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Management of Low back pain and Sciatica in primary care, Study notes of Pathology

Alder Grange High School, RawtenstallPathology

This guideline is based on NICE NG59 Low back pain and sciatica in over 16s. The aim is to provide guidance for clinicians in primary care for pain ...

Typology: Study notes

2021/2022

Uploaded on 09/12/2022

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Management of Low back pain and Sciatica in primary care
Date produced July 2021 Review date June 2024
Page 1 of 3
Management of Low back pain and Sciatica in primary care
Introduction
This guideline is based on NICE NG59 Low back pain and sciatica in over 16s. The aim is to provide
guidance for clinicians in primary care for pain management, with specific recommendations for
prescribed medication. Nevertheless, medications should usually be a small part of the pain
management plan and should be used in conjunction with non-pharmacological interventions.
Low back pain is pain in the lumbosacral area of the back, between the bottom of the ribs and the top
of the legs. Up to 60% of the adult population can expect to have low back pain at some time in their
life. Examples of specific causes of low back pain include sciatica, intra-abdominal pathology, or
ankylosing spondylitis. Non-specific low back pain refers to when the pain cannot be attributed to a
specific cause, although in many cases, may be related to trauma or musculoligamentous strain.
Sciatica describes symptoms of pain, tingling, and numbness which arise from impingement/
compression of lumbosacral nerve roots as they emerge from the spinal canal, and are felt in the
distribution of the nerve root (dermatome). Episodes of sciatica are usually transient, with rapid
improvements in pain and disability seen within a few weeks to a few months.
Assessment and Risk stratification
Think about alternative diagnoses when examining or reviewing people with low back pain/ sciatica,
particularly if they develop new or changed symptoms. Exclude specific causes e.g. infection, trauma
or inflammatory disease such as spondyloarthritis. Assess for the presence of red flag symptoms that
may suggest a serious underlying causes e.g. Caude equina syndrome or cancer. Do not routinely
offer imaging in a non-specialist setting for people with low back pain with or without sciatica.
Consider using risk stratification (e.g. STarT Back risk assessment tool) to inform decision making
regarding treatment:-
• simpler and less intensive support for people likely to improve quickly and have a good outcome
(e.g. reassurance, advice to keep active and guidance on self-management)
• more complex and intensive support for people at higher risk of a poor outcome (e.g. exercise
programmes with or without manual therapy or using a psychological approach).
Self-management advice
Provide people with advice and information, tailored to their needs and capabilities and
encouragement to continue with normal activities.
• Acute non-specific low back pain is not caused by serious structural damage. Most people can
reasonably be expected to recover from an episode of acute non-specific back pain within a
period of weeks.
• Sciatica symptoms usually settle within 4–6 weeks but may persist for longer in some people.
• Prolonged bed rest is not recommended. Normal movements may produce some pain which
should not be harmful if activities are resumed gradually and as tolerated. The person does not
need to be pain-free before returning to normal activities or work.
• For some patients weight loss may improve outcomes. Support for assistance with weight loss
efforts is available from Live life better Derbyshire website.
• Keeping as active as possible and exercising regularly is important to reduce the risk of
recurrence.
Examples of Patient Resources :-
• Live life better Derbyshire https://www.livelifebetterderbyshire.org.uk
• Versus Arthritis Patient Decision Aid
• Keele University Start back patient information- including leaflet, app, and animations.
• Backcare.org.uk Exercises for back pain patient information leaflet
DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE
(JAPC)
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Management of Low back pain and Sciatica in primary care Date produced July 2021 Review date June 2024

Management of Low back pain and Sciatica in primary care

Introduction This guideline is based on NICE NG59 Low back pain and sciatica in over 16s. The aim is to provide guidance for clinicians in primary care for pain management, with specific recommendations for

prescribed medication. Nevertheless, medications should usually be a small part of the pain

management plan and should be used in conjunction with non-pharmacological interventions. Low back pain is pain in the lumbosacral area of the back, between the bottom of the ribs and the top of the legs. Up to 60% of the adult population can expect to have low back pain at some time in their life. Examples of specific causes of low back pain include sciatica, intra-abdominal pathology, or ankylosing spondylitis. Non-specific low back pain refers to when the pain cannot be attributed to a specific cause, although in many cases, may be related to trauma or musculoligamentous strain. Sciatica describes symptoms of pain, tingling, and numbness which arise from impingement/ compression of lumbosacral nerve roots as they emerge from the spinal canal, and are felt in the distribution of the nerve root (dermatome). Episodes of sciatica are usually transient, with rapid improvements in pain and disability seen within a few weeks to a few months. Assessment and Risk stratification Think about alternative diagnoses when examining or reviewing people with low back pain/ sciatica, particularly if they develop new or changed symptoms. Exclude specific causes e.g. infection, trauma or inflammatory disease such as spondyloarthritis. Assess for the presence of red flag symptoms that may suggest a serious underlying causes e.g. Caude equina syndrome or cancer. Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica. Consider using risk stratification (e.g. STarT Back risk assessment tool) to inform decision making regarding treatment:-

