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Immediate ref for imaging, eval, and mgmt to preserve neurologic fxn if red flags:1-3 - Cauda equina syndrome (rapidly progressive motor/sensory loss, esp. motor deficits across multi roots; loss of bowel/bladder control; urinary retention; saddle anesthesia): emergency MRI recommended.2,4
- Fever, hx invasive spinal procedure, IVDA, immunosuppression (or UTI, per NASS3): MRI w/ or w/o gadolinium is gold standard,4,5 ESR and/or CRP.2
- Cancer or unexplained wt ↓: lumbosacral plain films, MRI OK per VA,2 but initial CT or MRI rec’d by ACR.4,5
- Trauma relative to age, osteoporosis status/risk, corticosteroid use: Plain films OK, but noncontrast CT L-spine gold standard to r/o fx in trauma.5
Footnotes 1 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
2 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
3 NASS 2020. North American Spine Society. NASS Evidence-based Guideline Development Committee. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. 2020. 1-217. PDF
4 ACR LBP 2016. Patel ND, et al. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016. Sept;13(9):1069-1078. Accessed February 27, 2020
5 ACR Fx 2018. Lubdha SM, et al. ACR Appropriateness Criteria Management of Vertebral Compression Fractures. J Am Coll Radiol. 2018. Nov;15(11):S347-S364. Accessed February 27, 2020
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Neurogenic claudication/radicular sx w/o red flags
Eval for serious pathology; consider imaging. - Consider MRI1 for dx of spinal stenosis or herniated disc, or radiography of pelvis, SI joint, and spine area of interest for dx of inflammatory LBP; may also r/o other serious pathology.1,2 If serious pathology on imaging, intervention to preserve neuro fxn.
If no serious pathology on imaging, initiate conservative tx.1,3-5 - Provide pt ed.
- Avoid bed rest.
- Exercise/PT
- Spinal manipulation tx
- NSAIDs rec’d as initial pharmacotherapy by ACP, AHRQ, VA.1,3,4
- Neuropathic meds (amitriptyline, duloxetine, gabapentin, or pregabalin) rec’d as initial tx by NICE,6 but insufficient evidence per ACP,3 VA.1
◦ Carefully evaluate pts for drug abuse hx before prescribing pregabalin or gabapentin; watch for signs of abuse/dependence.6
◦ Pregabalin may slightly ↑ risk of major congenital malformations if used in pregnancy. Pts should use effective contraception during tx and avoid use in pregnancy unless necessary.6 - Epidural steroid may provide short-term pain relief in sciatica,1,5 but rec’d against for claudication.5
- Tramadol recommended only short-term if acute rescue tx needed in pt who failed initial tx or if initial tx contraindicated.3,6
- Consider capsaicin cream in pt unable to take PO tx.6
- Not recommended: acetaminophen, PO corticosteroids, BZD, SSRI, traction, ultrasound, TENS/PENS, acupuncture.1,3,5
If conservative tx fails, reconsider imaging and referral (if not done). - Consider MRI if pain persists in spite of conservative tx (>6wk per ACR;2 rec’d against unless would affect tx, per NICE5).
- Consider surg ref for sciatica when non-surg tx not improving pain/fxn and imaging consistent w/ pt sx.5
- Trials of not previously used neuropathic meds (amitriptyline, duloxetine, gabapentin, pregabalin) rec’d by NICE.6
◦ Carefully evaluate pts for drug abuse hx before prescribing pregabalin or gabapentin; watch for signs of abuse/dependence.6
◦ Pregabalin may slightly ↑ risk of major congenital malformations if used in pregnancy. Pts should use effective contraception during tx and avoid use in pregnancy unless necessary.6 - Initiation of long-term opioids rec’d against by VA, NICE,1,5 considered by ACP only as last resort if benefits > risk after shared decision-making.3
- Consider epidural injections of local anesthetic and steroid in acute and severe sciatica, per NICE;5 however, VA says there’s insufficient evidence for/against epidural steroid injections relieving radicular sx.1
- Not recommended: Epidural injections not rec’d for neurogenic claudication in central spinal canal stenosis.5
- See Prescribing Opioids for Pain for Outpts ≥18 yo | 2022 CDC Guideline.
Footnotes 1 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
2 ACR LBP 2016. Patel ND, et al. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016. Sept;13(9):1069-1078. Accessed February 27, 2020
• MRI and CT have similar sensitivity/specificity for spinal stenosis. MRI preferred due to lack of radiation exposure and ability to evaluate soft tissue.
• Correlate MRI findings to sx, as asymptomatic findings common.
