Excerpt

This guideline covers the assessment and management of low back pain and sciatica in adults over the age of 16 years.

Low back pain causes more disability, worldwide, than any other condition. Episodes of back pain are usually transient with rapid improvements in pain and disability seen within a few weeks to a few months. Whilst the majority of back pain episodes resolve improve with initial primary care management, without the need for investigations or referral to specialist services, up to one third of patients report persistent back pain of at least moderate intensity one year after an acute episode requiring care and episodes of back pain often recur.

One of the greatest challenges remains the identification of risk factors that may predict the progression from a single back pain episode to a long term, persistent pain condition where quality of life is often very low and healthcare resource use high.

A complex and variable interplay between biological, psychological and social factors undoubtedly influences this progression and it is the modification of these factors that has become one of the mainstays of back pain research and treatment over the last decade or so.

The scope of this guideline is necessarily broad. We have reviewed the evidence for treatments and interventions individually and when used in combination - from self-management advice and simple non-invasive interventions to injections, nerve ablation techniques and spinal fusion.

We have reviewed the evidence for treatment stratification and the effectiveness of tailoring treatments to these stratified groups in the hope that clinicians know which patients are likely to need more focused and intensive treatment and which patients are likely to improve rapidly with primary care management alone, without the need for investigations or referral to specialised services.

