Low Back Pain (LBP)

NICE guideline [NG59] Low back pain and sciatica in over 16s: assessment and management. Last updated: Dec 2022.

Article Last Updated:20/06/2026

Background Information

Definitions

In the context of LBP and sciatica:

Acute: <3 months
Chronic: ≥3 months

Guidelines

Back Pain Red Flags

Serious underlying condition to exclude	Key red flags
Cauda equina syndrome	Sudden onset bilateral sciatica (or unilateral sciatica progressing to bilateral) Severe or progressive bilateral lower limb neurological deficit (e.g. major motor weakness with knee extension, ankle eversion, foot dorsiflexion) Difficulty walking / gait disturbance Saddle anaesthesia / paraesthesia (sensory loss in the perianal, perineal, genital regions) Reduced anal sphincter tone (laxity) Erectile dysfunction Urinary dysfunction: impaired sensation of urinary flow / difficulty initiating micturition Bowel dysfunction: loss of sensation of rectal fullness
Spinal fracture	History of major trauma In those with osteoporosis, minor trauma / strenuous lifting is possible to cause a spinal fracture Sudden onset of severe central spinal pain which is relieved by lying down Structural deformity of the spine Point tenderness over a vertebral body
Cancer	>50 y/o Gradual onset of symptoms or progressive pain Severe unremitting pain preventing sleep (nocturnal pain) Localised spinal tenderness Mechanical pain aggravated by standing / sitting / moving / straining Unexplained weight loss Past history of cancer (breast, lung, prostate, renal and gastric cancer are more likely to metastasise to the spine)
Infection (e.g. discitis, vertebral osteomyelitis, spinal / epidural abscess)	Fever / systemically unwell Recent infection Diabetes mellitus History of IVDU HIV / immunosuppressed / other cause of immunocompromise

TUNA FISH is a mnemonic / clinical screening tool used for low back pain red flags:

T: trauma
U: unexplained weight loss
N: neurological symptoms (esp. saddle anaesthesia, loss of bowel or bladder control)
A: age (<20 or >50 y/o carries a higher risk of serious non-mechanical causes)
F: fever
I: IVDU
S: steroid use
H: history of cancer

Investigation and Diagnosis

Clinical diagnosis (based on clinical history and physical examination)

Consider using the STarT Back risk assessment tool for risk assessment and stratification to guide management

DO NOT routinely offer imaging (including lumbar X-rays and MRI) in a non-specialist setting

Only consider imaging in a specialist setting if the result is likely to change management

Management

First, exclude red flags that may suggest a serious underlying cause

If cauda equina syndrome or spinal fracture is suspected → emergency referral to a spinal surgery service
If cancer or infection is suspected → urgent referral to a spinal surgery service or urgent MRI within 2 weeks

Choice of management based on risk stratification:

Likely to have a good outcome (e.g. low risk of chronicity on STarT Back) → simpler and less intensive support (e.g. reassurance + advice to keep active + guidance on self-management)
Higher risk of a poor outcome (e.g. high risk of chronicity on STarT Back) → more complex and intensive support (e.g. exercise programmes +/- manual therapy or psychological approach)

Conservative / General Management

Advise to:

Stay active and continue normal activities as much as possible
Perform exercises that promote strength, flexibility and aerobic fitness

Offer:

Structured exercise programme
+/- Manual therapy (e.g. spinal manipulation, mobilisation or massage)
+/- Psychological therapies using a CBT approach

Do NOT offer the following:

Belts, corsets, foot orthotics, and shoes
Manual traction therapy
Acupuncture
Electrotherapies (including: ultrasound, TENS, PENS, interferential therapy)

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

Do NOT offer the following:

Gabapentinoids (pregabalin and gabapentin) and other antiepileptics
Benzodiazepines
Corticosteroids
Opioids
SSRIs, SNRIs, TCAs

Interventional / Invasive Management

Be aware that interventional / invasive management is primarily for sciatica (i.e. lumbosacral radiculopathy), but not simply low back pain without evidence of radiculopathy.

Intervention	Indications
Radiofrequency denervation	Consider referring for assessment if ALL of the following are met: Non-surgical treatment has failed Main source of pain is thought to come from structures supplied by the medial branch nerve Moderate / severe localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) Only perform radiofrequency denervation after a +ve response to diagnostic medial branch block.
Epidural injection of LA and steroids	Consider in acute and severe sciatica Otherwise, do not routinely offer spinal injections
Surgical spinal decompression	Consider if: Non-surgical treatment has failed, and Radiological findings are consistent with sciatica

Intervention

Indications

Radiofrequency denervation

Consider referring for assessment if ALL of the following are met:

Non-surgical treatment has failed
Main source of pain is thought to come from structures supplied by the medial branch nerve
Moderate / severe localised back pain (rated as 5 or more on a visual analogue scale, or equivalent)

Only perform radiofrequency denervation after a +ve response to diagnostic medial branch block.

Epidural injection of LA and steroids

Consider in acute and severe sciatica

Otherwise, do not routinely offer spinal injections

Surgical spinal decompression

Consider if:

Non-surgical treatment has failed, and
Radiological findings are consistent with sciatica

Do NOT routinely offer the following:

Disc replacement
Spinal fusion (unless in a specialist setting where other interventions have been unsuccessful and the indication is clearly established)

References

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