Guidelines Summary
The following organizations have issued guidelines on the diagnosis and/or management of mechanical back pain:
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American College of Radiology (ACR)
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American College of Physicians (ACP)
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National Institute for Health and Care Excellence (NICE)
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American Pain Society (APS)
American College of Radiology
The ACR Appropriateness Criteria includes the following recommendations [5] :
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Uncomplicated acute low back pain and/or radiculopathy are benign, self-limited conditions that do not warrant any imaging studies.
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MRI of the lumbar spine should be considered for those patients presenting with red flags raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, or infection.
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In patients with a history of low-velocity trauma, osteoporosis, or chronic steroid use, initial evaluation with radiographs is recommended.
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In the absence of red flags, first-line treatment for chronic low back pain remains conservative therapy with both pharmacologic and nonpharmacologic (eg, exercise, remaining active) therapy.
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If there are persistent or progressive symptoms during or following 6 weeks of conservative management and the patient is a surgery or intervention candidate or diagnostic uncertainty remains, MRI of the lumbar spine has become the initial imaging modality of choice in evaluating complicated low back pain.
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MRI is the imaging procedure of choice in patients suspected of cord compression or spinal cord injury.
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Patients with recurrent low back pain and history of prior surgical intervention should be evaluated with contrast-enhanced MRI.
American College of Physicians (ACP)
The American College of Physicians (ACP) guidelines on noninvasive treatments for acute, subacute, and chronic low back pain include the following key recommendations [29] :
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For acute or subacute low back pain, improvement is seen over time regardless of treatment; thus, nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation should be the initial therapy selected.
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Use nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants, if pharmalogic treatment is needed.
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For chronic low back pain, initial nonpharmacologic treatment includes exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.
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For chronic low back pain with inadequate response to nonpharmacologic therapy, pharmacologic treatment with NSAIDs as first-line therapy or tramadol or duloxetine as second-line therapy may be considered.
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Opioids are an option in patients in whom nonpharmacologic and nonopioid pharmacologic treatments have failed, but only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients.
National Institute for Health and Care Excellence (NICE)
Similar to the ACP guidelines, the United Kingdom's National Institute for Health and Care Excellence (NICE) guidelines on low back pain prefers nonpharmacologic therapies over pharmacologic pain relief for the initial treatment of back pain. A stratified approach to management based on scores from prognostic screening questionnaires is also recommended in the NICE guidelines. [30]
NSAIDs are recommended by both ACP and NICE guidelines for treatment of acute and chronic low back pain. The NICE guidelines recommend offering weak opioids to patients with acute low back pain if NSAIDs are contraindicated or ineffective for acute pain, but prescribing opioids for chronic low back pain is discouraged. [30]
The NICE guidelines recommend radiofrequency denervation for selected patients with persistent low back pain. [30] However, the publication of the Mint randomized clinical trials has cast doubt on that recommendation. [41]
American Pain Society
Evidence-based clinical practice guidelines from the American Pain Society (APS) on chronic low back pain describe the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation. The recommendations for nonradicular pain include the following [36] :
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Interdisciplinary rehabilitation emphasizing cognitive-behavioral approaches should be considered for patients who do not respond to usual interventions.
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Provocative discography (injecting material into a disc nucleus in an attempt to reproduce the patient's typical pain) is not recommended.
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Facet joint corticosteroid injection, prolotherapy (repeated injections of irritant material to stimulate an inflammatory response), and intradiscal corticosteroid injection are not recommended.
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Persistent disabling symptoms and degenerative spinal changes should prompt discussion and shared decision-making regarding surgery or interdisciplinary rehabilitation (evidence is insufficient to weigh the risks and benefits of vertebral disc replacement in these patients).
The recommendations for persistent radiculopathy include the following [36] :
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For patients with herniated discs, the use of epidural steroid injection should be discussed.
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For patients with herniated discs and disabling leg pain from spinal stenosis, surgical options should be discussed.
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For patients with persistent pain after surgery, the risks and benefits of spinal cord stimulation should be discussed.
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Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.
