Guidelines Summary
American College of Radiology
The ACR Appropriateness Criteria includes the following recommendations [10, 22] :
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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 patients presenting with red flags that raise suspicion of 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 by radiography 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 after 6 weeks of conservative management and the patient is a candidate for surgery or intervention or if diagnostic uncertainty remains, MRI of the lumbar spine is the initial imaging modality of choice.
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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 a history of surgical intervention should be evaluated with contrast-enhanced MRI.
American College of Physicians
The American College of Physicians (ACP) guidelines on noninvasive treatments for acute, subacute, and chronic low back pain include the following key recommendations [23] :
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For acute or subacute low back pain, nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation should be the initial therapy.
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Use NSAIDs or skeletal muscle relaxants if pharmacologic treatment is necessary.
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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, and 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
The United Kingdom's National Institute for Health and Care Excellence (NICE) guidelines on low back pain recommend 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. [24]
NSAIDs are recommended by NICE for the treatment of both 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. [24]
The NICE guidelines recommend radiofrequency denervation for selected patients with persistent low back pain. [24]
American Pain Society
Recommendations from the American Pain Society (APS) include the following [25] :
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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).
