Guideline sources The following summarized guidelines for the evaluation and management of low back pain (LBP) are prepared by our editorial team based on guidelines from the American Society of Pain and Neuroscience (ASPN 2022), the American College of Occupational and Environmental Medicine (ACOEM 2021), the American College of Radiology (ACR 2021), the North American Spine Society (NASS 2020), the American Academy of Physical Medicine and Rehabilitation (AAPMR 2019), the American Association of Family Physicians (AAFP 2019), the American College of Physicians (ACP 2017), the National Institute for Health and Care Excellence (NICE 2017), the American Pain Society (APS 2009), and the American Pain Society (APS/ACP 2007). 1 2 3 4 5 6 7 8 9 10 Guidelines https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 1/16 6/29/23, 6:02 AM Low back pain Pathway 1. Screening and diagnosis Differential diagnosis: As per NASS 2020 guidelines, consider suspecting a non-structural cause of LBP in patients with diffuse LBP and tenderness. C As per NICE 2017 guidelines, exclude specific causes of LBP (such as cancer, infection, trauma, or inflammatory disease such as spondyloarthritis) when assessing patients with LBP, particularly if a change in symptoms occurs. E 2. Classification and risk stratification Risk stratification: consider obtaining risk stratification using validated instruments, such as the STarT Back risk assessment tool, at the first point of contact with a healthcare professional, in order to inform shared decision-making about stratified management. C Prognosis: As per NASS 2020 guidelines, recognize that history of LBP is a potential predictor of recurrence and conversion from acute to chronic LBP. B Show 3 more As per ACP 2007 guidelines, assess psychosocial risk factors to predict the risk for chronic disabling back pain. B 3. Diagnostic investigations Clinical history and pysical examination: As per NASS 2020 guidelines, insufficient evidence to recommend for or against the use of the following: fear avoidance behavior to determine the likelihood of a structural cause innominate movement patterns for the assessment of sacroiliac joint pain presence of diffuse back tenderness for the prediction of the presence of disc degeneration on radiographs assessment of centralization or peripheralization for the prediction of discography results pain localization in predicting response to a diagnostic injection. I As per APS 2007 guidelines, elicit a focused medical history and perform a physical examination to categorize patients with LBP into one of the following broad categories: nonspecific LBP back pain potentially associated with radiculopathy or spinal stenosis back pain potentially associated with another specific spinal cause. B Diagnostic imaging: https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 2/16 6/29/23, 6:02 AM Low back pain Pathway As per ACR 2021 guidelines, do not obtain routine imaging in patients with acute, subacute, or chronic LBP (with or without radiculopathy) with no red flags and no prior management. D Show 5 more As per NASS 2020 guidelines, insufficient evidence to recommend for or against obtaining imaging in the absence of red flags. I Show 4 more As per AAFP 2019 guidelines, do not obtain diagnostic imaging for LBP within the first 6 weeks, unless red flags are present. D As per AAPMR 2019 guidelines, do not obtain diagnostic imaging for LBP without performing a thorough physical examination. D As per NICE 2017 guidelines, avoid obtaining routine imaging in patients with LBP with or without sciatica presenting in a non-specialist setting. D As per APS 2007 guidelines, do not obtain routine imaging or other diagnostic tests in patients with nonspecific LBP. D Show 2 more Laboratory testing: insufficient evidence to recommend for or against obtaining laboratory tests to assess for inflammatory disease in patients with sacroiliac joint pain. I Electromyography: do not obtain EMG for LBP unless there is leg pain or sciatica. D Psychosocial evaluation: Obtain psychological evaluation as part of the evaluation and management of patients with chronic pain in order to identify psychosocial barriers contributing to disability and inhibiting function and to assess whether psychological factors will need to be considered and treated as part of the overall treatment plan. A Consider obtaining psychological evaluation in patients with moderate-to-severe chronic pain with the following indications: observed