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Back pain is a pervasive health problem in the United States, occurring in 85% of all persons at some point during their lifetimes. In fact, back pain is the second most common reason for visits to the doctor (the common cold is first). Primary care physicians, therefore, are in an especially important position for helping these patients. The causes of back pain are numerous, ranging from a recent injury that is easily identified to tumors that have metastasized to the spine. For these reasons, it is especially important to understand the epidemiology of back pain. To develop the most efficient and cost-effective management approach, one should be aware of the likelihood of back pain among various populations and of its risk factors and causes:
•   The annual prevalence of back pain is 15% to 20%.
•   Approximately 1% of the population is chronically disabled from back pain; another 1% is temporarily disabled.
•   Back pain is the most frequent cause of activity limitation in persons under age 45.
•   Hack pain is the fifth most common cause of hospitalization.
•   The lifetime prevalence of herniated disks is 1% to 3%.
•   Back surgery is the third most common surgical procedure.
•   The rate of disk operations is greatest in the United States, followed by the Netherlands, Great Britain, Sweden, and Finland (24).

Low Back Pain Studies
The study of low back pain is challenging because back pain is defined in many different ways, and the definitions used by one group of specialists frequently do not match those used by another. Many studies conducted by orthopedic or neurosurgical groups use sciatica, disk herniation, or results of clinical tests such as the straight leg raise test to compare patient groups. Yet when examined more closely, it is clear that even the straight leg test does not have a single definition. Other differences are over time frame (e.g.. definitions of acute and chronic back pain). Broad terms such as musculoskeletal low back pain can encompass a wide variety of diagnoses.
Adding to the complexity of comparing low back pain studies is the way back pain is tracked. Many studies use personal reports of back pain or measure time off from work, whereas others use the number of work-related injuries or workers compensation claims. Even fewer studies base their low back pain analyses on physical examination findings.
In some studies, exposure (i.e., contact with a risk factor) is evaluated. There are many ways to characterize exposure. For example: "Has the patient ever been exposed to a risk factor? One time? Many times? Can the exposure be eliminated or minimized?" Job exposure may be characterized, for instance, by the amount of time spent at work in a specific posture or lifting specific objects.
Evaluation of exposure can be both subjective and objective. It can also be challenging to compare accurately even two well - planned studies because of different methodologies used to track low back pain, time frames, variations in exposure, and the effects of recall bias.

The Role of the Medical-Legal System
Studies show that 90% of low back pain episodes resolve within 6 to 12 weeks. However, data also show that 70% to 90% of patients have recurrence, and one third of patients have persistent or intermittent low back pain after their initial episode. An obvious question arises: If 90% of low back pain improves, why do we see so many repeat patients with back pain in offices and clinics across the country? What drives patients outside the expected medical algorithm and gets them caught in a cycle of poor recovery?
Because back pain is a complex issue, one in which it is difficult to isolate causality, the simple back injury does not fall neatly into the workers compensation system. Take, for example, a woman working on an automobile assembly line who begins to experience back pain. If she feels her condition was caused or exacerbated by an occurrence at work, she can choose to file a workers compensation claim. However, as soon she makes this choice, she becomes involved in the legal process and the intricacies and rules of the insurance system. To obtain adequate compensation benefits, she may have to be concerned not only with her real pain but with assuring her physician that the pain has incapacitated her such that she can no longer work. Such a situation is just one of the legal and financial complexities that physicians must consider. Chapter 32 provides more detail on the workers compensation system and its role in back pain.

Costs
Low back pain is a significant problem not only in terms of patient suffering but in terms of economic impact. Annually, 2% of workers in the United States have compensable back injuries. In 1986, there were an estimated 175 million lost workdays and 20 million dollars in lost productivity, with more than 500,000 injuries. Today, the total estimated annual cost of back disorders ranges from $38 billion to $50 billion. Included in these estimates are direct medical expenses and indirect costs such as lost workdays and disability-related costs. Total indirect disability-related payments are estimated at two to four times the direct costs.
Using injury cost data to evaluate the magnitude of the problem may be misleading clue to the litigious environment and workers' compensation system in the United States. However, several studies have demonstrated that a small percentage of back pain workers compensation cases account for a very large percentage of the total costs. For example, in the Hoeing retrospective study, 19% of cases accounted for 41% of the total injury costs. In California, 24% of cases made up 87% of total costs.