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Low Back Pain (LBP) and Sciatica

NICE guideline [NG59] Low back pain and sciatica in over 16s: assessment and management. Last updated: Dec 2022.

Background Information

In the context of LBP and sciatica:
  • Acute: <3 months
  • Chronic: ≥3 months

Guidelines

Screen for red flags for:
  • Cauda equina syndrome
    Spinal fracture
  • Cancer
  • Infection (e.g. discitis, vertebral osteomyelitis, spinal / epidural abscess)

Consider using the STarT Back risk assessment tool for risk assessment and stratification to guide management.

DO NOT routinely offer imaging in non-specialist setting.
  • Only consider imaging in specialist setting if the result is likely to change 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)

  • 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 LBP.

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 LA and steroids in:
  • Acute and severe sciatica

Last resort: consider spinal decompression

  • Belts, corsets, foot orthotics, and shoes
  • Traction
  • Acupuncture
  • Electrotherapies
    • Do not offer ultrasound 
    • Do not offer transcutaneous electrical nerve stimulation (TENS) 
    • Do not offer percutaneous electrical nerve stimulation (PENS) 
    • Do not offer interferential therapy
  • Pharmacological Interventions
    • Do not offer paracetamol alone for managing low back pain with or without sciatica.
    • Do not offer gabapentinoids, other antiepileptic, oral corticosteroids, benzodiazepines 
    • Do not offer opioids for chronic sciatica 
    • Do not offer 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

Author: Adams Lau
Reviewer:
Last Edited: 21/04/25