or suspected significant psychosocial dysfunction to determine psychosocial factors contributing to the patient's pain reports and disability behaviors inadequate recovery, including continued dysfunctional status despite a duration exceeding the typical course of recovery, failure to benefit from indicated therapies or to return to work when medically indicated, a persistent pain problem inadequately explained by the patient's physical findings medication and/or drug issues, including any suspicion of drug overuse or misuse, aberrant drug behavior, substance abuse, addiction, or use of illicit substances, or for consideration of chronic use of opioids current or premorbid history of major psychiatric symptoms or disorder problems with compliance/adherence with prescribed medical treatment or rehabilitation program: for the evaluation of candidacy for or potential benefit from a proposed functional https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 3/16 6/29/23, 6:02 AM Low back pain Pathway restoration program, such as comprehensive occupational rehabilitation or interdisciplinary pain rehabilitation evidence of possible cognitive impairment associated with related significant activities of daily living dysfunction (secondary to injury and/or possible adverse effects of medical therapies initiated for chronic pain) catastrophic injuries with significant pain-related or other dysfunction, such as spinal cord injury for certain procedures, if contemplated, such as back surgery or spinal cord stimulation. B 4. Diagnostic procedures Provocative discography: As per NASS 2020 guidelines, recognize that provocative discography without manometric measurements correlates with pain reproduction in the presence of moderate-to-severe disc degeneration on MRI/CT discography and with the presence of endplate abnormalities on MRI. A Show 3 more As per APS 2009 guidelines, do not perform provocative discography for the diagnosis of discogenic LBP in patients with chronic nonradicular LBP. D Diagnostic nerve blocks: As per ACOEM 2021 guidelines, do not perform diagnostic medial branch blocks for acute or subacute LBP or radicular pain syndromes. D As per NASS 2020 guidelines: Insufficient evidence to recommend for or against uncontrolled medial branch blocks versus pericapsular blocks for the diagnosis of zygapophyseal joint pain based on the outcomes of medial branch nerve cryoablation. I Insufficient evidence to recommend for or against the use of a 50% reduction in pain following medial branch blockade for the diagnosis of zygapophyseal joint pain. I As per APS 2009 guidelines, insufficient evidence to recommend diagnostic selective nerve root block, intra-articular facet joint block, medial branch block, or sacroiliac joint block in patients with LBP (with or without radiculopathy). I 5. Medical management General principles: As per NICE 2017 guidelines: Consider providing simpler and less intensive support in patients with LBP (with or without sciatica) likely to improve quickly and have a good outcome. E Consider providing more complex and intensive support in patients with LBP (with or without sciatica) at higher risk of a poor outcome, such as exercise programs with or without manual https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 4/16 6/29/23, 6:02 AM Low back pain Pathway therapy or using a psychological approach. E As per ACP 2007 guidelines: Assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. Consider offering medications with proven benefits in conjunction with back care information and self-care. B Consider adding nonpharmacologic therapy with proven benefits (for acute LBP, spinal manipulation; for chronic or subacute LBP, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation) in patients not responding to self-care options. C Topical capsaicin: offer topical capsicum on a short-term basis ( 3 months) in patients with LBP. A Topical lidocaine: insufficient to recommend for or against the use of lidocaine patch for the treatment of LBP. A Nonsteroidal anti-inflammatory drugs: As per NASS 2020 guidelines: Consider prescribing nonselective NSAIDs for the treatment of LBP. C Insufficient evidence to recommend for or against the use of selective NSAIDs for the treatment of LBP. I As per ACP 2017 guidelines, prescribe NSAIDs, if pharmacotherapy is desired, as first-line therapy in patients with acute, subacute, B or chronic LBP. B As per NICE 2017 guidelines: Consider prescribing oral NSAIDs in patients with