Managing low back pain and sciatica

© NICE 2016…
Person aged 16 and over with low back pain with or without sciatica Information and advice to support self-management

  • Exercise
  • Pharmacological treatments
  • Manual therapy treatment package
  • Combined physical and psychological programmes
  • Psychological therapies treatment package
  • Radiofrequency denervation
  • Additional specific treatments for sciatica
  • Additional surgical procedures

Do not offer

  • Acupuncture and electrotherapy
  • Traction, orthotics, belts and corsets
  • Spinal injections and disc replacement
  • Spinal fusion (unless part of a randomised controlled trial)

 

Sciatica PainImaging i.e x-ray MRI CT SCANS…

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

MRI Scanner

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) within the NHS 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

1.2.3 …
Do not offer belts or corsets for managing low back pain with or without sciatica.
1.2.4
Do not offer foot orthotics for managing low back pain with or without sciatica.
1.2.5
Do not offer rocker sole shoes for managing low back pain with or without sciatica.

Orthotics

Traction Image

Manual therapies

1.2.6
Do not offer traction for managing low back pain with or without sciatica.
1.2.7
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

Managing low back pain and sciatica

© NICE 2016

Acupuncture

1.2.8 …
Do not offer acupuncture for managing low back pain with or without sciatica.

Electrotherapies
1.2.9
Do not offer ultrasound for managing low back pain with or without sciatica.
1.2.10
Do not offer percutaneous electrical nerve simulation (PENS) for managing low back pain with or without sciatica.
1.2.11
Do not offer transcutaneous electrical nerve simulation (TENS) for managing low back pain with or without sciatica.
1.2.12
Do not offer interferential therapy for managing low back pain with or without sciatica.

Managing low back pain and sciatica

© NICE 2016

Psychological TherapyPsychological therapy

1.2.13
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

1.2.14
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

Managing low back pain and sciatica

© NICE 2016

Return To Work ProgrammesReturn-to-work programmes

1.2.15
Promote and facilitate return to work or normal activities of daily living for people with low back pain with or without sciatica

Managing low back pain and sciatica

© NICE 2016

PillsPharmacological interventions

1.2.16 …
For recommendations on pharmacological management of sciatica, see NICE’s guideline on neuropathic pain in adults.
1.2.17
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.
1.2.18
When prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment.
1.2.19
Prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period of time.
1.2.20
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.
1.2.21
Do not offer paracetamol alone for managing low back pain.
1.2.22
Do not routinely offer opioids for managing acute low back pain (see recommendation 1.2.20).
1.2.23
Do not offer opioids for managing chronic low back pain.
1.2.24
Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain.
1.2.25
Do not offer anticonvulsants for managing low back pain.
1.3 Invasive treatments for low back pain and sciatica

Managing low back pain and sciatica

© NICE 2016

Invasive TreatmentInvasive treatments for low back pain and sciatica

1.3.1 Do not offer spinal injections for managing low back pain.
1.3.2 Consider referral for assessment for radiofrequency denervation for people with chronic low back pain when:
non-surgical treatment has not worked for them
the main source of pain is thought to come from structures supplied by the medial branch nerve
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.
1.3.3 Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block.
1.3.4 Do not offer imaging for people with low back pain with specific facet join pain as a prerequisite for radiofrequency denervation.
1.3.5 Consider epidural injections of local anaesthetic and steroid in people with acute and severe sciatica.
1.3.6 Do not use epidural injections for neurogenic claudication in people who have central spinal canal stenosis.
1.3.7 Do not allow a person’s BMI, smoking status or psychological distress to influence the decision to refer them for a surgical opinion for sciatica.
1.3.8 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.
1.3.9 Do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial.
1.3.10 Do not offer disc replacement in people with low back pain

Managing low back pain and sciatica

© NICE 2016

Meds1 Pharmacological therapies

What is the clinical and cost effectiveness of benzodiazepines for the acute management of low back pain?

Guidelines from many countries have said that muscle relaxants should be considered for short term use in people with low back pain when the paraspinal muscles are in spasm. The evidence for this mainly comes from studies on medications that are not licensed for this use in the UK. The 2009 NICE guideline on low back pain recommends to consider prescribing diazepam as a muscle relaxant in this situation, but the evidence base to support this particular medicine is extremely small. Benzodiazepines are not without risk of harm, even for short-term use. Because of this, there is a need to find out if diazepam is clinically and cost effective in the management of acute low back pain.

2 Pharmacological therapies

What is the clinical and cost effectiveness of codeine with and without paracetamol for the acute management of low back pain?

Codeine, often together with paracetamol, is commonly prescribed in primary care to people presenting with acute low back pain. This often happens with people who cannot tolerate nonsteroidal anti-inflammatory drugs (NSAIDs) or when a person has contraindications to these medications. Although there is evidence that opioids are not effective in chronic low back pain, there are relatively few studies that look at their use for acute low back pain (a problem commonly seen in primary care). Also, it is not known if using paracetamol and codeine together has a synergistic effect in the treatment of back pain.

Managing low back pain and sciatica

© NICE 2016

Radio FrequencyRadiofrequency denervation

What is the clinical and cost effectiveness of radiofrequency denervation for chronic low back pain in the long term?

Radiofrequency denervation is a minimally invasive and percutaneous procedure performed under local anaesthesia or light intravenous sedation. Radiofrequency energy is delivered along an insulated needle in contact with the target nerves. This focused electrical energy heats and denatures the nerve. This may allow axons to regenerate with time, requiring the repetition of the radiofrequency procedure.
The length of pain relief after radiofrequency denervation is uncertain. Data from randomised controlled trials suggest relief is at least 6–12 months but no study has reported longer-term outcomes. Pain relief for more than 2 years would not be an unreasonable clinical expectation. The economic model presented in this guideline suggested that radiofrequency denervation is likely to be cost effective if pain relief is above 16 months.
If radiofrequency denervation is repeated, we do not know whether the outcomes and duration of these outcomes are similar to the initial treatment. If repeated radiofrequency denervation is to be offered, we need to be more certain that this intervention is both effective and cost effective

Managing low back pain and sciatica

© NICE 2016

EpiduralsEpidurals

What is the clinical and cost effectiveness of image-guided compared with non-image-guided epidural injections for people with acute sciatica?

Epidural injection of treatments, including corticosteroids, is commonly offered to people with sciatica. Epidural injection might improve symptoms, reduce disability and speed up return to normal activities. Several different procedures have been developed for epidural delivery of corticosteroids. Some practitioners inject through the caudal opening to the spinal canal in the sacrum (caudal epidural), but others inject through the foraminal space at the presumed level of nerve root irritation (transforaminal epidural).

5 Spinal fusion

Should people with low back pain be offered spinal fusion as a surgical option?

Spinal FusionAn increasing number of procedures have been proposed for surgically managing low back pain. One of these procedures is surgical fixation with internal metalwork applied from the back, front, side, or any combination of the 3 routes. The cost of these operations has risen, and now that minimally invasive approaches are used, more of these operations are done with uncertain benefit….
As well as the cost, surgery can lead to complications – some studies report around a 20% complication rate in the short to medium term. There have been several studies (both randomised and cohort) looking at the clinical effectiveness of spinal fusion versus usual care, no surgery, different surgeries, and other treatments.
Overall, the studies do not show a clear advantage of fusion but do show some modest benefit for some elements of pain, function and quality of life. The studies also show healthcare use was lower. It is not known what treatments should be tried before surgery is considered. The evidence from the studies was weak because of low numbers of patients, large crossover and in-case selection bias. This means there is a need for a large, multicentre randomised trial with sufficient power to answer these important questions.

Please contact us for more information or to discuss your own situation.