Discogenic lumbosacral radiculopathy. Recommendations of the Russian Association for the Study of Pain (RSSP)

When examining a patient with lumbosacral pain, it is necessary to rule out the specific cause of the disease. The diagnosis of discogenic lumbosacral radiculopathy (DLSR) is based on clinical examination; magnetic resonance imaging (MRI) is of informative value in excluding other causes of radiculopathy and in evaluating disk herniation. If the signs of cauda equina and spinal cord compression are absent, and no epidural glucocorticoid injection or urgent surgical treatment is scheduled, there is no reason for early (within the first 4 weeks) MRI.
It is recommended to inform the patient with DLSR about the possibility of disk herniation regression and natural recovery and about the advisability of maintaining physical activity. Epidural administration of local anesthetics and glucocorticoids and use of non-steroidal anti-inflammatory drugs are advisable to relieve acute pain. Anticonvulsants (pregabalin and gabapentin), muscle relaxants, and B vitamins can be used as additional methods for acute DLSR; psychological therapies (cognitive behavioral therapy), antidepressants, therapeutic exercises (kinesiotherapy), manual therapy, and acupuncture are effective in chronic DLSR. Consultation with a neurosurgeon for possible microdiscectomy is indicated in the presence of cauda equina syndrome (urgently) and in the absence of medical therapy effects within 4–8 weeks.
Therapeutic exercises (kinesitherapy) with an educational program for prevention of strenuous physical activity and static and uncomfortable positions for a long time, as well as for teaching how to lift weights properly, etc. are recommended for preventive purposes.

1. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743-800. doi: 10.1016/S0140-6736(15)60692-4

2. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180-91. doi: 10.1016/j.spinee.2013.08.003

3. Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976). 2008;33(22):2464-72. doi: 10.1097/BRS.0b013e318183a4a2

4. Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust. 2017;206(6):268-73. doi: 10.5694/mja16.00828

5. Hartvigsen L, Hestbaek L, Lebouef-Yde C, et al. Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain. BMC Musculoskelet Disord. 2017;18(1):133. Published 2017 Mar 31. doi: 10.1186/s12891-017-1495-3

6. Podchufarova EV, Yakhno NN. Bol' v spine [Backache]. Moscow; 2010. 368 p. (In Russ.).

7. Kremer Yu. Zabolevaniya mezhpozvonkovykh diskov [Diseases of the intervertebral discs]. VA Shirokov, ed. 2 nd ed. Moscow: MEDpressinform; 2015. 472 p. (In Russ.).

8. Parfenov VA, Isaikin AI. Boli v nizhnei chasti spiny: mify i real'nost' [Pain in the lower back: myths and reality]. Moscow: IMA-PRESS; 2016. 104 p. (In Russ.).

9. Parfenov VA, Yakhno NN, Davydov OS, et al. Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP). Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2019;11(2S):7-16. doi: 10.14412/2074-2711-2019-2S-7-16 (In Russ.).

10. Parfenov VA, Yakhno NN, Kukushkin ML, et al. Acute nonspecific (musculoskeletal) low back pain Guidelines of the Russian Society for the Study of Pain (RSSP). Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2018;10(2):4-11. doi: 10.14412/2074-2711-2018-2-4-11 (In Russ.).

11. Deyo RA, Mirza SK. Clinical practice. Herniated Lumbar Intervertebral Disk. N Engl J Med. 2016;374(18):1763-72. doi: 10.1056/NEJMcp1512658

12. Shirokov VA, Terekhov NL, Potaturko AV. The influence of working conditions on the prevalence of lumbar pain syndromes (literature review). Ural'skiy meditsinskiy zhurnal. 2019;13(181):76-81. Available at: https://urmj.ru/13_2019/tproduct/146181851-451970388713-vliyanie-usloviitruda-na-rasprostranenn (In Russ.).

13. Stafford MA, Peng P, Hill DA. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. Br J Anaesth. 2007;99(4):461-73. doi: 10.1093/bja/aem238

14. Ropper AH, Zafonte RD. Sciatica. N Engl J Med. 2015;372(13):1240-8. doi: 10.1056/NEJMra1410151

15. Fardon DF, Williams AL, Dohring EJ, et al. Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J. 2014;14(11):2525-45. doi: 10.1016/j.spinee.2014.04.022

16. Schroeder GD, Guyre CA, Vaccaro AR. The epidemiology and pathophysiology of lumbar disc herniations. Semin Spine Surg. 2016;28(1):2-7. doi: 10.1053/j.semss.2015.08.003