LBP, taking into account the patient's risk factors, including age, and potential differences in gastrointestinal, hepatic, cardiac, and renal toxicities. C Do not use acetaminophen alone for the management of LBP. D Muscle relaxants: offer skeletal muscle relaxants, If pharmacologic treatment is desired, in patients with acute or subacute LBP. B Opioids: As per NASS 2020 guidelines, consider limiting the use of opioids and restricting their use to short duration for the treatment of LBP. C As per AAPMR 2019 guidelines, do not prescribe opioids in patients with acute disabling LBP before evaluation and a trial of other alternatives. D As per ACP 2017 guidelines, consider offering tramadol as second-line therapy in patients with chronic LBP with an inadequate response to nonpharmacologic therapy and NSAIDs and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. C As per NICE 2017 guidelines: Consider prescribing weak opioids (with or without acetaminophen) for the managing of acute LBP, only if NSAIDs are contraindicated, not tolerated, or have been ineffective. E https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 5/16 6/29/23, 6:02 AM Low back pain Pathway Do not use opioids for the management of chronic LBP. D Corticosteroids: avoid using oral or IV corticosteroids for the treatment of LBP. D Antidepressants: As per NASS 2020 guidelines, do not use antidepressants for the treatment of LBP. D As per ACP 2017 guidelines, consider offering duloxetine as second-line therapy in patients with chronic LBP with an inadequate response to nonpharmacologic therapy and NSAIDs. C Anticonvulsants: insufficient to recommend for or against the use of anticonvulsants for the treatment of LBP. A Ketamine: do not use ketamine infusions for the treatment of chronic LBP. D Vitamin D: insufficient to recommend for or against the use of vitamin D for the treatment of LBP. A 6. Nonpharmacologic interventions Physical therapy: As per NASS 2020 guidelines, offer back school to provide improvements in pain and function in patients with chronic LBP. A Show 3 more As per ACP 2017 guidelines: Offer exercise and multidisciplinary rehabilitation programs as initial therapy in patients with chronic LBP. B Consider offering tai-chi, yoga, motor control exercise, or progressive relaxation in patients with chronic LBP. B As per NICE 2017 guidelines: Consider offering a group exercise program (including biomechanical, aerobic, mind-body, or a combination of approaches) in patients with a specific episode or flare-up of LBP with or without sciatica, taking into account the patient's specific needs, preferences, and capabilities. C Consider offering a combined physical and psychological program incorporating a cognitive- behavioral approach (preferably in a group context taking into account the patient's specific needs and capabilities) in patients with persistent LBP or sciatica if there are substantial psychosocial obstacles to recovery (such as avoiding normal activities based on inappropriate beliefs about their condition) or previous treatments have not been effective. C Activity modifications, bed rest: As per NASS 2020 guidelines, advise remaining active over bed rest for better short-term outcomes in patients with nonspecific back pain. E As per AAPMR 2019 guidelines, do not advise bed rest for acute localized back pain without completing a thorough evaluation. D https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 6/16 6/29/23, 6:02 AM Low back pain Pathway Activity modifications (work-hardening programs): consider offering work hardening to improve return to work in patients with LBP, although insufficient evidence that work hardening is different than an active exercise program or guideline-based physical therapy. C Local heat: As per NASS 2020 guidelines, consider offering local heat application for short-term improvement of acute LBP. C As per ACP 2017 guidelines, offer application of superficial heat for acute or subacute LBP. B Mechanical traction: do not offer traction to improve pain or function in patients with subacute or chronic LBP. D Bracing: insufficient evidence to support the use of bracing to improve pain or function in patients with subacute LBP. I Psychosocial interventions: As per NASS 2020 guidelines, offer CBT in combination with physical therapy to improve pain levels in patients with LBP lasting > 12 months. A Show 7 more As per ACP 2017 guidelines, offer mindfulness-based stress reduction B , cognitive-behavioral therapy, or