3 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
4 AHRQ 2016. Chou R, et al. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review No. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-2012-00014-I.) AHRQ publication no. 16-EHC004-EF. Rockville: Agency for Healthcare Research and Quality; February 2016. Accessed February 27, 2020
5 NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE guideline {NG59}. National Institute for Health and Care Excellence. Published November 30, 2016. Updated December 11, 2020. Accessed December 18, 2023
6 NICE 2013. Neuropathic pain in adults: pharmacologic management in non-specialist settings. Clinical guideline {CG173}. National Institute for Health and Care Excellence. Published November 20, 2013. Updated September 22, 2020. Accessed December 18, 2023
Initiate conservative tx.1-4 - Provide pt ed.
- Avoid bed rest.
- Exercise/PT
- Spinal manipulation tx
- NSAIDs rec’d as initial pharmacotherapy by ACP, AHRQ, VA.1-3
- Epidural steroid may provide short-term pain relief in sciatica,2,4 but rec’d against for claudication.4
- Neuropathic meds (amitriptyline, duloxetine, gabapentin, or pregabalin) rec’d as initial tx by NICE,5 but insufficient evidence per ACP,1 VA.2
◦ Carefully evaluate pts for drug abuse hx before prescribing pregabalin or gabapentin; watch for signs of abuse/dependence.5
◦ Pregabalin may slightly ↑ risk of major congenital malformations if used in pregnancy. Pts should use effective contraception during tx and avoid use in pregnancy unless necessary.5 - Tramadol recommended only short-term if acute rescue tx needed in pt who failed initial tx or if initial tx contraindicated.1,5
- Consider capsaicin cream in pt unable to take PO tx.5
- Not recommended: acetaminophen, PO corticosteroids, BZD, SSRI, traction, ultrasound, TENS/PENS, acupuncture.1,2,4
Footnotes 1 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
2 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
3 AHRQ 2016. Chou R, et al. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review No. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-2012-00014-I.) AHRQ publication no. 16-EHC004-EF. Rockville: Agency for Healthcare Research and Quality; February 2016. Accessed February 27, 2020
4 NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE guideline {NG59}. National Institute for Health and Care Excellence. Published November 30, 2016. Updated December 11, 2020. Accessed December 18, 2023
5 NICE 2013. Neuropathic pain in adults: pharmacologic management in non-specialist settings. Clinical guideline {CG173}. National Institute for Health and Care Excellence. Published November 20, 2013. Updated September 22, 2020. Accessed December 18, 2023
Consider imaging, referral w/ failure of conservative tx. - Consider MRI if pain persists in spite of conservative tx (>6wk per ACR;1 rec’d against unless would affect tx, per NICE2).
- Consider surg ref for sciatica when non-surg tx not improving pain/fxn and imaging consistent w/ pt sx.2
- Trials of not previously used neuropathic meds (amitriptyline, duloxetine, gabapentin, pregabalin) rec’d by NICE.3
◦ Carefully evaluate pts for drug abuse hx before prescribing pregabalin or gabapentin; watch for signs of abuse/dependence.3
◦ Pregabalin may slightly ↑ risk of major congenital malformations if used in pregnancy. Pts should use effective contraception during tx and avoid use in pregnancy unless necessary.3 - Initiation of long-term opioids rec’d against by VA, NICE,2,4 considered by ACP only as last resort if benefits > risk after shared decision-making.5
- VA says there’s insufficient evidence for/against epidural steroid injections relieving radicular sx.4
- Not recommended: Epidural injections not rec’d for neurogenic claudication in central spinal canal stenosis.2
- See Prescribing Opioids for Pain for Outpts ≥18 yo | 2022 CDC Guideline.