17. Euro U, Knekt P, Rissanen H, et al. Risk factors for sciatica leading to hospitalization. Eur Spine J. 2018;27(7):1501-8. doi: 10.1007/s00586-017-5182-8

18. Cook CE, Taylor J, Wright A, et al. Risk factors for first time incidence sciatica: a systematic review. Physiother Res Int. 2014;19(2):65-78. doi: 10.1002/pri.1572

19. Sun Z, Zhang M, Zhao XH, et al. Immune cascades in human intervertebral disc: the pros and cons. Int J Clin Exp Pathol. 2013;6(6):1009-14. Available at: https://pubmed.ncbi.nlm.nih.gov/23696917/

20. Chiu CC, Chuang TY, Chang KH, et al. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184-95. doi: 10.1177/0269215514540919

21. Davydov OS, Yakhno NN, Kukushkin ML, et al. Neuropathic pain: clinical recommendations for the diagnosis and treatment of the Russian Society for the Study of Pain. Rossiyskiy zhurnal boli. 2018;16(57):5-41. Available at: https://painrussia.ru/russian-Journal-ofPain/10.25731/RGBoli_4_2018_Article25.pdf (In Russ.).

22. Da C Menezes Costa L, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012;184(11):E613-E624. doi: 10.1503/cmaj.111271

23. Stynes S, Konstantinou K, Ogollah R, et al. Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PLoS One. 2018;13(4):e0191852. Pub 2018 Apr 5. doi: 10.1371/journal.pone.0191852

24. Genevay S, Courvoisier DS, Konstantinou K, et al. Clinical classification criteria for radicular pain caused by lumbar disc herniation: the radicular pain caused by disc herniation (RAPIDH) criteria. Spine J. 2017;17(10):1464-71. doi: 10.1016/j.spinee.2017.05.005

25. Ailianou A, Fitsiori A, Syrogiannopoulou A, et al. Review of the principal extra spinal pathologies causing sciatica and new MRI approaches. Br J Radiol. 2012;85(1014):672-81. doi: 10.1259/bjr/84443179

26. Low Back Pain and Sciatica in Over 16s: Assessment and Management. London: National Institute for Health and Care Excellence (UK); 2016. Available at: www.nice.org.uk/guidance/ng59

27. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-30. doi: 10.7326/M16-2367

28. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2017. doi: 10.1007/s00586-017-5099-2

29. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6. doi: 10.3174/ajnr.A4173

30. Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29(6):1098-103. doi: 10.3174/ajnr.A0999

31. Macki M, Hernandez-Hermann M, Bydon M, et al. Spontaneous regression of sequestrated lumbar disc herniations: Literature review. Clin Neurol Neurosurg. 2014;120:136-41. doi: 10.1016/j.clineuro.2014.02.013

32. Konstantinou K, Dunn KM, Ogollah R, et al. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J. 2018;18(6):1030-40. doi: 10.1016/j.spinee.2017.10.071

33. Hooten WM, Cohen SP. Evaluation and treatment of low back pain: a clinically focused review for primary care specialists. Mayo Clin Proc. 2015;90(12):1699-718. doi: 10.1016/j.mayocp.2015.10.009

34. Casey E. Natural history of radiculopathy. Phys Med Rehabil Clin N Am. 2011;22(1):1-5. doi: 10.1016/j.pmr.2010.10.001

35. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166(7):493-505. doi: 10.7326/M16-2459

36. Olaya-Contreras P, Styf J, Arvidsson D, et al. The effect of the stay active advice on physical activity and on the course of acute severe low back pain. BMC Sports Sci Med Rehabil. 2015;7:19. Pub 2015 Aug 27. doi: 10.1186/s13102-015-0013-x

37. Vroomen PC, de Krom MC, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med. 1999;340(6):418-23. doi: 10.1056/NEJM199902113400602

38. Fernandez M, Hartvigsen J, Ferreira ML, et al. Advice to stay active or structured exercise in the management of sciatica: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2015;40(18):1457-66. doi: 10.1097/BRS.0000000000001036

39. Fernandez M, Ferreira ML, Refshauge KM, et al. Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis. Eur Spine J. 2016;25(11):3495-512. doi: 10.1007/s00586-015-4148-y

40. Machado LA, Maher CG, Herbert RD, et al. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med. 2010;8:10. Pub 2010 Jan 26. doi: 10.1186/17417015-8-10

41. Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J. 2006;6(2):131-7. doi: 10.1016/j.spinee.2005.08.001

42. Rubinstein SM, van Middelkoop M, Assendelft WJ, et al. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011;(2):CD008112. Pub 2011 Feb 16. doi: 10.1002/14651858.CD008112.pub2

43. Rubinstein SM, de Zoete A, van Middelkoop M, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l689. Pub 2019 Mar 13. doi: 10.1136/bmj.l689

44. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med. 2012;2012:953139.

