatment may significantly reduce the patient’s pain. Treatment of chronic LBP i. Radiofrequency targeted thermocoagulation of herniated discs