The ratings in parentheses indicate the
scientific evidence supporting each recommendation according to the following
scale:
A = strong research-based evidence (multiple
relevant and high-quality scientific studies).
B = moderate research-based evidence
(one relevant, high-quality scientific study or multiple adequate scientific
studies).
C = limited research-based evidence (at
least one adequate scientific study in patients with low back pain).
D = panel interpretation of evidence
not meeting inclusion criteria for research-based evidence.
The number of studies meeting panel review
criteria is noted for each category.
ACTION |
RECOMMEND |
OPTION |
RECOMMEND AGAINST |
History and physical exam
34 studies |
- Basic history (B).
- History of cancer/ infection (B).
- Signs/symptoms of cauda equina syndrome (C).
- History of significant trauma (C).
- Psychosocial history (C).
- Straight leg raising text (B).
- Focused neurological exam (B).
|
Pain drawing and visual analog scale (D). |
|
Patient education
14 studies |
- Patient education about low back symptoms (B).
- Back school in occupational settings (C).
|
Back school in nonoccupational settings (C). |
|
Medication
23 studies |
Acetaminophen (C).
NSAIDs (B). |
Muscle relaxants (C).
Opioids, short course (C). |
Opioids used > 2wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C). |
Physical treatment methods
42 methods |
Manipulation of low back during first month of symptoms (B). |
- Manipulation for patients with radiculopathy (C).
- Manipulation for patients with symptoms > 1 month (C).
- Self-application of heat or cold to low back.
- Shoe insoles (C).
- Corset for prevention in occupational setting (C).
|
- Manipulation for patients with undiagnosed neurologic deficits (D).
- Prolonged course of manipulation (D).
- Traction (B).
- TENS (C).
- Biofeedback (C).
- Shoe lifts (D).
- Corset for treatment (D).
|
Injections
26 studies |
|
Epidural steroid injections for radicular pain to avoid surgery (C). |
- Epidural injections for back pain without radiculopathy (D).
- Trigger point injections (C).
- Ligamentous injections (C).
- Facet joint injections (C).
- Needle acupuncture (D).
|
Bed rest
4 studies |
|
Bed rest of 2-4 days for severe radiulopathy (D). |
Bed rest > 4 days (B). |
Activities and exercise 20 studies |
- Temporary avoidance of activities that increase mechanical stress on
spine (D).
- Gradual return to normal activities (B).
- Low-stress aerobic exercise (C).
- Conditioning exercises for trunk mescles after 2 weeks (C).
- Exercise quotas (C).
|
|
- Back-specific exercise machines (D).
- Therapeutic stretching of back muscles (D).
|
Detection of physiologic abnormalities
14 studies |
- If no improvement after 1 month, consider:
- Bone scan (C).
- Needle EMG and H-reflex tests to clarify nerve root dysfunction (C).
- SEP to assess spinal stenosis (C).
|
|
- EMG for clinically obvious radiculopathy (D).
- Surface EMG and F-wave tests (C).
- Thermography (C).
|
X-rays of L-S spine
18 studies |
When red flags for fracture present (C).
When red flags for cancer or infection present (C). |
|
Routine use in first month of symptoms in absence of red flags (B).
Routine oblique views (B). |
Imaging
18 studies |
- CT or MRI when cauda equina, tumor, infection, or fracture stongly
suspected (C).
- MRI text of choice for patients with prior back surgery (D).
- Assure quality criteria for imaging tests (B).
|
Myelography or CT-myleography for preoperative planning (D). |
Use of imaging test before one month in absence red flags (B).
Discography or CT-discography (C). |
Surgical considerations
14 studies |
- Discuss surgical options with patients with persistent and severe sciatica
and clinical evidence of nerve root compromise after 1 month of conservative
therapy (B).
- Standard discectomy and microdiscectomy of similar efficacy in treatment
of herniated disc (B).
- Chymopapain, used after ruling out allergic sensitivity, acceptable
but less efficacious than discectomy to treat herniated disc (C).
|
|
- Disc surgery in patients with back pain alone, no red flags, and no
nerve root compression (D).
- Percutaneous discectomy less efficacious than chymopapain (C).
- Surgery for spinal stenosis within the first 3 months of symptoms (D).
- Stenosis surgery when justified by imaging test rather than patient's
functional status (D).
- Spinal fusion during the first 3 months of symptoms in the absence
of fracture, dislocation, complications of tumor or infection (C).
|
Psychosocial factors |
Social, economic, and psychological factors can alter patient response to
symptoms and treatment (D). |
|
Referral for extensive evaluation/treatment prior to exploring patient expectations
or psychosocial factors (D). |
Table 5. Summary of Guideline Recommendations
The ratings in parentheses indicate the
scientific evidence supporting each recommendation according to the following
scale:
A = strong research-based evidence (multiple
relevant and high-quality scientific studies).
