Low back pain and sciatica

This is an updated guideline from NICE on the management of low back pain and sciatica. There is quite a bit that is new in this guideline, but it probably doesn't really add much to our current management. The biggest change is that they don't advise the use of paracetamol on its own.

Risk stratify patients:

  • Use a tool like the STarT Back tool.
  • Low risk - less intensive support (eg advice on return to activities, reassurance, self-management).
  • Higher risk - more intensive support (eg exercise as below).

Non-Invasive Treatments


They advise a group exercise programme referral. Looking at the full guideline, this is because it is cheaper than individual exercise. There is no evidence that one form of exercise is more effective than another.

Manual therapies

Consider a referral for this alongside exercise, with or without psychological therapy (see below). This includes massage and spinal manipulation. Again the full guideline advises that there is no evidence that massage is effective, but acknowledges that there is a placebo effect. There may be limited clinical benefit from manipulation. Hence the advice not to refer to these on their own.

Psychological therapies

Consider CBT alongside exercise, with or without manual therapy. This is especially the case for people with chronic symptoms with psychological barriers to recovery (eg avoidance of normal activities).

Do NOT offer

  • Orthotics
  • Ultrasound
  • Acupuncture
  • TENS

Pharmacological management

Sciatica -

As per NICE neuropathy guideline.

Low back pain

NSAIDs  - consider

Opioids - only weak ones and only if you can't use NSAIDs, or they are ineffective. Consider adding in paracetamol with them.

Do NOT use:

  • Paracetamol on its own.
  • Opioids routinely.
  • Opioids for chronic back pain.
  • Anticonvulsants or antidepressants.

Secondary Care Management

  • Radio-frequency denervation may be suitable in some cases.
  • Epidurals can be considered for acute severe sciatica.
  • Do NOT use spinal injections.
  • Spinal decompression can be considered for sciatica which hasn't responded to non-surgical treatment.