Management of low back pain and sciatica

Non-specific low back pain is one that is not associated with serious or potentially serious causes. Sciatica is leg pain, secondary to lumbosacral nerve root compression.

The information below is based on the following NICE guideline:

  • NICE NG59 – Low back pain and sciatica in over 16s: assessment and management (November 2016)

With each new episode of low back pain with or without sciatica, consider using the 9 point STarT Back risk assessment tool to inform shared decision-making

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).

Non- pharmacological interventions

Self-management

People with low back pain with or without sciatica should be encouraged to continue with normal activities. Provide advice and information (including the nature of low back pain and sciatica) to help them self-manage at all steps of the treatment pathway.

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.

Manual therapies

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.

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.

Pharmacological interventions

Sciatica

For recommendations on pharmacological management of sciatica, see formulary guidance on management of neuropathic pain.

Low back pain
  • Consider oral non-steroidal anti-inflammatory drugs (see section 10.1.1 Non-Steroidal anti-inflammatory drugs (NSAIDs))
    • When prescribing oral NSAIDs, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
  • Do not routinely offer opioids for managing acute low back pain.
    • Only if an NSAID is contraindicated, not tolerated or has been ineffective, consider weak opioids (with or without paracetamol) for acute low back pain e.g. codeine, co-codamol, or co-dydramol (see section 4.7.2 Opioid analgesics and section 4.7.1 compound analgesic preparations)
    • In such circumstances, advise intermittent (not regular) use of opioid analgesia
  • Do not offer opioids for managing chronic low back pain
  • Do not offer paracetamol alone for managing low back pain.

 

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