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Low back pain

Key sources
The following summarized guidelines for the evaluation and management of low back pain are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2023), the American Society of Pain and Neuroscience (ASPN 2022), the American College of Radiology (ACR 2021), the American College of Occupational and Environmental Medicine (ACOEM 2021), the North American Spine Society (NASS 2020), the American Academy of Family Physicians (AAFP 2019), the American Academy of Physical Medicine and Rehabilitation (AAPMR 2019), the National Institute for Health and Care Excellence (NICE 2017), the American College of Physicians (ACP 2017), the American Pain Society (APS 2009), and the American Pain Society (APS/ACP 2007).
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Guidelines

1.Screening and diagnosis

Differential diagnosis: as per NASS 2020 guidelines, consider suspecting a non-structural cause of LBP in patients with diffuse LBP and tenderness.
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2.Classification and risk stratification

Risk stratification: consider obtaining risk stratification using validated instruments, such as the STarT Back risk assessment tool, at the first point of contact with a healthcare professional, in order to inform shared decision-making about stratified management.
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  • Prognosis

3.Diagnostic investigations

History and physical examination: as per NASS 2020 guidelines, insufficient evidence to recommend for or against the use of the following:
fear avoidance behavior to determine the likelihood of a structural cause
innominate movement patterns for the assessment of sacroiliac joint pain
presence of diffuse back tenderness for the prediction of the presence of disc degeneration on radiographs
assessment of centralization or peripheralization for the prediction of discography results
pain localization in predicting response to a diagnostic injection.
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  • Diagnostic imaging

  • Laboratory testing

  • EMG

  • Psychosocial evaluation

4.Diagnostic procedures

Provocative discography: as per NASS 2020 guidelines, recognize that provocative discography without manometric measurements correlates with pain reproduction in the presence of moderate-to-severe disc degeneration on MRI/CT discography and with the presence of endplate abnormalities on MRI.
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  • Diagnostic nerve blocks

5.Medical management

General principles
As per NICE 2017 guidelines:
Consider providing simpler and less intensive support in patients with LBP (with or without sciatica) likely to improve quickly and have a good outcome.
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Consider providing more complex and intensive support in patients with LBP (with or without sciatica) at higher risk of a poor outcome, such as exercise programs with or without manual therapy or using a psychological approach.
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  • Topical capsaicin

  • Topical lidocaine

  • NSAIDs

  • Skeletal muscle relaxants

  • Opioids

  • Corticosteroids

  • Antidepressants

  • Anticonvulsants

  • Ketamine

  • Cannabinoids

  • Vitamin D

6.Nonpharmacologic interventions

Activity modifications, bed rest, NASS: advise remaining active over bed rest for better short-term outcomes in patients with nonspecific back pain.
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  • Activity modifications (work-hardening programs)

  • Physical therapy

  • Local heat

  • Bracing

  • Assistive devices

  • Weight loss

  • Psychological interventions

  • Alternative and complementary medicine (manual therapy)

  • Alternative and complementary medicine (traction)

  • Alternative and complementary medicine (acupuncture and acupressure)

  • Alternative and complementary medicine (dry needling)

  • Alternative and complementary medicine (therapeutic ultrasound)

  • Alternative and complementary medicine (laser therapy)

  • Alternative and complementary medicine (electromyographic biofeedback)

  • Alternative and complementary medicine (herbal products)

7.Therapeutic procedures

Epidural injections: as per ACOEM 2021 guidelines, offer epidural corticosteroid injections in selected circumstances for the treatment of acute or subacute radicular pain syndromes, typically after treatment with NSAIDs and waiting at least 3 weeks.
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  • Intrathecal injections

  • Facet joint injections

  • Sacroiliac joint injections

  • Intradiscal injections

  • Intraligamentous injections

  • Intramuscular injections

  • Trigger point injections

  • Intradiscal electrothermal therapy

  • Radiofrequency denervation

  • Cryodenervation

  • Medial branch block

  • Spinal cord stimulation

  • Peripheral nerve stimulation

8.Surgical interventions

Surgical neurotomy: do not offer surgical neurotomy for the treatment of chronic LBP or other lumbar spinal conditions, even if confirmed with diagnostic blocks.
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  • Spinal decompression

  • Vertebroplasty

  • Kyphoplasty

  • Vertebral disc replacement

  • Facet rhizotomy

  • Sacroiliac joint surgery

  • Spinal fusion

9.Patient education

General counseling: as per WHO 2023 guidelines, consider offering structured and standardized education and/or advice interventions in adult patients with chronic primary LBP.
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