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Chronic low back pain

Chronic low back pain is back pain that has persisted for more than three months. It usually has more than one contributor, and working out which structures and processes are involved is the first step. Treatment combines targeted procedures, where indicated, with a rehabilitation plan.

Low back pain is one of the most common reasons people see a doctor, and most episodes settle within weeks. When pain persists beyond three months it behaves differently: the chance of it simply resolving on its own falls, and the factors keeping it going are often no longer the ones that started it. Many people referred here have had pain for years, have tried many treatments, and have been told their scans do not explain their symptoms. That experience is common, and it does not mean nothing can be done.

Why hasn't my back pain gone away? Persistent pain usually involves several contributors at once. There may be an ongoing structural source — a facet joint, the sacroiliac joint, a disc, or a nerve root. On top of that, the nervous system itself can become sensitised, so that signals from the back are amplified. Reduced activity leads to loss of strength and confidence in movement, sleep suffers, and mood follows — and each of these feeds back into the pain. An assessment that only looks for one cause will usually reach an incomplete answer.

What structures cause chronic low back pain? The facet joints — the small paired joints at the back of the spine — are a common source, particularly with pain that is worse with extension or rotation. The sacroiliac joint, linking spine to pelvis, is frequently missed and typically causes pain below the belt line. Discs can generate pain themselves or irritate a nerve root, which usually produces leg-dominant pain. Muscles and their attachments contribute, particularly once movement patterns have changed. Often several of these are present together, and the label "non-specific low back pain" frequently means the source has not yet been carefully examined rather than that no source exists.

How is the source identified? Assessment starts with the history — where the pain is felt, what provokes and eases it, how it began — and a physical examination. Imaging is reviewed with an important caveat: degenerative changes on scans are common in people with no pain at all, so a scan finding is not automatically the cause of your pain. Where a specific structure is suspected, image-guided diagnostic injections can test it directly — numbing the nerves to a facet joint, or injecting the sacroiliac joint, and observing whether your pain reduces. This turns an educated guess into evidence.

What does treatment involve? It depends on what the assessment finds. Where facet joints are confirmed as a source, radiofrequency neurotomy can provide months of relief. Where the sacroiliac joint is responsible, injection and lateral branch procedures are options. Where a nerve root is inflamed, epidural or nerve root injections can help while natural recovery occurs. Alongside any procedure, a rehabilitation plan rebuilds strength, movement confidence and capacity — because a procedure creates a window, and what happens in that window determines whether improvement lasts. Medication is reviewed rather than accumulated.

Do I need surgery? Usually not. Most chronic low back pain is not caused by anything an operation can fix, and back surgery for pain alone — without nerve compression or instability — has limited evidence. Where your assessment does suggest a surgical problem, Dr Martin will say so and refer you to an appropriate surgeon with the diagnostic groundwork already done.

What is a realistic goal? For long-standing pain, honest goals are substantial reduction in pain and meaningful recovery of function — work, sleep, activity — rather than complete abolition. Progress is usually stepwise, and the combination of accurate diagnosis, targeted treatment and structured rehabilitation is what moves things.

Sources: Australian Commission on Safety and Quality in Health Care — Low Back Pain Clinical Care Standard; Healthdirect Australia; International Association for the Study of Pain.