Back pain – NICE guidelines

This is the BMJ Learning module I started when I was trying to look up red flags for back pain; as promised, I’ve now gone back to finish the module.

Guidelines recommend using the STarTBack questionnaire for identifying risk of ongoing problems and targeting higher levels of physio towards them; this is supposed to be more cost-effective. However, when I checked out the study in question, I found that all participants still received a basic level of intervention (30-minute assessment, 15-minute video, and a copy of The Back Book produced by the RCGP) that’s beyond what we’d be able to manage as GPs, so it strikes me it would make far more sense for us to continue referring anyone whose pain isn’t settling in short order to the physiotherapists and for them to do the STartTBack assessment.

Prescription-wise, we’re limited. Paracetamol don’t help and have more long-term risks than we previously acknowledged. NSAIDs are first line; weak opioids are second-line where NSAIDs don’t work, aren’t tolerated, or are contraindicated. Opioids should be avoided in chronic low back pain (not helpful, risk of addiction), as should anything designed to work on neurological pain. This leaves us with the option of telling patients to go away because we’re not going to prescribe anything, which is a lot easier said than done.

According to a Cochrane review, there is evidence, not of brilliant quality, that exercise is of some help in chronic back pain.

Recommendations are for ‘manual therapy’, which can include physio, osteopathy and chiropractic and ideally includes a combination of therapies used holistically in combination with advice on getting back to work. Acupuncture is not now recommended as it only has a placebo effect. Though, of course, a placebo effect isn’t to be sneezed at.

In the case of sciatica, surgical treatment actually gives similar results to conservative treatment in the long term; the only difference is that it gives the results more quickly. For LBP, surgery is not recommended except as part of an RCT; there isn’t enough evidence of benefit to outweigh the significant potential harms.

Spinal injections aren’t recommended for LBP by NICE guidance; the evidence of benefit isn’t clear, and there are potential harms.

There is one useful treatment I hadn’t heard of; where the pain arises from the facet joints, radiofrequency denervation (in which the nerves leading to the facet joints are ablated) can be useful. The problem is that there is no clinical way of telling which back pains arise from the facet joints. Therefore, the best approach seems to be to try a local anaesthetic block of the facet joints in patients with LBP who haven’t responded to other approaches, and try RFD if that works.

About Dr Sarah

I'm a GP with a husband and two young children.
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