B = moderate research-based evidence
(one relevant, high-quality scientific study or multiple adequate scientific
studies).
C = limited research-based evidence (at
least one adequate scientific study in patients with low back pain).
D = panel interpretation of evidence
not meeting inclusion criteria for research-based evidence.
The number of studies meeting panel review
criteria is noted for each category.
ACTION |
RECOMMEND |
OPTION |
RECOMMEND AGAINST |
History and physical exam
34 studies |
- Basic history (B).
- History of cancer/ infection (B).
- Signs/symptoms of cauda equina syndrome (C).
- History of significant trauma (C).
- Psychosocial history (C).
- Straight leg raising text (B).
- Focused neurological exam (B).
|
Pain drawing and visual analog scale (D). |
|
Patient education
14 studies |
- Patient education about low back symptoms (B).
- Back school in occupational settings (C).
|
Back school in nonoccupational settings (C). |
|
Medication
23 studies |
Acetaminophen (C).
NSAIDs (B). |
Muscle relaxants (C).
Opioids, short course (C). |
Opioids used > 2wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C). |
Physical treatment methods
42 methods |
Manipulation of low back during first month of symptoms (B). |
- Manipulation for patients with radiculopathy (C).
- Manipulation for patients with symptoms > 1 month (C).
- Self-application of heat or cold to low back.
- Shoe insoles (C).
- Corset for prevention in occupational setting (C).
|
- Manipulation for patients with undiagnosed neurologic deficits (D).
- Prolonged course of manipulation (D).
- Traction (B).
- TENS (C).
- Biofeedback (C).
- Shoe lifts (D).
- Corset for treatment (D).
|
Injections
26 studies |
|
Epidural steroid injections for radicular pain to avoid surgery (C). |
- Epidural injections for back pain without radiculopathy (D).
- Trigger point injections (C).
- Ligamentous injections (C).
- Facet joint injections (C).
- Needle acupuncture (D).
|
Bed rest
4 studies |
|
Bed rest of 2-4 days for severe radiulopathy (D). |
Bed rest > 4 days (B). |
Activities and exercise 20 studies |
- Temporary avoidance of activities that increase mechanical stress on
spine (D).
- Gradual return to normal activities (B).
- Low-stress aerobic exercise (C).
- Conditioning exercises for trunk mescles after 2 weeks (C).
- Exercise quotas (C).
|
|
- Back-specific exercise machines (D).
- Therapeutic stretching of back muscles (D).
|
Detection of physiologic abnormalities
14 studies |
- If no improvement after 1 month, consider:
- Bone scan (C).
- Needle EMG and H-reflex tests to clarify nerve root dysfunction (C).
- SEP to assess spinal stenosis (C).
|
|
- EMG for clinically obvious radiculopathy (D).
- Surface EMG and F-wave tests (C).
- Thermography (C).
|
X-rays of L-S spine
18 studies |
When red flags for fracture present (C).
When red flags for cancer or infection present (C). |
|
Routine use in first month of symptoms in absence of red flags (B).
Routine oblique views (B). |
Imaging
18 studies |
- CT or MRI when cauda equina, tumor, infection, or fracture stongly
suspected (C).
- MRI text of choice for patients with prior back surgery (D).
- Assure quality criteria for imaging tests (B).
|
Myelography or CT-myleography for preoperative planning (D). |
Use of imaging test before one month in absence red flags (B).
Discography or CT-discography (C). |
Surgical considerations
14 studies |
- Discuss surgical options with patients with persistent and severe sciatica
and clinical evidence of nerve root compromise after 1 month of conservative
therapy (B).
- Standard discectomy and microdiscectomy of similar efficacy in treatment
of herniated disc (B).
- Chymopapain, used after ruling out allergic sensitivity, acceptable
but less efficacious than discectomy to treat herniated disc (C).
|
|
- Disc surgery in patients with back pain alone, no red flags, and no
nerve root compression (D).
- Percutaneous discectomy less efficacious than chymopapain (C).
- Surgery for spinal stenosis within the first 3 months of symptoms (D).
- Stenosis surgery when justified by imaging test rather than patient's
functional status (D).
- Spinal fusion during the first 3 months of symptoms in the absence
of fracture, dislocation, complications of tumor or infection (C).
|
Psychosocial factors |
Social, economic, and psychological factors can alter patient response to
symptoms and treatment (D). |
|
Referral for extensive evaluation/treatment prior to exploring patient expectations
or psychosocial factors (D). |