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
- Bilateral symptoms; sudden-onset bilateral radicular leg pain or unilateral radicular pain progressing to bilateral pain
- Severe or progressive neurological deficit
- Urine problems; recent-onset difficulty initiating micturition or impaired sensation of urinary flow; urinary retention and/or overflow urinary incontinence (late signs)
- Foecal problems; recent-onset loss of sensation of rectal fullness; faecal incontinence (late sign)
- Recent-onset erectile dysfunction or sexual dysfunction
- Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
- Unexpected laxity of the anal sphincter
- Gait disturbance or difficulty walking
- Spinal fracture
- Sudden onset of severe central spinal pain which is relieved by lying down
- History of major trauma, minor trauma or even just strenuous lifting in people with osteoporosis
- Structural deformity of the spine
- Point tenderness over a vertebral body
- Cancer
- >50 y/o
- Gradual onset of symptoms or progressive pain
- Severe unremitting lumbar pain / throacic back pain / night spinal pain preventing sleep / spinal pain aggravated by straining
- Localised spinal tenderness
- Mechanical pain aggravated by standing / sitting / moving
- Unexplained weight loss
- Past history of cancer (breast, lung, prostate, renal and gastric cancer are more likely to metastasize to the spine)
- Infection
- Fever / Systemically unwell
- Recent infection
- Diabetes mellitus
- History of IVDU
- HIV infection / use of immunosuppressant drugs / other cause of immunocompromise
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 LBPLower back pain and sciatica.
Invasive Management
Consider referral for assessment for radiofrequency denervation if:
-
Non-surgical treatment has not worked, and
-
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 LAlocal anaesthetic 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:
-
Belts, corsets, foot orthotics, and shoes
-
Traction
-
Acupuncture
-
Electrotherapies (including: ultrasound, TENStranscutaneous electrical nerve stimulation, PENSpercutaneous electrical nerve stimulation, interferential therapy)
-
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.
-
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)
References
NICE Low back pain and sciatica in over 16s: assessment and management