operant therapy in patients with chronic LBP. B As per NICE 2017 guidelines: Consider offering psychological therapies using a cognitive-behavioral approach but only as part of a treatment strategy including exercise for the management of LBP with or without sciatica. C Consider offering a combined physical and psychological program incorporating a cognitive- behavioral approach (preferably in a group context taking into account the patient's specific needs and capabilities) in patients with persistent LBP or sciatica if there are substantial psychosocial obstacles to recovery (such as avoiding normal activities based on inappropriate beliefs about their condition) or previous treatments have not been effective. C As per APS 2009 guidelines: Consider offering an intensive interdisciplinary rehabilitation program with a cognitive- behavioral emphasis in patients with nonradicular LBP not responding to usual, noninterdisciplinary interventions. B Counsel patients with persistent and disabling back pain despite recommended noninterdisciplinary therapies about interdisciplinary rehabilitation programs (defined as an integrated intervention with rehabilitation plus a psychological and/or social/occupational component). Alternative and complementary medicine, manual therapy: As per NASS 2020 guidelines: Consider offering spinal manipulative therapy to improve pain and function in patients with acute or chronic LBP. C Insufficient evidence to recommend 12-18 over 6 visits of spinal manipulative therapy. B https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 7/16 6/29/23, 6:02 AM Low back pain Pathway Insufficient evidence to recommend the addition of massage to an exercise program for improvement in pain in patients with LBP. I As per ACP 2017 guidelines, consider offering spinal manipulation in patients with chronic LBP. B As per ACP 2017 guidelines, consider offering spinal manipulation or massage therapy in patients with acute or subacute LBP. B As per NICE 2017 guidelines, consider offering manual therapy (manipulation, mobilization, or soft tissue techniques such as massage) but only as part of a treatment strategy including exercise in patients with LBP with or without sciatica. C Alternative and complementary medicine, acupuncture and acupressure: As per NASS 2020 guidelines, offer acupuncture in addition to usual care for short-term improvement of pain and function in patients with chronic LBP. A Show 2 more As per ACP 2017 guidelines, consider offering acupuncture in patients with acute, subacute B , or chronic LBP. B As per NICE 2017 guidelines, do not offer acupuncture for the management of LBP with or without sciatica. D Alternative and complementary medicine (dry needling): insufficient evidence to recommend for or against dry needling in patients with chronic LBP. I Alternative and complementary medicine (therapeutic ultrasound): avoid offering ultrasound to improve functional outcomes in patients with chronic LBP. D Alternative and complementary medicine, laser therapy: As per NASS 2020 guidelines, consider offering laser therapy (low- or high-level) in addition to exercise for better short-term relief of pain, but not in function, in patients with LBP. C As per ACP 2017 guidelines, consider offering low-level laser therapy in patients with chronic LBP. B Alternative and complementary medicine (electromyographic biofeedback): consider offering electromyographic biofeedback in patients with chronic LBP. B 7. Therapeutic procedures Epidural injections: As per ACOEM 2021 guidelines, offer epidural corticosteroid injections in selected circumstances for the treatment of acute or subacute radicular pain syndromes, typically after treatment with NSAIDs and waiting at least 3 weeks. A Show 5 more As per NASS 2020 guidelines, insufficient evidence to recommend for or against the use of caudal epidural or interlaminar corticosteroid injections in patients with LBP. I https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 8/16 6/29/23, 6:02 AM Low back pain Pathway As per NICE 2017 guidelines, consider epidural injections of local anesthetic and steroids in people with acute and severe sciatica. C As per APS 2009 guidelines, insufficient evidence to recommend epidural corticosteroid injections in patients with nonradicular LBP. I Intrathecal injections: As per ASPN 2022 guidelines: Consider offering intrathecal drug delivery in patients with chronic refractory pain of spinal origin C , refractory failed back surgery syndrome, and B chronic non-cancer pain. C Ensure shared decision-making if contemplating intrathecal drug therapy in patients with multiple comorbidities affecting cardiopulmonary function, hematopoietic function, or central nervous function. B As per APS 2009 guidelines, insufficient evidence to recommend intrathecal injections with opioids or other medications in patients with nonradicular LBP. I Facet joint injections: As per ASPN 2022 guidelines, do not offer intra-articular facet corticosteroid injections to replace or delay the need for radiofrequency ablation. D Show 3 more As per ACOEM 2021 guidelines, do not perform diagnostic facet joint injections for the evaluation of patients with acute, subacute, D , or chronic LBP, or radicular pain syndromes, even if the pain is significantly exacerbated by extension and rotation or associated with lumbar rigidity. D Show 3 more As per NASS 2020 guidelines, avoid administering intra-articular corticosteroid injections in patients selected for facet joint procedures using diagnostic criteria of physical exam and a response to a single diagnostic intra-articular injection with 50% relief. D Show 3 more As per APS 2009 guidelines, do not offer facet joint corticosteroid injections in patients with persistent nonradicular LBP. D Sacroiliac joint injections: As per ASPN 2022 guidelines, consider offering sacroiliac joint injections for short-term relief of sacroiliac joint dysfunction. C As per ACOEM 2021 guidelines: Offer corticosteroid injections as a treatment option in patients with a specific known cause of sacroiliitis (proven rheumatologic inflammatory arthritis, such as rheumatoid arthritis, ankylosing spondylitis, involving the sacroiliac joints) with symptoms of at least 1-2 months and prior treatment that has included NSAIDs. B Do not perform sacroiliac joint injections for the treatment of acute LBP (including pain thought to be sacroiliac joint-related) subacute or chronic non-specific LBP (including pain attributed to the sacroiliac joints) but without evidence of inflammatory sacroiliitis (rheumatologic disease) or any radicular pain syndrome. D https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 9/16 6/29/23, 6:02 AM Low back pain Pathway As per NASS 2020 guidelines, consider offering intra-articular corticosteroid injections in patients with suspected sacroiliac joint pain. C As per APS 2009 guidelines, insufficient evidence to recommend scaroiliac joint corticosteroid injections in patients with nonradicular LBP. I Intradiscal injections: As per ASPN 2022 guidelines, consider offering the following intradiscal regenerative therapies in patients with discogenic LBP: platelet-rich plasma B allogeneic mesenchymal stem cells B marrow-derived mesenchymal stem cells B adipose tissue-derived mesenchymal stem cells. B As per ACOEM 2021 guidelines, do not offer intradiscal corticosteroid injections for the treatment of acute, D subacute, or chronic LBP. D As per NASS 2020 guidelines: Consider offering intradiscal corticosteroid injections for short-term improvements in pain and function in patients with Modic changes. C Insufficient evidence to recommend intradiscal corticosteroids, bone marrow concentrate, platelet-rich plasma, or methylene blue for improvements in pain or function in patients with discogenic LBP. I As per APS 2009 guidelines, do not offer intradiscal corticosteroid injections in patients with persistent nonradicular LBP. D Intraligamentous injections: As per ACOEM 2021 guidelines, do not offer prolotherapy injections for the treatment of acute, subacute, or chronic LBP or radicular pain syndromes. D As per APS 2009 guidelines, do not offer prolotherapy in patients with persistent nonradicular LBP. D Intramuscular injections: As per ACOEM 2021 guidelines: Insufficient evidence to recommend for or against the use of intramuscular clonidine injections for the treatment of pyriformis syndrome or other low back conditions. I Insufficient evidence to recommend for or against the use of botulinum injections for the treatment of acute, subacute, or chronic LBP or radicular pain syndromes or other low back- related problems, recognizing that botulinum injections are invasive, costly, and have adverse effects that include fatalities. I As per APS 2009 guidelines, insufficient evidence to recommend local injections, including botulinum toxin injections, in patients with nonradicular LBP. I Trigger point injections: As per ASPN 2022 guidelines: https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 