Chronic Lower Back Pain

Chronic lower back pain is multifactorial. The most common structural causes seen in neurosurgical practice in Melbourne include:

Degenerative Disc Disease

Wear and tear of the intervertebral discs is the most common underlying structural cause of chronic lower back pain. Degenerate discs lose their shock-absorbing capacity, become a source of pain (discogenic pain), and lead to altered spinal biomechanics that stress adjacent structures.

Facet Joint Arthritis

Arthritis of the small joints at the back of the spine (facet joints or zygapophyseal joints) is a significant contributor to chronic lower back pain, often co-existing with disc degeneration.

Spondylolisthesis

Slipping of one vertebra on another — whether due to degenerative changes or a bony defect — can cause instability and chronic back pain, often with associated leg symptoms.

Lumbar Spinal Stenosis

Narrowing of the spinal canal causing compression of the cauda equina, producing neurogenic claudication (leg pain with walking) and often accompanied by chronic back pain.

Muscle and Soft Tissue Dysfunction

Weakness and deconditioning of the core and paraspinal muscles — particularly the multifidus — reduces spinal stability and is a major driver of chronic lower back pain, often persisting after an initial structural injury.

Psychological and Social Factors

Chronic pain is influenced by psychological factors including anxiety, depression, fear avoidance, and central sensitisation. These are not to be dismissed — they are real neurological phenomena that amplify pain perception and are important targets of treatment.

The initial assessment of chronic lower back pain focuses on:

Identifying the Pain Generator

A detailed history will characterise the pain — its onset, character, distribution, aggravating and relieving factors, and relationship to activity. This helps distinguish discogenic pain (worsened by sitting and flexion), facet joint pain (worsened by extension and rotation), and neurogenic pain (radiating to legs).

Screening for Serious Causes (Red Flags)

Urgent assessment is required if back pain is accompanied by any of the following:

• Unexplained weight loss or night sweats — possible malignancy
• Fever — possible spinal infection
• History of cancer — possible metastatic disease
• Bladder or bowel dysfunction — possible cauda equina syndrome
• Trauma — possible spinal fracture
• Age over 50 with new onset severe back pain and no prior history

Neurological Assessment

Neurological examination identifies any associated leg symptoms, nerve root compression, or features of spinal cord compression that change the clinical management pathway.

At One Brain and Spine, investigations are selected based on clinical findings and are used to confirm the source of pain and guide treatment:

• MRI lumbar spine — the most important investigation; demonstrates disc degeneration, disc herniation, canal stenosis, spondylolisthesis, and Modic endplate changes
• CT scan — for bony detail when MRI is insufficient or contraindicated
• Full-length standing X-ray (EOS scan) — assesses global spinal alignment, sagittal balance, and scoliosis
• Dynamic X-rays (flexion/extension) — identifies segmental instability
• Bone scan (SPECT CT) — identifies metabolically active pain generators — active disc degeneration and facet joint arthritis — helping to direct injection and surgical planning
• Discography — provocative disc injection to confirm discogenic pain; not routinely performed due to risk of accelerating disc degeneration, but may be considered in selected pre-surgical cases

Non-Surgical Treatment Options

Non-surgical management is the foundation of treatment for chronic lower back pain. The evidence strongly supports sustained, active, multimodal non-operative care as the primary approach. Surgery is only considered after a genuine and sustained period of conservative management.

Evidence-based non-surgical treatments available in Melbourne include:

• Exercise therapy — the single most effective intervention for chronic lower back pain. Core strengthening, functional rehabilitation, and graduated return to activity.
• Clinical Pilates — targeted core stability exercises with strong evidence for chronic back pain
• Physiotherapy — manual therapy, McKenzie approach, postural training, and functional restoration
• Cognitive Behavioural Therapy (CBT) and pain neuroscience education — addressing central sensitisation and pain catastrophising
• Analgesic medications — paracetamol, NSAIDs; opioids used cautiously and only short-term for acute exacerbations
• Antidepressants (low-dose) — have evidence for chronic non-specific back pain modulation
• Epidural steroid injections — for concurrent nerve-related or stenosis-related leg pain
• Facet joint injections — when active facet joint arthritis is confirmed
• Formal pain management programmes — multidisciplinary programmes including psychology, physiotherapy, and medication management
• Weight management — BMI reduction relieves lumbar disc and joint loading
• Smoking cessation — reduces further disc degeneration

When is Surgery Required?

Surgery for chronic lower back pain is considered in carefully selected patients who have failed intensive, prolonged non-operative management and have a clearly identifiable structural pain generator. At One Brain and Spine, surgery is recommended as a partnership — patients must be motivated, realistic, and have genuinely engaged with conservative treatment. Surgery is not a quick fix for back pain, and outcomes are best when both surgeon and patient have shared, realistic expectations.

Surgical options include spinal fusion (for discogenic back pain, spondylolisthesis, or instability) and, in selected patients, lumbar disc replacement. Your neurosurgeon will discuss the options most appropriate for your specific situation.