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Low back pain

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Updated 2024 ASPN guidelines for the diagnosis and management of sacroiliitis.

Guidelines

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 American Academy of Family Physicians (AAFP 2024,2021,2019), the American College of Radiology (ACR 2024,2021), the American Society of Pain and Neuroscience (ASPN 2024,2022), the World Health Organization (WHO 2023), the American College of Occupational and Environmental...
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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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Classification and risk stratification

Risk stratification: as per NICE 2017 guidelines, 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

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

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

Medical management

General principles: as per AAFP 2024 guidelines, Offer nonpharmacologic treatments as first-line therapy in patients with chronic LBP in the absence of conditions requiring specific medical or surgical attention.
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  • Topical capsaicin

  • Topical lidocaine

  • NSAIDs

  • Skeletal muscle relaxants

  • Opioids

  • Corticosteroids

  • Antidepressants

  • Anticonvulsants

  • Ketamine

  • Cannabinoids

  • Vitamin D

Nonpharmacologic interventions

Activity modifications, bed rest: as per NASS 2020 guidelines, 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)

Therapeutic procedures

Epidural injections: as per AAFP 2024 guidelines, Consider offering epidural corticosteroid injections to provide a slight reduction in short-term pain and disability in patients with radicular pain, recognizing that they are not effective in the long term.
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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

Surgical interventions

Surgical neurotomy: as per ACOEM 2021 guidelines, 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

Specific circumstances

Patients with upper back pain: as per ACR 2024 guidelines, Do not obtain routine imaging in adult patients with acute, subacute, or chronic thoracic back pain without myelopathy, radiculopathy, or red flags.
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Consider obtaining thoracic spine X-ray in patients with subacute or chronic thoracic back pain.
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Patient education

General counseling: as per AAFP 2024 guidelines, Provide early patient education focusing on the importance of remaining physically active, avoiding bed rest, and setting expectations for a positive treatment response.
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