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A 45-year-old construction worker with a 7-year history of intermittent low back pain is seen by his family physician. The pain has gradually increased over the past 4 months, despite pain medications, physical therapy, and two epidural corticosteroid injections. The pain is described as a dull ache in the lumbosacral area with episodic aching in the posterior aspect of both thighs; it worsens with prolonged standing and sitting. He is concerned about losing his job, while at the same time worried that continuing to work could cause further pain. The results of a neurologic examination and a straight-leg–raising test are normal. Magnetic resonance imaging (MRI) shows evidence of moderate degenerative disk disease at the L4–L5 and L5–S1 levels and a small midline disk herniation at L5–S1 without frank nerve impingement. The patient wonders whether acupuncture would be beneficial and asks for a referral to a licensed acupuncturist.

The Clinical Problem

An estimated 70% of persons in Western industrialized countries have back pain sometime in their lives. In the United States, low back pain is one of the most common reasons for visits to a physician. Approximately 90% of acute episodes resolve within 6 weeks. However, 25% or more of patients have recurrent pain within the next year, and chronic low back pain develops in up to 7% of patients.

The full differential diagnosis of low back pain is extensive, but most of the causes are infrequently seen in general medical practice. Cancer, infection, and inflammatory disorders each account for less than 1% of cases. Structural disorders of the spine itself, such as compression fractures, spinal stenosis, and disk herniation, are somewhat more common and together account for some 10 to 15% of cases. However, the most common problem (85% of cases) is “nonspecific” or “idiopathic” low back pain, and it is this disorder that is most often associated with chronic or recurrent symptoms.

Low back pain results in substantial morbidity. By one estimate, 6.8 million U.S. adults had physical disability associated with back pain in 1999. Patients with back pain account for more than $90 billion annually in health care expenses, with approximately $26 billion of that amount directly attributable to the treatment of back pain.