Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Assessment of low back pain and sciatica

Alternative diagnoses

1.1.1 Think about alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop new or changed symptoms. Exclude specific causes of low back pain, for example, cancer, infection, trauma or inflammatory disease such as spondyloarthritis. If serious underlying pathology is suspected, refer to relevant NICE guidance on:

Risk assessment and risk stratification tools

1.1.2 Consider using risk stratification (for example, the STarT Back risk assessment tool) at first point of contact with a healthcare professional for each new episode of low back pain with or without sciatica to inform shared decision-making about stratified management. [2016]

1.1.3 Based on risk stratification, consider:

  • simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)

  • more complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor outcome (for example, exercise programmes with or without manual therapy or using a psychological approach). [2016]

Imaging

1.1.4 Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica. [2016]

1.1.5 Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging. [2016]

1.1.6 Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management. [2016]

1.2 Non-invasive treatments for low back pain and sciatica

Non-pharmacological interventions

Self-management

1.2.1 Provide people with advice and information, tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway. Include:

  • information on the nature of low back pain and sciatica

  • encouragement to continue with normal activities. [2016]

Exercise

1.2.2 Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica. Take people's specific needs, preferences and capabilities into account when choosing the type of exercise. [2016]

Orthotics

1.2.3 Do not offer belts or corsets for managing low back pain with or without sciatica. [2016]

1.2.4 Do not offer foot orthotics for managing low back pain with or without sciatica. [2016]

1.2.5 Do not offer rocker sole shoes for managing low back pain with or without sciatica. [2016]

Manual therapies

1.2.6 Do not offer traction for managing low back pain with or without sciatica. [2016]

1.2.7 Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy. [2016]

Acupuncture

1.2.8 Do not offer acupuncture for managing low back pain with or without sciatica. [2016]

Electrotherapies

1.2.9 Do not offer ultrasound for managing low back pain with or without sciatica. [2016]

1.2.10 Do not offer percutaneous electrical nerve simulation (PENS) for managing low back pain with or without sciatica. [2016]

1.2.11 Do not offer transcutaneous electrical nerve simulation (TENS) for managing low back pain with or without sciatica. [2016]

1.2.12 Do not offer interferential therapy for managing low back pain with or without sciatica. [2016]

Psychological therapy

1.2.13 Consider psychological therapies using a cognitive behavioural approach for managing low back pain with or without sciatica but only as part of a treatment package including exercise, with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage). [2016]

Combined physical and psychological programmes

1.2.14 Consider a combined physical and psychological programme, incorporating a cognitive behavioural approach (preferably in a group context that takes into account a person's specific needs and capabilities), for people with persistent low back pain or sciatica:

  • when they have significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or

  • when previous treatments have not been effective. [2016]

Return-to-work programmes

1.2.15 Promote and facilitate return to work or normal activities of daily living for people with low back pain with or without sciatica. [2016]

Pharmacological management of sciatica

1.2.16 Do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm. [2020]

1.2.17 Do not offer opioids for managing chronic sciatica. [2020]

1.2.18 If a person is already taking opioids, gabapentinoids or benzodiazepines for sciatica, explain the risks of continuing these medicines. [2020]

1.2.19 As part of shared decision making about whether to stop opioids, gabapentinoids or benzodiazepines for sciatica, discuss the problems associated with withdrawal with the person. [2020]

NICE is developing a guideline on medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management.

1.2.20 Be aware of the risk of harms and limited evidence of benefit from the use of non-steroidal anti-inflammatory drugs (NSAIDs) in sciatica. [2020]

1.2.21 If prescribing NSAIDs for sciatica:

  • take into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age

  • think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment

  • use the lowest effective dose for the shortest possible period of time. [2020]

For a short explanation of why the committee made the 2020 recommendations and how they might affect practice, see the rationale and impact section on pharmacological management of sciatica.

The committee have also made research recommendations on opioids for the management of acute sciatica, and antidepressants for the management of sciatica.

Full details of the evidence and the committee's discussion are in evidence review A: pharmacological management of sciatica.

Pharmacological management of low back pain

1.2.22 Consider oral NSAIDs for managing low back pain, taking into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age. [2016]

1.2.23 When prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment. [2016]

1.2.24 Prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period of time. [2016]

1.2.25 Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective. [2016]

1.2.26 Do not offer paracetamol alone for managing low back pain. [2016]

1.2.27 Do not routinely offer opioids for managing acute low back pain (see recommendation 1.2.25). [2016]

1.2.28 Do not offer opioids for managing chronic low back pain. [2016]

1.2.29 Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain. [2016]

1.2.30 Do not offer gabapentinoids or antiepileptics for managing low back pain. [2016, amended 2020]

1.3 Invasive treatments for low back pain and sciatica

Non-surgical interventions

Spinal injections

1.3.1 Do not offer spinal injections for managing low back pain. [2016]

Radiofrequency denervation

1.3.2 Consider referral for assessment for radiofrequency denervation for people with chronic low back pain when:

  • non-surgical treatment has not worked for them and

  • the main source of pain is thought to come from structures supplied by the medial branch nerve and

  • they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral. [2016]

1.3.3 Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block. [2016]

1.3.4 Do not offer imaging for people with low back pain with specific facet join pain as a prerequisite for radiofrequency denervation. [2016]

Epidurals

1.3.5 Consider epidural injections of local anaesthetic and steroid in people with acute and severe sciatica. [2016]

1.3.6 Do not use epidural injections for neurogenic claudication in people who have central spinal canal stenosis. [2016]

Surgical interventions

Surgery and prognostic factors

1.3.7 Do not allow a person's BMI, smoking status or psychological distress to influence the decision to refer them for a surgical opinion for sciatica. [2016]

Spinal decompression

1.3.8 Consider spinal decompression for people with sciatica when non-surgical treatment has not improved pain or function and their radiological findings are consistent with sciatic symptoms. [2016]

Spinal fusion

1.3.9 Do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial. [2016]

Disc replacement

1.3.10 Do not offer disc replacement in people with low back pain. [2016]

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

Acute

Less than 3 months duration.

Chronic

A 3-month duration or longer. The intensity of pain may fluctuate over time.

  • National Institute for Health and Care Excellence (NICE)