45. Bronfort G, Hondras MA, Schulz CA, et al. Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation. Ann Intern Med. 2014;161(6):381-91. doi: 10.7326/M14-0006

46. Khabirov FA, Khabirova YuF. Bol' v sheye i spine: rukovodstvo dlya vrachey [Pain in the neck and back: a guide for doctors]. Kazan': Meditsina; 2014. 504 p. (In Russ.).

47. Ivanichev GA. Miofastsial'naya bol' [Myofascial pain]. Kazan'; 2007. 392 p. (In Russ.).

48. Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic lowback pain. Cochrane Database Syst Rev. 2010;2010(7):CD002014. Pub 2010 Jul 7. doi: 10.1002/14651858.CD002014.pub3

49. Lamb SE, Hansen Z, Lall R, et al. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet. 2010;375(9718):916-23. doi: 10.1016/S01406736(09)62164-4

50. Sturgeon JA. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag. 2014;7:115-24. Pub 2014 Apr 10. doi: 10.2147/PRBM.S44762

51. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315(12):1240-9. doi: 10.1001/jama.2016.2323

52. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2014;(9):CD000963. Pub 2014 Sep 2. doi: 10.1002/14651858.CD000963.pub3

53. Ji M, Wang X, Chen M, et al. The efficacy of acupuncture for the treatment of sciatica: a systematic review and meta-analysis. Evid Based Complement Alternat Med. 2015;2015:192808. doi: 10.1155/2015/192808

54. Huang Z, Liu S, Zhou J, et al. Efficacy and safety of acupuncture for chronic discogenic sciatica, a randomized controlled sham acupuncture trial. Pain Med. 2019;20(11):2303-10. doi: 10.1093/pm/pnz167

55. Furlan AD, Giraldo M, Baskwill A, et al. Massage for low-back pain. Cochrane Database Syst Rev. 2015;(9):CD001929. Pub 2015 Sep 1. doi: 10.1002/14651858.CD001929.pub3

56. Wegner I, Widyahening IS, van Tulder MW, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2013;2013(8):CD003010. Pub 2013 Aug 19. doi: 10.1002/14651858.CD003010.pub5

57. Pinto RZ, Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ. 2012;344:e497. Pub 2012 Feb 13. doi: 10.1136/bmj.e497

58. Rasmussen-Barr E, Held U, Grooten WJ, et al. Nonsteroidal anti-inflammatory drugs for sciatica: an updated cochrane review. Spine (Phila Pa 1976). 2017;42(8):586-94. doi: 10.1097/BRS.0000000000002092

59. Van der Gaag WH, Roelofs PD, Enthoven WT, et al. Non-steroidal antiinflammatory drugs for acute low back pain. Cochrane Database Syst Rev. 2020;4(4):CD013581. Pub 2020 Apr 16. doi: 10.1002/14651858.CD013581

60. Roelofs PD, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008;(1):CD000396. Pub 2008 Jan 23. doi: 10.1002/14651858.CD000396.pub3

61. Kuritzky L, Samraj GP. Nonsteroidal antiinflammatory drugs in the treatment of low back pain. J Pain Res. 2012;5:579-90. doi: 10.2147/JPR.S6775

62. Karateev AE, Nasonov EL, Ivashkin VT, et al; Association of Rheumatologists of Russia, Russian Society for the Study of Pain, Russian Gastroenterology Association, Russian Scientific Medical Society of Therapists, Association of Traumatologists and Orthopedists of Russia, Russian Association of Palliative Medicine. Rational use of nonsteroidal anti-inflammatory drugs. Clinical guidelines. Nauchno-prakticheskaya revmatologiya = Rheumatology Science and Practice. 2018;56(Suppl. 1):1-29. doi: 10.14412/19954484-2018-1-29 (In Russ.).

63. Robertson K, Marshman LAG, Plummer D, Downs E. Effect of gabapentin vs pregabalin on pain intensity in adults with chronic sciatica: a randomized clinical trial [published correction appears in JAMA Neurol. 2019 Jan 1;76(1):117]. JAMA Neurol. 2019;76(1):28-34. doi: 10.1001/jamaneurol.2018.3077

64. Davydov OS. Antiepileptic drugs beyond epilepsy (the use of anticonvulsants in the treatment of pain syndromes). Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. Spetsvypuski. 2013;113(4):58-65. Available at: https://www.mediasphera.ru/issues/zhurnalnevrologii-i-psikhiatrii-im-s-s-korsakova2/2013/4/031997-72982013431 (In Russ.).

65. Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med. 2017;376(12):1111-20. doi: 10.1056/NEJMoa1614292

66. Enke O, New HA, New CH, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. CMAJ. 2018;190(26):E786-E793. doi: 10.1503/cmaj.171333

67. Skljarevski V, Zhang S, Desaiah D, et al. Duloxetine versus placebo in patients with chronic low back pain: a 12-week, fixed-dose, randomized, double-blind trial. J Pain. 2010;11(12):1282-90. doi: 10.1016/j.jpain.2010.03.002

68. Mibielli MA, Geller M, Cohen JC, et al. Diclofenac plus B vitamins versus diclofenac monotherapy in lumbago: the DOLOR study. Curr Med Res Opin. 2009;25(11):2589-99. doi: 10.3111/13696990903246911

69. Kukushkin ML. Vitamins of group B (B1 , B6 , B12 ) in complex therapy of pain syndromes. Rossiyskiy zhurnal boli. 2019;17(3):39-45. doi: 10.25731/RASP.2019.03.31 (In Russ.).

70. Calderon-Ospina CA, Nava-Mesa MO, Arbelaez Ariza CE. Effect of combined diclofenac and B vitamins (thiamine, pyridoxine, and cyanocobalamin) for low back pain management: systematic review and metaanalysis. Pain Med. 2020;21(4):766-81. doi: 10.1093/pm/pnz216

71. Van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev. 2003;2003(2):CD004252. doi: 10.1002/14651858.CD004252

72. Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015;313(19):1915-23. doi: 10.1001/jama.2015.4468

73. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586-96. doi: 10.1016/S0140-6736(14)60805-9

74. Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015;350:h1225. Pub 2015 Mar 31. doi: 10.1136/bmj.h1225

75. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4(4):CD013577. Pub 2020 Apr 9. doi: 10.1002/14651858.CD013577

76. Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med. 2015;163(5):373-81. doi: 10.7326/M15-0934

77. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441-50. doi: 10.1001/jama.296.20.2441

78. Jacobs WC, van Tulder M, Arts M, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011;20(4):513-22. doi: 10.1007/s00586-010-1603-7

79. Clark R, Weber RP, Kahwati L. Surgical management of lumbar radiculopathy: a systematic review. J Gen Intern Med. 2020;35(3):855-64. doi: 10.1007/s11606-019-05476-8

80. Association of Neurosurgeons of the Russian Federation. Clinical recommendations for the diagnosis and treatment of herniated discs of the lumbosacral region. 2014]. Available at: http://www.mst.ru/information/manual/lumbar_disc_herniation.pdf (In Russ.).

81. Shriver MF, Xie JJ, Tye EY, et al. Lumbar microdiscectomy complication rates: a systematic review and meta-analysis. Neurosurg Focus. 2015;39(4):E6. doi: 10.3171/2015.7.FOCUS15281

82. Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine (Phila Pa 1976). 2006;31(21):2409-14. doi: 10.1097/01.brs.0000239178.08796.52

83. Kennedy DJ, Zheng PZ, Smuck M, et al. A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation. Spine J. 2018;18(1):29-35. doi: 10.1016/j.spinee.2017.08.264

84. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009;34(10):1094-109. doi: 10.1097/BRS.0b013e3181a105fc

85. Kumar K, North R, Taylor R, et al. Spinal Cord Stimulation vs. Conventional Medical Management: A Prospective, Randomized, Controlled, Multicenter Study of Patients with Failed Back Surgery Syndrome (PROCESS Study). Neuromodulation. 2005;8(4):213-8. doi: 10.1111/j.1525-1403.2005.00027.x

86. North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56(1):98-107. doi: 10.1227/01.neu.0000144839.65524.e0

87. Kumar K, Taylor RS, Jacques L, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month followup of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery. 2008;63(4):762-70. doi: 10.1227/01.NEU.0000325731.46702.D9

88. Schu S, Slotty PJ, Bara G, et al. A prospective, randomised, double-blind, placebo-controlled study to examine the effectiveness of burst spinal cord stimulation patterns for the treatment of failed back surgery syndrome. Neuromodulation. 2014;17(5):443-50. doi: 10.1111/ner.12197

89. Zhao L, Manchikanti L, Kaye AD, AbdElsayed A. Treatment of discogenic low back pain: current treatment strategies and future options – a literature review. Curr Pain Headache Rep. 2019;23(11):86. Pub 2019 Nov 9. doi: 10.1007/s11916-019-0821-x

90. Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199-208. doi: 10.1001/jamainternmed.2015.7431