Looking back on back pain: trial and error of diagnoses in the 20th century.

Context: The societal costs of low back pain and associated disability are immense. However, very little is known about the etiology of low back pain. Lumbar disc disease was discovered in the last century and became the predominant etiology for back pain. Today we know that for the majority of low back pain cases, a specific etiology cannot be determined.

Objective: To analyze the evolution of the "disc paradigm" and to compare our contemporary understanding to the scientific discussion in the beginning of the last century.

Design: Survey of the highest ranked German medical journal from 1900 to 1999.

Data Extraction: The indexes of 5185 journal issues of the Deutsche Medizinische Wochenschrift were reviewed for articles about low back pain.

Data Synthesis: For each article, the etiologies were identified, categorized, and counted per decade. In addition, each important etiology was described.

Conclusions: In the beginning of the last century, many heterogeneous etiologies coexisted. In the second half of the century, the theory of disc degeneration took over almost the entire literature about low back pain. Pre-existing theories disappeared, but re-entered the discussion in the last decade. Two factors seemed to influence this development: 1) a tendency to prefer organic, visible abnormalities as etiologies; and 2) an inclination to trust technical diagnostic results more than clinical judgment.