Clinical update: low back pain and sciatica

The National Institute for Health and Care Excellence (NICE) has just published a new updated clinical guideline on the assessment and management of non-specific low back pain and sciatica in adults. The guideline has been developed by a multidisciplinary team following an extensive review of the evidence for the various interventions currently available. The goal of this clinical update is to summarise the key recommendations.

Assessment

The use of routine spinal imaging such as X-ray or MRI in the assessment process is not recommended in any non-specialist care setting. When referring patients for a specialist opinion it should be explained to them that they are being referred for that specialist opinion and that they may not need imaging. In the specialist care setting, imaging should only be used only if the result is likely to change the management of the patient.

Within the assessment process the guideline recommends that clinicians consider using risk stratification tools to inform shared decision-making about referral for rehabilitation. One example is the StartBack tool. On that basis, consider giving simpler and less intensive support to people who are likely to improve quickly and more complex intensive support for people at higher risk of a poor outcome.

Management

Simpler, less intensive support should include advice and information to help patients to self-manage including information about the nature of low back pain and sciatica, encouragement to continue with normal activities as far as possible and promoting and facilitating normal activities of daily living.

More complex support options should be based on the following recommendations where appropriate:

Pharmacological options

• Oral nonsteroidal anti-inflammatory drugs (NSAIDs) should be offered after consideration of any potential differences in gastro-intestinal, liver and cardio-renal toxicity and risk factors including age. They should be used at the lowest effective dose for the shortest possible period of time.
• weak opioids with or without paracetamol should only be considered where NSAIDs are contraindicated, not tolerated or have not been found to be adequately helpful.
• paracetamol, anticonvulsants, tricyclic antidepressants and selective serotonin reuptake inhibitors should not be offered. Opioids should not be routinely offered in acute low back pain and should not be offered in chronic low back pain.

Non-pharmacological options

Movement and exercise are at the heart of the non-pharmacological recommendations. The guideline recommends that clinicians consider a group exercise programme (biomechanical, aerobic, mind-body or a combination of approaches) within the NHS for people with a specific episode or flare-up of non-specific low back pain with or without sciatica. It is important to take people’s specific needs, preferences and capabilities into account when choosing the type of exercise.

Beyond exercise, manual therapy and/or psychological therapies, such as cognitive behavioural treatment, can be considered but, importantly, not as stand-alone therapies. Where used these should be part of a combined treatment package that also includes exercise therapy. It is important to note that these options are not mandatory components of a multimodal treatment package, but are optional modalities that might be considered in some cases.

Where patients present with significant psychosocial obstacles to recovery or when previous treatments have not been effective, consider a combined physical and psychological programme (preferably in a group context, that takes into account a person’s specific needs and capabilities) for people with persistent non-specific low back pain or sciatica. 

A number of non-pharmacological interventions are not recommended. The guideline recommends that clinicians do not offer traction, electrotherapies, back support, shoe orthotics and acupuncture.

Invasive interventions

For low back pain the guideline recommends that clinicians do not offer spinal injections, or disc replacement surgery. Lumbar fusion surgery is not recommended unless it is offered within the context of a clinical trial that would help to reduce the current uncertainty regarding its benefits and risks.

In cases of moderate to severe chronic low back pain that has not responded to other therapeutic options, and where the facet joint is suspected as a source of pain, the guideline makes the following recommendation: consider referring the patent for diagnostic blocks to identify pain arising from structure supplied by the medial branch nerve, with a view to possible radiofrequency denervation treatment. fl

Neil O’Connell, a physiotherapist and senior lecturer at Brunel University, was on the NICE guideline development group

Sciatica

For cases of sciatica, the guideline follows the NICE recommendations for the pharmacological management of neuropathic pain. In acute cases, NICE recommends that clinicians consider epidural injections of local anaesthetic and steroid. Where these options are unsuccessful in improving pain or function spinal decompression, surgery should be considered.

The guidelines present a treatment algorithm. This can be seen on pages 14-17 of the full guidance.

This new guidance aims to improve the management of low back pain and sciatica in the NHS. The goal is to improve the equity, effectiveness and efficiency of treatment. This will require the proactive engagement of clinicians in implementing the recommendations. Physiotherapists are both well placed and well skilled to deliver key components of the guideline.

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