Non-specific/mechanical low back pain

Back pain is a very common problem in the UK - with eight out of ten people suffering from it at some point during their lives.

It can affect anyone, at any age, and is usually caused by a sprain or a strain of the muscles, ligaments, joints or discs in the back. Most of us know that this can be very painful, and inconvenient, but it is not serious.

Back pain is classified as acute or chronic, depending on how long you have had the pain. Acute pain is shorter lived and more common. We call back pain chronic once you have had it for more than 3 months. Managing back pain well prevents people developing chronic back pain.

Most people experience back pain on one or both sides of their backs but may also feel it around their hips and buttocks and occasionally into one or both thighs. But with simple advice, most people will see a great improvement in their back pain within two weeks.

Chronic back pain can last much longer and usually requires treatment such as medication or physiotherapy.

In most cases though, your back will heal itself. It is important that you keep active and continue as normal, but if your pain is severe and persistent then you should seek medical advice for diagnosis and the appropriate treatment.

National Back Pain and Radicular Pain Pathway

Scope

  • Assessment, treatment, and management of non-specific/mechanical low back pain not attributed to a serious pathology in adults within primary care.

Out of scope

  • Cauda Equina Syndrome and Suspected Cancer (see Red Flag section)
  • Children under age 16 years Assessment, treatment and management of nerve root pain (see nerve root pain guidelines)
  • Inflammatory back pain

Assessment

Use diagnostic triage

Differentiate between red flags, nonspecific lower back pain (NSLBP) and nerve root pain (sciatica)

Guidance on assessment of LBP for GP

Also see section on Red Flags

History taking is most important in differentiating NSLBP from nerve root pain or stenotic leg pain and serious pathology.

Use of stratification STarT back screening tool is recommended by NICE and UKSSB. Tool can be completed online (link to online STarT back tool and GP guidance on use of tool:

If low risk STarT back; See guidance on managing low risk patients

  • good prognosis
  • advice and information on self-management (see patient info below)
  • pain management
  • activity modification, but reassurance pain not damaging, stay at work if possible (even if modification required)
  • referral should not be required on first contact

If medium or high risk STarT back;

  • advice as above PLUS refer to physiotherapy
  • Physiotherapy can refer on to secondary care services if indicated. This is the agreed spinal pathway.

If patient re-presents to GP with persisting symptoms reassess red flags (See management section).

Differential Diagnosis

Consider the following differential diagnoses:

  • Fracture – history of trauma or osteoporosis risk
  • Atypical nerve root pain e.g. part of dermatome such as buttock, lateral hip or lateral lower leg only. Ipsilateral low back pain with spasm could also be atypical nerve root pathology
  • Pathology in an adjacent structure
  • Malignancy: in the kidney or pelvis, e.g. prostate, ovaries, myeloma, metastases
  • Infection:
    • lower urinary tract infection (UTI)
    • pyelonephritis or perinephric abscess
    • pelvic inflammatory disease (PID)
    • shingles and post-herpetic neuralgia
    • endocarditis
    • viral syndromes
  • Other:
    • renal calculi
    • hydronephrosis
    • aortic aneurysm
    • pancreatitis
    • endometriosis
    • ovarian cysts
    • dysmenorrhoea
    • coccydynia
    • inflammatory disorders:
      • ankylosing spondylitis
      • polymyalgia rheumatica
  • metabolic bone disease
  • inflammatory back pain – see separate guidance

Can refer directly to Rheumatology if symptoms and signs strongly suggestive of Axial Spondylarthropathy OR refer to Spinal Team if mixed picture

NB: Common findings such as osteoarthritis or lumbar spondylosis are extremely common in asymptomatic people and may not be the source of pain.

Red Flags

The presence of 2 or more Red flags significantly raises the likelihood of serious spinal pathology. Please refer to the STarT back Red flags :

Send to ED if suspicion of

Spinal infection (history of immunosuppression, intravenous drug user (IVDU), fever, blood test sepsis, recent bacterial infection)

Refer URGENTLY to Spinal TEAM at RD&E via DRSS

  • in presence of deteriorating neurology (consider upper and lower motor neurone signs)
  • in cases of suspected cancer

Mark referrals clearly as URGENT and why.

Investigations

Current NICE /UKSSB guidelines state MRI only for use in specialist clinic if it will change outcome. Patients should be told they may not need imaging if being referred to specialist clinic. There is a high level of incidental findings on scans e.g. disc degeneration therefore appropriate clinical interpretation is needed when feeding back MRI results is essential.