Contents

• Guideline Development Group members
• NGC technical team members
• Co-optees
• Acknowledgements
• 1. Guideline summary
  • 1.1. Algorithm
  • 1.2. Full list of recommendations
• 2. Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE clinical guideline?
  • 3.2. Remit
  • 3.3. Epidemiology
  • 3.4. Who developed this guideline?
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Identifying and analysing evidence of effectiveness
  • 4.4. Identifying and analysing evidence of cost-effectiveness
  • 4.5. Developing recommendations
• Assessment and Non-Invasive Treatments
  • 5. Clinical examination
    • 5.1. Introduction
    • 5.2. Review question: In people with suspected (or under investigation for) sciatica, what is the clinical and cost effectiveness of clinical examination compared to history alone or history with imaging, when each is followed by treatment for sciatica, in improving patient outcomes?
    • 5.3. Clinical evidence
    • 5.4. Economic evidence
    • 5.5. Evidence statements
    • 5.6. Recommendations and link to evidence
  • 6. Risk assessment tools and stratification
    • 6.1. Introduction
    • 6.2. Review question 1: Which validated risk assessment tools are the most accurate for identifying people with low back pain or sciatica at risk of poor outcome/delayed improvement?
    • 6.3. Review question 2: What is the clinical and cost effectiveness of stratifying management of non-specific low back pain or sciatica according to outcome of a risk assessment tool/questionnaire?
    • 6.4. Clinical evidence
    • 6.5. Evidence statements
    • 6.6. Recommendations and link to evidence
  • 7. Imaging
    • 7.1. Introduction
    • 7.2. Review question: What is the clinical and cost effectiveness of performing imaging (X-ray or MRI) compared with no investigation to improve functional disability, pain or psychological distress in people with low back pain and/or sciatica?
    • 7.3. Clinical evidence
    • 7.4. Economic evidence
    • 7.5. Evidence statements
    • 7.6. Recommendations and link to evidence
  • 8. Self-management
    • 8.1. Introduction
    • 8.2. Review question: What is the clinical and cost effectiveness of self-management in the management of non-specific low back pain and sciatica?
    • 8.3. Clinical evidence
    • 8.4. Economic evidence
    • 8.5. Evidence statements
    • 8.6. Recommendations and link to evidence
  • 9. Exercise therapies
    • 9.1. Introduction
    • 9.2. Review question: What is the clinical and cost-effectiveness of exercise therapies in the management of non-specific low back pain and sciatica?
    • 9.3. Clinical evidence
    • 9.4. Economic evidence
    • 9.5. Evidence statements
    • 9.6. Recommendations and link to evidence
  • 10. Postural therapies
    • 10.1. Introduction
    • 10.2. Review question: What is the clinical and cost effectiveness of postural therapies in the management of non-specific low back pain and sciatica?
    • 10.3. Clinical evidence
    • 10.4. Economic evidence
    • 10.5. Evidence statements
    • 10.6. Recommendations and link to evidence
  • 11. Orthotics and appliances
    • 11.1. Introduction
    • 11.2. Review question: What is the clinical and cost effectiveness of orthotics and appliances in the management of non-specific low back pain and sciatica?
    • 11.3. Clinical evidence
    • 11.4. Economic evidence
    • 11.5. Evidence statements
    • 11.6. Recommendations and link to evidence
  • 12. Manual therapies
    • 12.1. Introduction
    • 12.2. Review question: What is the clinical and cost effectiveness of manual therapies in the management of non-specific low back pain and sciatica?
    • 12.3. Clinical evidence
    • 12.4. Economic evidence
    • 12.5. Evidence statements
    • 12.6. Recommendations and link to evidence
  • 13. Acupuncture
    • 13.1. Introduction
    • 13.2. Review question: What is the clinical and cost-effectiveness of acupuncture in the management of non-specific low back pain and sciatica?
    • 13.3. Clinical evidence
    • 13.4. Economic evidence
    • 13.5. Evidence statements
    • 13.6. Recommendations and link to evidence
  • 14. Electrotherapies
    • 14.1. Introduction
    • 14.2. Review question: What is the clinical and cost effectiveness of electrotherapy (non-invasive interventions) in the management of non-specific low back pain and sciatica?
    • 14.3. Clinical evidence
    • 14.4. Economic evidence
    • 14.5. Evidence statements
    • 14.6. Recommendations and link to evidence
  • 15. Psychological interventions
    • 15.1. Introduction
    • 15.2. Review question: What is the clinical and cost effectiveness of psychological therapies in the management of non-specific low back pain and sciatica?
    • 15.3. Clinical evidence
    • 15.4. Combinations of interventions – psychological therapy adjunct
    • 15.5. Economic evidence
    • 15.6. Evidence statements
    • 15.7. Recommendations and link to evidence
  • 16. Pharmacological interventions
    • 16.1. Introduction
    • 16.2. Review question: What is the clinical and cost effectiveness of pharmacological treatment in the management of non-specific low back pain?
    • 16.3. Clinical evidence
    • 16.4. Economic evidence
    • 16.5. Evidence statements
    • 16.6. Recommendations and link to evidence
  • 17. Multidisciplinary biopsychosocial rehabilitation (MBR) programmes
    • 17.1. Introduction
    • 17.2. Review question: What is the clinical and cost effectiveness of MBR programmes in the management of non-specific low back pain and sciatica?
    • 17.3. Clinical evidence
    • 17.4. Economic evidence
    • 17.5. Evidence statements
    • 17.6. Recommendations and link to evidence
  • 18. Return to work programmes
    • 18.1. Introduction
    • 18.2. Review question: What is the clinical and cost effectiveness of return to work programmes in the management of non-specific low back pain and sciatica?
    • 18.3. Clinical evidence
    • 18.4. Economic evidence
    • 18.5. Evidence statements
    • 18.6. Recommendations and link to evidence
  • 19. Reference list
  • 20. Acronyms and abbreviations
  • 21. Glossary
• Invasive Treatments
  • 22. Spinal injections
    • 22.1. Introduction
    • 22.2. Review question: What is the clinical and cost effectiveness of spinal injections in the management of non-specific low back pain?
    • 22.3. Clinical evidence
    • 22.4. Economic evidence
    • 22.5. Evidence statements
    • 22.6. Recommendations and link to evidence
  • 23. Radiofrequency denervation for facet joint pain
    • 23.1. Introduction
    • 23.2. Review question: What is the clinical and cost effectiveness of radiofrequency denervation for facet joint pain in the management of non-specific low back pain?
    • 23.3. Clinical evidence
    • 23.4. Economic evidence
    • 23.5. Evidence statements
    • 23.6. Recommendations and link to evidence
  • 24. Epidural injections for sciatica
    • 24.1. Introduction
    • 24.2. Review question: What is the clinical and cost effectiveness of epidural injections in the management of people with sciatica?
    • 24.3. Clinical evidence
    • 24.4. Economic evidence
    • 24.5. Evidence statements
    • 24.6. Recommendations and link to evidence
  • 25. Surgery and prognostic factors
    • 25.1. Introduction
    • 25.2. Review question: Does history of previous fusion surgery, smoking status, BMI or psychological distress predict response to surgery in people with non-specific low back pain?
    • 25.3. Review question: Does image concordant pathology or presence of radicular symptoms predict response to surgery in people with suspected sciatica?
    • 25.4. Clinical evidence
    • 25.5. Economic evidence
    • 25.6. Evidence statements
    • 25.7. Recommendations and link to evidence
  • 26. Disc replacement
    • 26.1. Introduction
    • 26.2. Review question: What is the clinical and cost-effectiveness of disc replacement surgery in people with non-specific low back pain?
    • 26.3. Clinical evidence
    • 26.4. Economic evidence
    • 26.5. Evidence statements
    • 26.6. Recommendations and link to evidence
  • 27. Spinal fusion
    • 27.1. Introduction
    • 27.2. Review question: What is the clinical and cost effectiveness of spinal fusion/arthrodesis in people with non-specific low back pain?
    • 27.3. Clinical evidence
    • 27.4. Economic evidence
    • 27.5. Evidence statements
    • 27.6. Recommendations and link to evidence
  • 28. Spinal decompression for sciatica
    • 28.1. Introduction
    • 28.2. Review question: What is the clinical and cost effectiveness of spinal decompression in people with sciatica?
    • 28.3. Clinical evidence
    • 28.4. Economic evidence
    • 28.5. Evidence statements
    • 28.6. Recommendations and link to evidence
  • 29 Reference list
  • 30. Acronyms and abbreviations
  • 31. Glossary
• Appendices A – G
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Clinical review protocols
  • Appendix D. Health economic review protocol
  • Appendix E. Clinical article selection
  • Appendix F. Health economic article selection
  • Appendix G. Literature search strategies
• Appendix H. Clinical evidence tables
• Appendices I-J
  • Appendix I. Economic evidence tables
  • Appendix J. GRADE tables
  • References
• Appendices K-Q
  • Appendix K. Forest plots
  • Appendix L. Excluded clinical studies
  • Appendix M. Excluded health economic studies
  • Appendix N. Cost-effectiveness analysis: Radiofrequency denervation
  • Appendix O. Research recommendations
  • Appendix P. Additional information
  • Appendix Q. NICE technical team
  • References

Developed by the National Guideline Centre, Hosted by the Royal College of Physicians

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer.