Executive summary
- Imaging: Do NOT offer X-ray/MRI for non-specific low back pain. Imaging is only for red flags or if the result will change management (e.g. surgery).
- Risk Stratification: Use the STarT Back tool to stratify into Low, Medium, or High risk of chronicity.
- Sciatica: Distinguish from non-specific pain. Neuropathic agents (Amitriptyline/Gabapentin) are for sciatica, NOT simple back pain.
Red Flags (Cauda Equina)
- Ask every patient:
- Difficulty passing urine (retention) or loss of sensation when passing.
- Faecal incontinence or loss of sensation.
- Saddle anaesthesia (numbness in anus/genitals/buttocks).
- Bilateral severe sciatica or progressive motor weakness.
- Action: If suspected -> Emergency Refer (A&E) for urgent MRI. Time is spine.
Management Steps
- 1. Non-Specific Low Back Pain:
- Movement: Stay active. Bed rest is harmful.
- Pharmacology: Oral NSAIDs (Naproxen 500mg bd + PPI) are first line. Do not offer Paracetamol alone. Do not offer Opioids routiney.
- Physio: Group exercise (biomechanical/aerobic/mind-body) is the core intervention.
- 2. Sciatica (Neuropathic):
- Amitriptyline: 10mg nocte -> Titrate to 25-50mg. (First line).
- Gabapentin: 300mg od (Day 1) -> 300mg bd (Day 2) -> 300mg tds (Day 3). Titrate to max 1200mg tds. (Controlled drug risk).
- Pregabalin: 75mg bd -> Max 300mg bd. (Controlled drug risk).
- Epidural: Consider referral for epidural injection if severe/refractory.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.