Editor—The optimal management of patients with chronic low back pain remains a challenge for healthcare services, as discussed by Koes,¹ but the importance of vitamin D is not widely appreciated.

Many studies have shown the high prevalence of vitamin D deficiency in various populations. For example, 93% of 150 patients presenting to a university affiliated inner city primary care clinic in Minneapolis with persistent, non-specific musculoskeletal pain had deficient concentrations of vitamin D.²

Most patients (83%) attending spinal and internal medicine clinics in Saudi Arabia over six years who had experienced low back pain that had no obvious cause for more than six months had an abnormally low level of vitamin D.³ After treatment with vitamin D supplements, clinical improvement in symptoms was seen in all of those who had a low initial concentration of vitamin D. The authors concluded that screening (of patients with chronic low back pain) for vitamin D deficiency should be mandatory.

A report in the Medical Journal of Australia described two patients with failed spinal fusion for chronic low back pain who were subsequently found to have severe vitamin D deficiency.⁴ Both responded positively to vitamin D supplementation. The authors highlight the need for attending surgeons and physicians to be aware of the potential for vitamin D deficiency in their patients since failure to recognise this easily reversible problem may result in complications of treatment, including failure of spinal fusion surgery, additional morbidity, and the substantial costs of further surgery and hospitalisation.

All patients with persistent, musculoskeletal pain are at high risk of the consequences of unrecognised and untreated vitamin D deficiency. Current clinical guidelines for managing chronic low back pain should include assessment of vitamin D status (by measuring serum 25-hydroxyvitamin D concentrations), together with advice on appropriate vitamin D supplementation in those found to be deficient.