Low back pain / Sciatica

Common - can usually be managed in primary care. However, patients with cauda equina manifestations such as perineal anaesthesia or new bladder or bowel symptoms require urgent same day assessment by a specialist spinal surgery team.

In other circumstances, consider referral:

1. Progressive, persistent or severe neurological deficit (refer neurosurgery or orthopaedics)

2. Pain or disability remains problematic despite self-help measures and simple analgesia (refer for physiotherapy or other physical therapies)

3. Radicular symptoms are still disabling or distressing after six weeks (consider MRI if direct GP access is available, and/or referral for specialist assessment)

Resources

• Low back pain and sciatica in over 16s: assessment and management (NICE NG59)

• Back pain (NHS Choices), Back pain (Arthritis Research UK), STarT Back Screening Tool (Keele University), Teenagers with back pain (BMJ, 2015)

• Sciatica / Cauda equina syndrome: Sciatica (NHS Choices), Sciatica - lumbar radiculopathy (CKS), Slipped disc (NHS Choices)

Red flags

Serious conditions whose signs/sx may overlap with sciatica:

Cauda equina syndrome, consider if:

• • Bilateral sciatica

  • Severe or progressive bilateral neuro deficit of the legs e.g. major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.

  • Difficulty initiating micturition or impaired sensation of urinary flow (untreated may lead to irreversible urinary retention with overflow urinary incontinence)

  • Loss of sensation of rectal fullness (untreated may lead to irreversible faecal incontinence)

  • Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia).

  • Laxity of the anal sphincter (consider assessment of anal tone but may not need to be performed in primary care)

Spinal fracture, consider if:

• • Sudden onset of severe central spinal pain relieved by lying down

  • H/o major trauma (e.g. RTA or fall from a height), minor trauma, or even just strenuous lifting (if osteoporosis or corticosteroid use)

  • Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra)

  • Point tenderness over a vertebral body.

Cancer, consider if:

• • Age≥ 50Y

  • Gradual onset

  • Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain

  • Localised spinal tenderness

  • No improvement after 4-6W of conservative LBP therapy

  • Unexplained weight loss

  • PMH of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine

Infection (such as discitis, vertebral osteomyelitis, or spinal epidural abscess), consider if:

• • Fever

  • TB, or recent UTI

  • DM

  • History of IVDU

  • HIV, immunosuppressant use, other immunocompromise

Spinal infections are difficult to diagnose due to the subtle onset of symptoms and low specificity of signs. Back pain and fevers should raise suspicion of a spinal infection. A spinal fracture is less likely if able to has move, there is no spinal tenderness and no history of trauma.

Chronic (>3M)

• Manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) as options for managing LBP +/- sciatica, but only as part of a treatment package including exercise +/- psychological therapy

Cauda equina syndrome

• Cauda equina (Latin: horse's tail): Lower end of the spinal cord is at L1-2. The nerves then form the conus medullaris, then continue to branch out below to form the cauda equina. Carries nerves which control the bladder and bowel. movement of the legs, and nerves which sense light touch and pain in the legs or around the back passage (perineum).

• Cauda equina syndrome: pressure on the nerves at the very bottom of the spinal cord

• Cauda equina syndrome (patient.info), Cauda equina syndrome: implications for primary care (BJGP, 2014)

​Central spinal stenosis

• Combined physical and psychological programme. Acupuncture and transcutaneous electrical nerve stimulation not recommended. Morphine is not ideal for back pain and is very addictive. Steroid injections are not recommended for people with central spinal stenosis.

• Neurogenic claudication associated with spinal stenosis - may mimic PVD; pain in thigh/buttock after walking, relieved by rest and lumbar flexion (e.g. leaning forward on walking stick). ABPI normal

Coccydynia

• Coccydynia - tailbone pain (NHS Choices)

Ankylosing spondylitis

• LBP and stiffness - worse in the morning (about an hour) - tends to improve over the course of the day and with exercise. Raised ESR/CRP. Refer rheumatology

• Spondyloarthritis in Over 16s: diagnosis and management (NG65, 2017), Ankylosing spondylitis (NHS Choices), Ankylosing spondylitis (CKS)

Kyphosis / Scoliosis

• Kyphosis (NHS Choices), Scoliosis (NHS Choices)

Spondylolisthiasis

• Spondylolisthiasis (NHS Choices)

Spina bifida

• Spina bifida (NHS Choices)

Spinal muscular atrophy​

• Spinal muscular atrophy (NHS Choices)