Low back pain is the world's leading cause of disability, affecting roughly 619 million people globally — yet a sweeping narrative review published in JAMA confirms that most cases don't have a clear structural cause. In fact, 90% of primary care presentations are classified as "nonspecific," meaning no identifiable spinal culprit like a herniated disc or fracture can be pinpointed. Despite this, clinicians often turn to imaging — a habit the review says can backfire.

Routine X-rays, CT scans, and MRIs are not recommended unless red flags are present (think: history of cancer, age over 70, fever, or progressive neurological deficits). Degenerative changes spotted on scans are common even in people without pain and can mislead clinicians into over-diagnosing and over-treating, while also increasing patient anxiety. MRI should be reserved for suspected cauda equina syndrome — a rare but genuine emergency affecting approximately 0.1% of cases.

Key Takeaways:

• First-line management = patient education, staying active, and self-management — not bed rest
• NSAIDs (ibuprofen, naproxen) are the go-to pharmacologic option when needed
• Exercise is the cornerstone of chronic low back pain treatment, ideally before any medication
• Opioids, spinal injections, and surgery are reserved for severe, refractory cases only
• ~72% of patients recover within 12 months; chronic cases have a notably poorer prognosis

Why it matters: With hundreds of millions affected globally and significant healthcare costs tied to unnecessary imaging and interventions, this review offers a clear, evidence-based roadmap for clinicians — one that prioritizes doing less to achieve better outcomes.