Low back pain and sciatica: Assessment and management, NICE guidelines

Assessment of Low Back Pain and Sciatica

Alternative Diagnoses

Think about alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop new or changed symptoms. Exclude specific causes of low back pain, for example, cancer, infection, trauma or inflammatory disease such as spondyloarthritis.

Risk Assessment and Risk Stratification Tools

Consider using risk stratification (for example, the STarT Back risk assessment tool) at first point of contact with a healthcare professional for each new episode of low back pain with or without sciatica to inform shared decision-making about stratified management.

Based on risk stratification, consider:

• Simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)


• More complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor outcome (for example, exercise programmes with or without manual therapy or using a psychological approach)

Imaging

Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica.

Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging.

Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.

Non-invasive Treatments for Low Back Pain and Sciatica

Non-pharmacological Interventions

Self-management

Provide people with advice and information, tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway. Include:

• Information on the nature of low back pain and sciatica


• Encouragement to continue with normal activities

Exercise

Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) for people with a specific episode or flare-up of low back pain with or without sciatica. Take people's specific needs, preferences and capabilities into account when choosing the type of exercise.

Orthotics

Do not offer belts or corsets for managing low back pain with or without sciatica.

Do not offer foot orthotics for managing low back pain with or without sciatica.

Do not offer rocker sole shoes for managing low back pain with or without sciatica.

Manual Therapies

Do not offer traction for managing low back pain with or without sciatica.

Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.

Acupuncture

Do not offer acupuncture for managing low back pain with or without sciatica.

Electrotherapies

Do not offer ultrasound for managing low back pain with or without sciatica.

Do not offer percutaneous electrical nerve simulation (PENS) for managing low back pain with or without sciatica.

Do not offer transcutaneous electrical nerve simulation (TENS) for managing low back pain with or without sciatica.

Do not offer interferential therapy for managing low back pain with or without sciatica.

Psychological Therapy

Consider psychological therapies using a cognitive behavioural approach for managing low back pain with or without sciatica but only as part of a treatment package including exercise, with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage).

Combined Physical and Psychological Programmes

Consider a combined physical and psychological programme, incorporating a cognitive behavioural approach (preferably in a group context that takes into account a person's specific needs and capabilities), for people with persistent low back pain or sciatica:

• When they have significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or


• When previous treatments have not been effective

Return-to-Work Programmes

Promote and facilitate return to work or normal activities of daily living for people with low back pain with or without sciatica.

Pharmacological Interventions

Consider oral non-steroidal anti-inflammatory drugs (NSAIDs) for managing low back pain, taking into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age.

When prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment.

Prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period of time.

Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective.

Do not offer paracetamol alone for managing low back pain.

Do not routinely offer opioids for managing acute low back pain.

Do not offer opioids for managing chronic low back pain.

Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain.

Do not offer anticonvulsants for managing low back pain.

Invasive Treatments for Low Back Pain and Sciatica

Non-surgical Interventions

Spinal Injections

Do not offer spinal injections for managing low back pain.

Radiofrequency Denervation

Consider referral for assessment for radiofrequency denervation for people with chronic low back pain when:

• Non-surgical treatment has not worked for them and


• The main source of pain is thought to come from structures supplied by the medial branch nerve and


• They have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral

Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block.

Do not offer imaging for people with low back pain with specific facet join pain as a prerequisite for radiofrequency denervation.

Epidurals

Consider epidural injections of local anaesthetic and steroid in people with acute and severe sciatica.

Do not use epidural injections for neurogenic claudication in people who have central spinal canal stenosis.

Surgical Interventions

Surgery and Prognostic Factors

Do not allow a person's body mass index (BMI), smoking status or psychological distress to influence the decision to refer them for a surgical opinion for sciatica.

Spinal Decompression

Consider spinal decompression for people with sciatica when non-surgical treatment has not improved pain or function and their radiological findings are consistent with sciatic symptoms.

Spinal Fusion

Do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial.

Disc Replacement

Do not offer disc replacement in people with low back pain.

You can read the full Guideline by clicking on the link :

National Guideline Centre. Low back pain and sciatica in over 16s: assessment and management. London (UK): National Institute for Health and Care Excellence (NICE); 2016 Nov 30. 18 p. (NICE guideline; no. 59).