Based on our experience with the four cases presented here and with other patients in our clinic, we believe that addition of the lidocaine patch 5% to the analgesic regimen in chronic low back pain may be beneficial. Prospective, controlled clinical trials are planned to further evaluate the efficacy and safety of the lidocaine patch for treatment of chronic low back pain with or without a neuropathic component.

Neuropathic low back pain is examined from a structural standpoint, distinguishing processes that start from chronic inflammation and mechanical compromise and cross into the realm of neuropathy with primary neurogenic pathophysiology. The disease of chronic pain is discussed, examining peripheral and central changes in neuroanatomy, neurophysiology, and neuromolecular dynamics. The limitations of inadequate random controlled trials regarding long-term pharmacologic interventions are contrasted with excellent work in the basic science of chronic pain. Complex rational pharmacologic strategies for structural pathology, central pain processes, sites of medication action, and differing routes of administration are delineated.

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