Refer for X-ray only in cases of suspected fracture

  • sudden new back pain in women aged over 60
  • history of osteoporosis,
  • history of steroid use,
  • history of Ankylosing Spondylitis
  • other history suggests patient at risk of osteoporosis; (NICE guideline Osteoporosis - assessing the risk of fragility fracture)

If fracture is confirmed;

  • screen for myeloma or cancer and refer for DEXA scan
  • appropriate analgesia
  • consider referral to physiotherapy if function limited
  • refer to Spinal Pathway if pain not settling after 6-8 weeks or suspicion of serious underlying pathology

Bloods appropriate for suspicion of infection or cancer.

Management

Self-care and self-management underpins all activities within this guideline, please encourage patients to engage with this approach throughout

  • Positive attitude to outcome – try to keep patient at work and maintain activity levels. Assess and address issues of distress or depression
  • Encourage early activity – activity is not harmful and may help to reduce pain in many patients
  • Avoid prolonged bed rest – at most one or two days in simple back pain
  • Education and rehabilitation – emphasise self-management and reinforce positive attitudes to outcome
  • Give patient supportive information on self-management (see Patient Information below)
  • It is expected that patients will have completed 12 weeks of conservative management, including completion of a Back Fit (Spinal Rehabilitation) programme before considering onward referral to any specialist service

At each re-attendance:

  • review diagnosis and reconsider differential diagnosis
  • retest neurology and range of movement/pain levels
  • check compliance with advice
  • check compliance/attendance with physiotherapy

Pharmacological interventions

  • Consider oral non-steroidal anti-inflammatory drugs (see section 10.1.1 Non-Steroidal anti-inflammatory drugs (NSAIDs)
    • When prescribing oral NSAIDs, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
  • Do not routinely offer opioids for managing acute low back pain
    • Only if an NSAID is contraindicated, not tolerated or has been ineffective, consider weak opioids (with or without paracetamol) for acute low back pain e.g. codeine, co-codamol, or codydramol (see section 4.7.2 Opioid analgesics and section 4.7.1 compound analgesic preparations)
    • In such circumstances, advise intermittent (not regular) use of opioid analgesia
  • Do not offer opioids for managing chronic low back pain
  • Do not offer paracetamol alone for managing low back pain.

Guidance for healthcare professionals on drug driving

Referral

Referral Criteria

Refer to Physiotherapy:

  • If medium or high risk STarT back;
  • Low risk STarT back with no improvement after 4-6 weeks of Primary Care Management
  • If the patient has relapsed following previous successful treatment

It is expected that ALL patients will have completed 12 weeks of conservative management, including completion of a Back Fit (Spinal Rehabilitation) programme before considering onward referral to ANY specialist service.

Refer To Pain Clinic:

  • Patients with mechanical/non-specific low back pain who have failed primary care conservative management
  • Patients with multiple sites of pain
  • Patients on high levels of analgesia without evidence of benefit
  • Patients with disabling levels of distress, depression or anxiety
  • Patients who are significantly functionally impaired
  • Patients who have failed numerous interventions

Refer To RD&E Spinal Team:

  • Patients with mechanical/non-specific low back pain AND nerve root pain who have failed primary care conservative management
  • Patients with a high suspicion or radiological evidence of PARs defect +/- spondylolisthesis

Referral Instructions

Refer via e-Referral Service:

  • Specialty: Orthopaedics
  • Clinic Type: Spinal
  • Service: DRSS-Eastern-Orthopaedics-Devon CCG- 15N

Referral Forms

DRSS Referral Form

Supporting Information​

GP Information

MyHealth Devon

Start Back tool online Keele University website and GP advice on use of tool

Nice guidelines NG 59 - Low back pain and sciatica in over 16s: assessment and management

UKSSB (UK Spine Societies Board)

Opioids and driving - Guidance for healthcare professionals

Sheffield aches and pains - guidance for primary care.

Patient Information

MyHealth Devon

Recommended resources for patients and carers. NEW Devon CCG does not take responsibility for the content of third party information resources.

British Association Spinal Surgeons: patients area/ patient information

Low back pain, back pain management and understanding pain - Good videos to show to patients (see links below)

Arthritis Research UK - exercises and useful advice (see link below)

Arthritis Research UK - Patient information - What should I know about back pain?

Drugs and the driving law

NICE - patient information

Sheffield back pain - patient information

The Pain toolkit – self-management website for people in chronic pain, wide ranging resource with details of the pain cycle, patient videos as well as guidance for health care professionals.

Evidence

McCullough BJ, Johnson GR, Brook MI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012; 262: 941-946.

Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-1571

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: February 2019

 

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