Pain Generators and Hypotheses of Low Back Pain

Low back pain (LBP) remains the leading global cause of disability, with a complex pathophysiology that extends beyond simple structural pathology. This chapter explores the evolving understanding of LBP through the lens of multiple pain models—mechanical, neuropathic, nociplastic, and biopsychosocial—while detailing the anatomical pain generators that contribute to both acute and chronic presentations. The discussion integrates degenerative and nondegenerative causes of LBP, including discogenic, facet joint, sacroiliac, ligamentous, myofascial, vertebrogenic, and extraspinal sources. It further analyzes the neurobiology of pain transmission and central sensitization. Modulating factors such as genetics, psychological states, lifestyle behaviors, and social context are addressed for their influence on pain perception and chronicity. Emphasizing the limitations of singular-source diagnosis and overt reliance on imaging, the chapter advocates for a multimodal, stratified approach and introduces future directions in precision medicine, digital therapeutics, and integrated care models aimed at improving outcomes in LBP management.