Risk Factors for Low Back Pain and Spine Surgery

A Retrospective Cohort Study in Soldiers


      Musculoskeletal low back pain (LBP) is commonly treated symptomatically, with practice guidelines advocating reserving surgery for cases that fail conservative care. This study examined medical comorbidities and demographic variables as risk factors for chronic/recurrent LBP, spinal surgery, and time to surgery.


      A 2015 retrospective cohort study was conducted in U.S. Army soldiers (N=1,092,420) from 2002 to 2011. Soldiers with medical encounters for LBP were identified using ICD-9 codes. Surgical treatment for LBP was identified according to Current Procedural Terminology codes. Comorbid medical conditions (psychological disorders, sleep disorders, tobacco use, alcohol use, obesity) and demographic variables were examined as risk factors for chronic/recurrent LBP within 1 year of the incident encounter, surgery for LBP, and time to surgery.


      Of 383,586 patients with incident LBP, 104,169 (27%) were treated for chronic/recurrent LBP and 7,446 (1.9%) had surgery. Comorbid variables showed increased risk of chronic/recurrent LBP ranging from 26% to 52%. Tobacco use increased risk for surgery by 33% (risk ratio, 1.33; 95% CI=1.24, 1.44). Comorbid variables showed 10%–42% shorter time to surgery (psychological disorders, time ratio [TR]=0.90, 95% CI=0.83, 0.98; sleep disorders, TR=0.68, 95% CI=0.60, 0.78; obesity, TR=0.88, 95% CI=0.79, 0.98; tobacco use, TR=0.58, 95% CI=0.54, 0.63; alcohol use, TR=0.85, 95% CI=0.70, 1.05). Women showed 20% increased risk of chronic/recurrent LBP than men but 42% less risk of surgery.


      In the presence of comorbidities associated with mental health, sleep, obesity, tobacco use, and alcohol use, LBP shows increased risk of becoming chronic/recurrent and faster time to surgery.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Murray C.J.
        • Atkinson C.
        • Bhalla K.
        • et al.
        The state of U.S. health, 1990-2010: burden of diseases, injuries, and risk factors.
        JAMA. 2013; 310: 591-608
        • Taylor J.B.
        • Goode A.P.
        • George S.Z.
        • Cook C.E.
        Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis.
        Spine J. 2014; 14: 2299-2319
        • Croft P.R.
        • Papageorgiou A.C.
        • Ferry S.
        • Thomas E.
        • Jayson M.I.
        • Silman A.J.
        Psychologic distress and low back pain. Evidence from a prospective study in the general population.
        Spine (Phila Pa 1976). 1995; 20: 2731-2737
      1. Macfarlane GJ, Thomas E, Papageorgiou AC, Croft PR, Jayson MI, Silman AJ. Employment and physical work activities as predictors of future low back pain. Spine (Phila Pa 1976). 1997;22(10):1143–1149.

