How can I effectively manage a patient with chronic low back pain before considering surgical options?

Effective management of a patient with chronic low back pain before considering surgical options involves a comprehensive non-surgical approach focused on assessment, self-management, physical activity, psychological support, and cautious use of medications.

Assessment and Risk Stratification: Begin with a thorough assessment to exclude serious underlying causes and use risk stratification tools (e.g., STarT Back) to guide management intensity and shared decision-making.

Non-Pharmacological Management: Encourage self-management with tailored advice and information about the nature of low back pain and the importance of continuing normal activities. Promote regular exercise through group exercise programmes (biomechanical, aerobic, mind-body, or combined approaches) considering the patient's preferences and capabilities. Consider referral to physiotherapy for manual therapy (spinal manipulation, mobilisation, or massage) as part of a package including exercise. For patients with significant psychosocial barriers or persistent symptoms, offer psychological therapies using a cognitive behavioural approach, alone or combined with physical therapies. Facilitate return to work or normal daily activities.

Pharmacological Management: Use oral non-steroidal anti-inflammatory drugs (NSAIDs) as first-line pharmacological treatment at the lowest effective dose for the shortest duration, considering gastrointestinal, liver, and cardio-renal risks and using gastroprotection if indicated. Avoid paracetamol alone, opioids, gabapentinoids, antiepileptics, antidepressants, benzodiazepines, and muscle relaxants for chronic low back pain due to lack of evidence of benefit and potential harms.

Interventional and Surgical Considerations: Do not offer spinal injections or surgery unless specific indications arise. Consider referral for radiofrequency denervation only after non-surgical treatments have failed and diagnostic medial branch block is positive. Surgical options such as spinal decompression may be considered for sciatica with consistent radiological findings after failed non-surgical treatment, but spinal fusion and disc replacement are not recommended outside trials.

This approach ensures that surgery is reserved for patients who have not responded to comprehensive conservative management, optimising outcomes and minimizing unnecessary surgical risks.

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