Management of acute simple low back pain

Assessment of low back pain and sciatica

Alternative diagnoses

• consider alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop new or changed symptoms
  • exclude specific causes of low back pain, for example, cancer, infection, trauma or inflammatory disease such as spondyloarthritis

Risk assessment and risk stratification tools

• consider using risk stratification (for example, the STarT Back risk assessment tool) at first point of contact with a healthcare professional for each new episode of low back pain with or without sciatica to inform shared decision-making about stratified management
• based on risk stratification, consider:
  • simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)
  • more complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor outcome (for example, exercise programmes with or without manual therapy)

Imaging

• do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica
• explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging
• consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management

Non-invasive treatments for low back pain and sciatica

• self-management
• consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica
• promote and facilitate return to work or normal activities of daily living for people with low back pain with or without sciatica

Pharmacological management of low back pain

• consider oral NSAIDs for managing low back pain, taking into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age
• when prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
• prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period of time
• consider weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective
• do not offer paracetamol alone for managing low back pain
• do not routinely offer opioids for managing acute low back pain
• do not offer opioids for managing chronic low back pain
• do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain
• do not offer gabapentinoids or antiepileptics for managing low back pain

Invasive treatments for low back pain

• do not offer spinal injections for managing low back pain
• radiofrequency denervation
  • consider referral for assessment for radiofrequency denervation for people with chronic low back pain when:
    • non-surgical treatment has not worked for them and
    • the main source of pain is thought to come from structures supplied by the medial branch nerve and
    • they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral
  • only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block
  • do not offer imaging for people with low back pain with specific facet join pain as a prerequisite for radiofrequency denervation
• do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial
• do not offer disc replacement in people with low back pain

Notes:

• acute low back pain is less than 3 months duration; and chronic low back pain is 3-month duration or longer

Reference:

1. NICE (July 2026). Low back pain and sciatica in over 16s: assessment and management