10/16 6/29/23, 6:02 AM Low back pain Pathway Consider offering trigger point injections with botulinum toxin type A in medically refractory cases. C Consider using dilute local anesthetic concentrations for less injection pain. B Consider offering novel injectables for myofascial pain syndrome. Consider offering adjunct therapies to prolong the relief of trigger poinh injections for myofascial pain syndrome. B As per ACOEM 2021 guidelines, do not offer trigger and/or tender point injections for the treatment of acute LBP. D Show 2 more As per NASS 2020 guidelines, insufficient evidence to recommend for or against trigger point injections in patients with LBP. I Intradiscal electrothermal therapy: As per ACOEM 2021 guidelines: Do not offer intradiscal electrothermal therapy for the treatment of acute, subacute, or chronic LBP or any other back-related disorder. D Avoid offering percutaneous intradiscal radiofrequency thermocoagulation for the treatment of acute, subacute, or chronic LBP, particularly discogenic LBP. D As per NASS 2020 guidelines, consider offering intradiscal electrothermal annuloplasty for improvements in pain and function in patients with LBP, recognizing that this treatment is limited in its effectiveness with roughly 40-50% of patients receiving a 50% reduction in pain. C Show 2 more As per APS 2009 guidelines, insufficient evidence to recommend intradiscal electrothermal therapy in patients with nonradicular LBP. I Radiofrequency denervation: As per ASPN 2022 guidelines: Consider offering conventional radiofrequency ablation in patients with LBP. B Consider offering sacroiliac joint denervation/ablation in patients with sacroiliac joint dysfunction pain. C As per ACOEM 2021 guidelines: Do not offer radiofrequency neurotomy for the treatment of chronic LBP or other lumbar spinal conditions, even if confirmed with diagnostic blocks. D Avoid performing radiofrequency lesioning of the dorsal root ganglia for the treatment of chronic sciatica. D As per NASS 2020 guidelines, consider offering thermal radiofrequency ablation in patients with LBP from the zygapophyseal joints. Use more stringent diagnostic criteria for more reliable outcomes of this procedure. Recognize that the relief from ablation is durable for at least 6 months following the procedure. C As per NICE 2017 guidelines, consider referring people with chronic LBP for radiofrequency denervation. C As per APS 2009 guidelines, insufficient evidence to recommend radiofrequency denervation in patients with nonradicular LBP. I https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 11/16 6/29/23, 6:02 AM Low back pain Pathway Cryodenervation: Insufficient evidence to recommend for or against cryodenervation for the treatment of zygapophyseal joint pain. I Consider offering cooled radiofrequency ablation of the sacral lateral branch nerves and dorsal ramus of L5 in patients with sacroiliac joint pain diagnosed with dual diagnostic blocks. C Medial branch block: as per APS 2009 guidelines, insufficient evidence to recommend therapeutic medial branch blocks in patients with nonradicular LBP. I Spinal cord stimulation: As per ASPN 2022 guidelines, consider offering spinal cord stimulation following lumbar spinal surgery, B in patients with non-surgical LBP, C and in patients with predominate lumbar spinal stenosis. C As per ACOEM 2021 guidelines, do not offer implantable spinal cord stimulators for the treatment of acute, subacute, chronic LBP, radicular pain syndromes, or failed back surgery syndrome. D As per NASS 2020 guidelines, insufficient evidence to recommend for or against spinal cord stimulation in patients with LBP. I Peripheral nerve stimulation: As per ASPN 2022 guidelines: Consider offering percutaneous peripheral nerve stimulation for sustained improvement in pain and function in patients with severe, disabling chronic LBP. C Consider offering peripheral nerve field stimulation in patients with chronic axial low back, with and without radicular symptoms in lower extremities, if other treatment modalities have failed. C As per NASS 2020 guidelines, insufficient evidence to recommend transcutaneous electrical nerve stimulation for improvement in pain or function in patients with LBP. I 8. Surgical interventions Surgical neurotomy: do not offer surgical neurotomy for the treatment of chronic LBP or other lumbar spinal conditions, even if confirmed with diagnostic blocks. D Spinal decompression: As per ASPN 2022 guidelines: Offer percutaneous lumbar decompression for ligamentum flavum hypertrophy in patients with lumbar spinal stenosis. B Consider offering stand-alone interspinous spacers for indirect decompression in patients with mild-to-moderate lumbar spinal stenosis. B As per ACOEM 2021 guidelines, consider offering lumbar discectomy to speed recovery in patients with radiculopathy due to ongoing nerve root compression failing to improv significantly after 4-6 weeks and appropriate conservative therapy. C https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 12/16 6/29/23, 6:02 AM Low back pain Pathway Show 4 more As per NICE 2017 guidelines, consider offering spinal decompression in patients with sciatica (with radiological findings consistent with sciatic symptoms) if non-surgical treatment has not improved pain or function. C Vertebroplasty: Do not offer vertebroplasty as a routine treatment in patients with acute, D subacute, or chronic low back or thoracic pain or acute low back or thoracic pain due to vertebral compression fractures. D Insufficient evidence to recommend for or against vertebroplasty in highly selected patients with low back or thoracic pain due to unusual vertebral compression fractures (severe pain lasting > 2 months failed other interventions, including quality medical management, non-resolving significant pain, pathological fractures due to neoplasias, 3 simultaneous compression fractures, failed bisphosphonate therapy). I Kyphoplasty: insufficient evidence to recommend for or against kyphoplasty for the treatment of low back or thoracic pain due to vertebral compression fractures. I Vertebral disc replacement: As per ACOEM 2021 guidelines: Do not offer artificial disc replacement for the treatment of chronic non-specific LBP and any other spinal pain syndrome. D Insufficient evidence to recommend artificial disc replacement as a treatment option for subacute or chronic radiculopathy or myelopathy. I As per APS 2009 guidelines, insufficient evidence to recommend vertebral disc replacement in patients with nonradicular LBP, common degenerative spinal changes, and persistent disabling symptoms. I Facet rhizotomy: do not offer facet rhizotomy for the treatment of chronic LBP or other lumbar spinal conditions, even if confirmed with diagnostic blocks. D Sacroiliac joint surgery: do not offer sacroiliac joint fusion surgery or other sacroiliac joint surgical procedures for the treatment of any LBP disorder. D Spinal fusion: As per ASPN 2022 guidelines: Consider offering interspinous fixation as a stand-alone device for decompression C and spinal fusion. C Consider offering interspinous fixation in patients ineligible for pedicle screw fixation, non- surgical candidates, and in patients early in the treatment paradigm. C As per ACOEM 2021 guidelines, offer lumbar fusion in patients with isthmic spondylolisthesis. B Show 4 more As per NASS 2020 guidelines: https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 13/16 6/29/23, 6:02 AM Low back pain Pathway Insufficient evidence to recommend for or against a particular fusion technique for the treatment of LBP. I Insufficient evidence to support whether radiographic evidence of fusion correlates with better clinical outcomes in patients with LBP. I 9. Patient education General counseling: As per NICE 2017 guidelines: Provide information and advice to help patients self-manage their LBP (with or without sciatica) at all steps of the treatment pathway. Include information on the nature of LBP and sciatica, and encouragement to continue with normal activities. E Explain to patients with LBP (with or without sciatica) that, if they are being referred for specialist opinion, they may not need imaging. B As per APS 2009 guidelines, discuss the risks and benefits of surgery in patients with nonradicular LBP, common degenerative spinal changes, and persistent disabling symptoms. B Include a specific discussion about the following in shared decision-making regarding surgery for nonspecific LBP: intensive interdisciplinary rehabilitation as a similarly effective option the small-to-moderate average benefit from surgery versus noninterdisciplinary nonsurgical therapy the fact that the majority of such patients undergoing surgery do not experience an optimal outcome, defined as minimum or no pain, discontinuation of or occasional pain medication use, and return of high-level function. Show 5 more As per ACP 2007 guidelines, provide patients with evidence-based information on LBP with