Footnotes 1 ACR LBP 2016. Patel ND, et al. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016. Sept;13(9):1069-1078. Accessed February 27, 2020
2 NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE guideline {NG59}. National Institute for Health and Care Excellence. Published November 30, 2016. Updated December 11, 2020. Accessed December 18, 2023
3 NICE 2013. Neuropathic pain in adults: pharmacologic management in non-specialist settings. Clinical guideline {CG173}. National Institute for Health and Care Excellence. Published November 20, 2013. Updated September 22, 2020. Accessed December 18, 2023
4 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
5 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
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No red flags/neurogenic claudication/radicular sx
Awaiting 1st-line nonpharmacologic tx Use nonpharmacologic tx 1st, as most pts improve w/ time. - Provide pt ed re: course of condition/tx.1-4
- Avoid bed rest.1,2,5
- Superficial heat1,2
- Massage1
- Acupuncture1
- Spinal manipulation1
- Clinician-directed exercise2,3
- Not recommended: traction, ultrasound, TENS/PENS.1,3
Footnotes 1 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
2 AHRQ 2016. Chou R, et al. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review no. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-2012-00014-I.) AHRQ publication no. 16-EHC004-EF. Rockville: Agency for Healthcare Research and Quality; February 2016. Accessed February 27, 2020
3 NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE guideline {NG59}. National Institute for Health and Care Excellence. Published November 30, 2016. Updated December 11, 2020. Accessed December 18, 2023
4 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
5 NICE 2018. Best evidence for a better back (BE FABB) – A triage, assessment and education service for patients with low back pain with or without sciatica. Hillingdon Hospitals NHS Foundation Trust. August 2018. Accessed December 22, 2023
Failed 1st-line nonpharmacologic tx Use meds after failure of conservative measures. - NSAIDs (no diff in efficacy b/t traditional vs. COX-2 selective)1-5
- Non-BZD skeletal muscle relaxants (inconsistent evidence for combining w/ NSAID)1,3
- Cautious use of limited-duration opioids may be considered,4,5 but should not be offered routinely.1,5
- Topical capsaicin6 (on a short-term basis, per NASS4); insufficient evidence for other topicals, including lidocaine.2-4
- Not recommended: acetaminophen. Systemic corticosteroids recommended against due to lack of efficacy vs. placebo.1-4 NICE recommends against antidepressants, anti-epileptic medications.5
- NASS recommends against epidural or facet injections.4
Footnotes 1 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
2 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
3 AHRQ 2016. Chou R, et al. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review no. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-2012-00014-I.) AHRQ publication no. 16-EHC004-EF. Rockville: Agency for Healthcare Research and Quality; February 2016. Accessed February 27, 2020
4 NASS 2020. North American Spine Society. NASS Evidence-based Guideline Development Committee. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. 2020. 1-217. PDF
5 NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE guideline {NG59}. National Institute for Health and Care Excellence. Published November 30, 2016. Updated December 11, 2020. Accessed December 18, 2023
6 NICE 2013. Neuropathic pain in adults: pharmacologic management in non-specialist settings. Clinical guideline {CG173}. National Institute for Health and Care Excellence. Published November 20, 2013. Updated September 22, 2020. Accessed December 18, 2023
Awaiting 1st-line nonpharmacologic tx Use nonpharmacologic tx 1st. - Exercise, including tai chi, yoga, or Pilates1-4
- Multidisciplinary rehab1-4
- Acupuncture1-4
- Mindfulness-based stress reduction1,3
- CBT;1-3 operant therapy appropriate per ACP, AHRQ.1,3
- Massage3
- Motor control exercise (PT)1
- EMG biofeedback1
- Low-level laser tx,1,3 though NASS suggests benefit only when combined w/ exercise.4
- Spinal manipulation1-4
- Insufficient evidence re: bracing or supports.2,4
Footnotes 1 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
2 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
3 AHRQ 2016. Chou R, et al. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review no. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-2012-00014-I.) AHRQ publication no. 16-EHC004-EF. Rockville: Agency for Healthcare Research and Quality; February 2016. Accessed February 27, 2020
4 NASS 2020. North American Spine Society. NASS Evidence-based Guideline Development Committee. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. 2020. 1-217. PDF
Failed 1st-line nonpharmacologic tx Use meds after failure of conservative measures. - NSAIDs considered tx of choice (no diff in efficacy b/t traditional vs. COX-2 selective, but fewer GI side effects w/ COX-2 selective).1-5
- If NSAID fails or is contraindicated, tramadol or duloxetine recommended.1-3
- Initiation of long-term opioids rec’d against by VA, NICE,2,5 considered by ACP only as last resort if benefits > risk after shared decision-making.1
- See Prescribing Opioids for Pain for Outpts ≥18 yo | 2022 CDC Guideline.
- Though AHRQ suggests BZD is better than placebo,3 VA recommends against use in chronic LBP.2
Footnotes 1 ACP 2017. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. April 4;166(7):514-530. Accessed February 27, 2020
2 VA/DoD 2022. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. (Based on evidence reviewed through February 01, 2021). Version 3.0. Department of Veterans Affairs. Department of Defense. February 2022. PDF
3 AHRQ 2016. Chou R, et al. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review no. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-2012-00014-I.) AHRQ publication no. 16-EHC004-EF. Rockville: Agency for Healthcare Research and Quality; February 2016. Accessed February 27, 2020
4 NASS 2020. North American Spine Society. NASS Evidence-based Guideline Development Committee. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. 2020. 1-217. PDF
5 NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE guideline {NG59}. National Institute for Health and Care Excellence. Published November 30, 2016. Updated December 11, 2020. Accessed December 18, 2023
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