        • Symmons D.P.
        • van Hemert A.M.
        • Vandenbroucke J.P.
        • Valkenburg H.A.
        A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings.
        Ann Rheum Dis. 1991; 50: 162-166
        • George S.Z.
        • Childs J.D.
        • Teyhen D.S.
        • et al.
        Predictors of occurrence and severity of first time low back pain episodes: findings from a military inception cohort.
        PLoS One. 2012; 7: e30597
        • Masset D.F.
        • Piette A.G.
        • Malchaire J.B.
        Relation between functional characteristics of the trunk and the occurrence of low back pain. Associated risk factors.
        Spine (Phila Pa 1976). 1998; 23: 359-365
        • Pietri F.
        • Leclerc A.
        • Boitel L.
        • Chastang J.F.
        • Morcet J.F.
        • Blondet M.
        Low-back pain in commercial travelers.
        Scand J Work Environ Health. 1992; 18: 52-58
        • Knox J.B.
        • Orchowski J.R.
        • Scher D.L.
        • Owens B.D.
        • Burks R.
        • Belmont Jr, P.J.
        Occupational driving as a risk factor for low back pain in active-duty military service members.
        Spine J. 2014; 14: 592-597
        • Ernat J.
        • Knox J.
        • Orchowski J.
        • Owens B.
        Incidence and risk factors for acute low back pain in active duty infantry.
        Mil Med. 2012; 177: 1348-1351
        • Knox J.B.
        • Orchowski J.R.
        • Owens B.
        Racial differences in the incidence of acute low back pain in United States military service members.
        Spine (Phila Pa 1976). 2012; 37: 1688-1692
        • Knox J.
        • Orchowski J.
        • Scher D.L.
        • Owens B.D.
        • Burks R.
        • Belmont P.J.
        The incidence of low back pain in active duty United States military service members.
        Spine (Phila Pa 1976). 2011; 36: 1492-1500
        • Lauder T.D.
        • Baker S.P.
        • Smith G.S.
        • Lincoln A.E.
        Sports and physical training injury hospitalizations in the army.
        Am J Prev Med. 2000; 18: 118-128
        • Scofield D.E.
        • Kardouni J.R.
        The tactical athlete: a product of 21st century strength and conditioning.
        Strength Cond J. 2015; 37: 2-7
        • Rothman K.J.
        • Greenland S.
        • Lash T.L.
        Modern Epidemiology.
        3rd ed. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia2008
        • Behrend C.
        • Prasarn M.
        • Coyne E.
        • Horodyski M.
        • Wright J.
        • Rechtine G.R.
        Smoking cessation related to improved patient-reported pain scores following spinal care.
        J Bone Joint Surg Am. 2012; 94: 2161-2166
        • Shiri R.
        • Karppinen J.
        • Leino-Arjas P.
        • Solovieva S.
        • Viikari-Juntura E.
        The association between smoking and low back pain: a meta-analysis.
        Am J Med. 2010; 123: 87
        • Ferreira P.H.
        • Pinheiro M.B.
        • Machado G.C.
        • Ferreira M.L.
        Is alcohol intake associated with low back pain? A systematic review of observational studies.
        Man Ther. 2013; 18: 183-190
        • Gorman D.M.
        • Potamianos G.
        • Williams K.A.
        • Frank A.O.
        • Duffy S.W.
        • Peters T.J.
        Relationship between alcohol abuse and low back pain.
        Alcohol Alcohol. 1987; 22: 61-63
        • Shiri R.
        • Karppinen J.
        • Leino-Arjas P.
        • Solovieva S.
        • Viikari-Juntura E.
        The association between obesity and low back pain: a meta-analysis.
        Am J Epidemiol. 2010; 171: 135-154
        • Auvinen J.P.
        • Tammelin T.H.
        • Taimela S.P.
        • et al.
        Is insufficient quantity and quality of sleep a risk factor for neck, shoulder and low back pain? A longitudinal study among adolescents.
        Eur Spine J. 2010; 19: 641-649
        • Alsaadi S.M.
        • McAuley J.H.
        • Hush J.M.
        • et al.
        Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain.
        Arthritis Rheumatol. 2014; 66: 1388-1394
        • Alsaadi S.M.
        • McAuley J.H.
        • Hush J.M.
        • Maher C.G.
        Prevalence of sleep disturbance in patients with low back pain.
        Eur Spine J. 2011; 20: 737-743
        • Linton S.J.
        A review of psychological risk factors in back and neck pain.
        Spine (Phila Pa 1976). 2000; 25: 1148-1156
        • Angstman K.B.
        • Bansal S.
        • Chappell D.H.
        • Bock F.A.
        • Rasmussen N.H.
        Effects of concurrent low back conditions on depression outcomes.
        J Am Osteopath Assoc. 2013; 113: 530-537
        • Andersson G.B.
        Epidemiological features of chronic low-back pain.
        Lancet. 1999; 354: 581-585
        • Shaw W.S.
        • Means-Christensen A.J.
        • Slater M.A.
        • et al.
        Psychiatric disorders and risk of transition to chronicity in men with first onset low back pain.
        Pain Med. 2010; 11: 1391-1400
        • Ellegaard H.
        • Pedersen B.D.
        Stress is dominant in patients with depression and chronic low back pain. A qualitative study of psychotherapeutic interventions for patients with non-specific low back pain of 3-12 months’ duration.
        BMC Musculoskelet Disord. 2012; 13: 166
        • Eadie J.
        • van de Water A.T.
        • Lonsdale C.
        • et al.
        Physiotherapy for sleep disturbance in people with chronic low back pain: results of a feasibility randomized controlled trial.
        Arch Phys Med Rehabil. 2013; 94: 2083-2092
        • Koes B.W.
        • van Tulder M.
        • Lin C.W.
        • Macedo L.G.
        • McAuley J.
        • Maher C.
        An updated overview of clinical guidelines for the management of non-specific low back pain in primary care.
        Eur Spine J. 2010; 19: 2075-2094
        • Willems P.
        Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion.
        Acta Orthop Suppl. 2013; 84: 1-35
        • Savigny P.
        • Watson P.
        • Underwood M.
        Early management of persistent non-specific low back pain: summary of NICE guidance.
        BMJ. 2009; 338: b1805
        • Fritz J.M.
        • Childs J.D.
        • Wainner R.S.
        • Flynn T.W.
        Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs.
        Spine (Phila Pa 1976). 2012; 37: 2114-2121
        • Hoy D.
        • Brooks P.
        • Blyth F.
        • Buchbinder R.
        The Epidemiology of low back pain.
        Best Pract Res Clin Rheumatol. 2010; 24: 769-781
        • Weinstein J.N.
        • Lurie J.D.
        • Olson P.R.
        • Bronner K.K.
        • Fisher E.S.
        United States’ trends and regional variations in lumbar spine surgery: 1992-2003.
        Spine (Phila Pa 1976). 2006; 31: 2707-2714
        • Irwin Z.N.
        • Hilibrand A.
        • Gustavel M.
        • et al.
        Variation in surgical decision making for degenerative spinal disorders. Part II: cervical spine.
        Spine (Phila Pa 1976). 2005; 30: 2214-2219
        • Freburger J.K.
        • Holmes G.M.
        • Agans R.P.
        • et al.
        The rising prevalence of chronic low back pain.
        Arch Intern Med. 2009; 169: 251-258
        • Ferreira M.L.
        • Machado G.
        • Latimer J.
        • Maher C.
        • Ferreira P.H.
        • Smeets R.J.
        Factors defining care-seeking in low back pain—a meta-analysis of population based surveys.
        Eur J Pain. 2010; 14: 747
        • Jordan K.P.
        • Kadam U.T.
        • Hayward R.
        • Porcheret M.
        • Young C.
        • Croft P.
        Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study.
        BMC Musculoskelet Disord. 2010; 11: 144
        • Dionne C.E.
        • Von Korff M.
        • Koepsell T.D.
        • Deyo R.A.
        • Barlow W.E.
        • Checkoway H.
        Formal education and back pain: a review.
        J Epidemiol Community Health. 2001; 55: 455-468
      2. Biglarian A, Seifi B, Bakhshi E, et al. Low back pain prevalence and associated factors in Iranian population: findings from the national health survey. Pain Res Treat. 2012;2012:653060.

      CHORUS Manuscript

      View Open Manuscript