regard to their expected course, advise patients to remain active, and provide information about effective self-care options. B Clinical findings Patient demographics Symptoms Elderly age Anxiety Depression Past medical history Mechanical pain Pain worsens after prolonged sitting or standing Lumbar spinal stenosis Malignancy Radicular pain Muscle or ligament strain Obesity Social history Osteoporosis https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 14/16 6/29/23, 6:02 AM Low back pain Pathway Cigarette smoking Neurological exam Musculoskeletal exam Cauda equina syndrome Sciatica Arthritis Imaging findings Bulging or Ruptured disks Disc herniation Studies 2023 STRIVE In patients aged 18-85 years scheduled to undergo elective spinal fusion surgical procedures, S. aureus four-antigen vaccine was not superior to placebo with respect to S. aureus blood stream infection. Hamid Hassanzadeh et al. Clin Infect Dis. 2023 May 1. 2003 Radiograph vs. MRI for low back pain In patients age 18 years with low back pain, early MRI was not superior to initial imaging with spine radiograph with respect to a back-related disability measured by the 12-month Roland Scale score. Jarvik JG et al. JAMA. 2003 Jun 4. References 1. Sayed D, Grider J, Strand N et al. The American Society of Pain and Neuroscience ASPN Evidence- Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res. 2022 Dec 6;15 3729 3832. Open 2. Qaseem A, Wilt TJ, McLean RM et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166 7 514 530. Open 3. Kurt T Hegmann, Russell Travis, Gunnar B J Andersson et al. Invasive Treatments for Low Back Disorders. J Occup Environ Med. 2021 Apr 1;63 4):e215-e241. Open 4. Roger Chou, John D Loeser, Douglas K Owens et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine Phila Pa 1976 . 2009 May 1;34 10 1066 77. Open 5. North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. NASS. 2020. Open 6. Bernstein IA, Malik Q, Carville S et al. Low back pain and sciatica: summary of NICE guidance. BMJ. 2017 Jan 6;356:i6748. Open https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 15/16 6/29/23, 6:02 AM Low back pain Pathway 7. American Academy of Physical Medicine and Rehabilitation. Choosing Wisely: Recommendations of the American Academy of Physical Medicine and Rehabilitation. Choosing Wisely. Open 8. Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147 7 478 91. Open 9. Expert Panel on Neurological Imaging, Troy A Hutchins, Miriam Peckham et al. ACR Appropriateness Criteria Low Back Pain: 2021 Update. J Am Coll Radiol. 2021 Nov;18 11S S361 S379. Open 10. American Academy of Family Physicians. Choosing Wisely: Recommendations of the American Academy of Family Physicians. Choosing Wisely. Open 11. Dubinsky RM, Miyasaki J. Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010 Jan 12;74 2 173 6. Open 12. Ivan Urits, Aaron Burshtein, Medha Sharma et al. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep. 2019 Mar 11;23 3 23. Open 13. B W Koes, M W van Tulder, S Thomas. Diagnosis and treatment of low back pain. BMJ. 2006 Jun 17;332 7555 1430 4. Open 14. Brian A Casazza. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012 Feb 15;85 4 343 50. Open 15. Y Xi ng J W ng, J n-Q ng W ng, Zolt n K pl r. Increased low back pain prevalence in females than in males after menopause age: evidences based on synthetic literature review. Quant Imaging Med Surg. 2016 Apr;6 2 199 206. Open 16. Octavia Plesh, Sally H Adams, Stuart A Gansky. Racial/Ethnic and gender prevalences in reported common pains in a national sample. J Orofac Pain. Winter 2011;25 1 25 31. Open 17. Adrienne Kassis. Antidepressants to treat nonspecific low back pain. Am Fam Physician. 2008 Jul 1;78 1 51 2. Open 18. Joseph V Pergolizzi Jr, Jo Ann LeQuang. Rehabilitation for Low Back Pain: A Narrative Review for Managing Pain and Improving Function in Acute and Chronic Conditions. Pain Ther. 2020 Jun;9 1 83 96. Open 19. Santosh Baliga, Katrina Treon, Niall John Angus Craig. Low Back Pain: Current Surgical Approaches. Asian Spine J. 2015 Aug;9 4 645 57. Open 20. Sue A Ferguson, Andrew Merryweather, Matthew S Thiese et al. Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States. BMC Musculoskelet Disord. 2019 May 22;20 1 243. Open 21. Aimin Wu, Lyn March, Xuanqi Zheng et al. Global low back pain prevalence and years lived with disability from 1990 to 2017 estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020 Mar;8 6 299. Open https://web.pathway.md/diseases/recXdC2Vytw8kfUiq 16/16