  • simpler and less intensive support for people likely to improve quickly and have a good outcome (e.g. reassurance, advice to keep active and guidance on self-management)
  • more complex and intensive support for people at higher risk of a poor outcome (e.g. exercise programmes with or without manual therapy or using a psychological approach). Self-management advice Provide people with advice and information, tailored to their needs and capabilities and encouragement to continue with normal activities.
  • Acute non-specific low back pain is not caused by serious structural damage. Most people can reasonably be expected to recover from an episode of acute non-specific back pain within a period of weeks.
  • Sciatica symptoms usually settle within 4–6 weeks but may persist for longer in some people.
  • Prolonged bed rest is not recommended. Normal movements may produce some pain which should not be harmful if activities are resumed gradually and as tolerated. The person does not need to be pain-free before returning to normal activities or work.
  • For some patients weight loss may improve outcomes. Support for assistance with weight loss efforts is available from Live life better Derbyshire website.
  • Keeping as active as possible and exercising regularly is important to reduce the risk of recurrence. Examples of Patient Resources :-
  • Live life better Derbyshire https://www.livelifebetterderbyshire.org.uk
  • Versus Arthritis Patient Decision Aid
  • Keele University Start back patient information- including leaflet, app, and animations.
  • Backcare.org.uk Exercises for back pain patient information leaflet

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE

(JAPC)

Management of Low back pain and Sciatica in primary care Date produced July 2021 Review date June 2024 Non-pharmacological interventions Options recommended by NICE include group exercise programme, manual therapy and/or psychological therapies (cognitive behavioural approach) as part of a treatment package including exercise. See below referral section for more information. Being active when in pain can be a challenge and it is therefore important for patients to know that it is safe to be active in spite of pain; provide reassurance that pain does not always indicate harm especially when pain persists for a long time. Pharmacological Management For treatments of minor, short-term back pain, patients are encouraged to self-care with lifestyle changes and over-the-counter painkillers e.g. paracetamol, ibuprofen. British Pain Society (BPS) has produced a useful patient information leaflet on managing pain using OTC medicines. Oral NSAIDs

  • Consider oral NSAIDs for managing low back pain. Be aware of the risk of harms and limited evidence of benefit from the use of NSAIDs in sciatica.
  • Ibuprofen up to1200mg daily first line; alternatively naproxen up to 1000mg daily (NB use plain tablets).
  • Use lowest effective dose for the shortest possible time.
  • Add lansoprazole 15mg or omeprazole 20mg daily if high risk for serious GI adverse events as per JAPC guideline
  • NSAIDs may be used with or without paracetamol 1g 3-4 times daily (Consider dose reduction in patients at risk of hepatotoxicity and those <50kg)
  • British pain society (BPS) patient information leaflet- NSAID for treatment of pain Opioids
  • Do NOT routinely offer opioids for managing acute low back pain. Consider weak opioid (first line- codeine) with or without paracetamol for managing acute low back pain, only if an NSAID is contraindicated, not tolerated or has been ineffective.
  • Provide verbal and written information on weak opioids (if used) and pain management. Ensure patients are counselled on side effects e.g. constipation, driving, and risk of addiction. See opioid resource page for templates and patient information leaflets.
  • Do NOT offer opioids for managing chronic (≥3 months) low back pain or chronic sciatica. Gabapentinoids (gabapentin, pregabalin) and antiepileptics
  • NICE does NOT recommend gabapentinoids or antiepileptics for managing low back pain or sciatica, as there is no overall evidence of benefit and there is evidence of harm. See meta- analysis on chronic low back pain.
  • Local pain specialists recognise the potential issues in the long-term use of these medications for back pain and sciatica, however, reserves the option to use of gabapentinoids and some antiepiliptics e.g. carbamazepine, oxcarbazepine for small number of selected individuals after considering all other options. These should be started on specialist recommendation on a trial basis with clear plan to review/ stop. Other medications
  • Paracetamol alone for managing low back pain is not recommend by NICE.
  • Do NOT offer SSRI, SNRI, TCA for managing low back pain.
  • Do NOT offer oral corticosteroids or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm.