Low Back Pain (LBP) and Sciatica
NICE guideline [NG59] Low back pain and sciatica in over 16s: assessment and management. Last updated: Dec 2022.
Background Information
Definitions
In the context of LBP and sciatica:
- Acute: <3 months
- Chronic: ≥3 months
Guidelines
Red Flags
Screen for red flags for:
- Cauda equina syndrome
- Spinal fracture
- Cancer
- Infection (e.g. discitis, vertebral osteomyelitis, spinal / epidural abscess)
Investigation and Diagnosis
Consider using the STarT Back risk assessment tool for risk assessment and stratification to guide management
DO NOT routinely offer imaging in a non-specialist setting
- Only consider imaging in a specialist setting if the result is likely to change management
Management
General Advice / Conservative Management
Advise the patient:
- Stay active and continue normal activities as much as possible
- Perform exercises that promote strength, flexibility and aerobic fitness
Treatment package of:
- Structured exercise programme
- +/- Manual therapy (e.g. spinal manipulation, mobilisation or massage)
- +/- Psychological therapies using a CBT approach
Choice of management based on risk stratification:
- Likely to have a good outcome → simpler and less intensive support (e.g. reassurance + advice to keep active + guidance on self-management)
- Higher risk of a poor outcome → more complex and intensive support (e.g. exercise programmes +/- manual therapy or psychological approach)
Pharmacological Management
- 1st line: oral NSAIDs (use the lowest effective dose for the shortest possible period of time)
- 2nd line: weak opioid +/- paracetamol
Do not offer paracetamol alone for managing LBP and sciatica.
Invasive Management
Consider referral for assessment for radiofrequency denervation if:
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Non-surgical treatment has not worked, and
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Main source of pain is thought to come from structures supplied by the medial branch nerve, and
- Moderate / severe localised back pain (rated as 5 or more on a visual analogue scale, or equivalent), and
Only perform radiofrequency denervation after a +ve response to diagnostic medial branch block
Consider epidural injections of LA and steroids in:
- Acute and severe sciatica
Last resort: consider spinal decompression
The following are NOT recommended by NICE for the management of LBP and sciatica:
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Belts, corsets, foot orthotics, and shoes
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Traction
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Acupuncture
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Electrotherapies (including: ultrasound, TENS, PENS, interferential therapy)
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Pharmacological Interventions – DO NOT offer:
- Paracetamol monotherapy for managing low back pain with or without sciatica.
- Gabapentinoids, other antiepileptics, oral corticosteroids, benzodiazepines
- Opioids for chronic sciatica
- SSRIs / SNRIs / TCA just for managing low back pain (unless there is another indication, such as depression, that needs treatment)
-
Spinal Injections
- Do not offer spinal injections for managing low back pain (for example, facet joint injections), unless the person has sciatica and meets specific criteria for epidural injections.
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Surgical Interventions
- Do not offer disc replacement for people with low back pain.
- Do not offer spinal fusion for people with low back pain, unless as part of a specific, carefully selected pathway (for example, in a specialist setting where other interventions have been unsuccessful and the indication is clearly established)