1.

1 Assessment of low back pain and sciatica

Alternative diagnoses
1.1.1Think about alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop
new or changed symptoms. Exclude specific causes of low back pain, for example, cancer, infection, trauma or
inflammatory disease such as spondyloarthritis. If serious underlying pathology is suspected, refer to relevant NICE
guidance on:

• Metastatic spinal cord compression in adults

• Spinal injury

• Spondyloarthritis

• Suspected cancer

Risk assessment and risk stratification tools

1.1.2Consider using risk stratification (for example, the STarT Back risk assessment tool) at first point of contact with a
healthcare professional for each new episode of low back pain with or without sciatica to inform shared decision-making
about stratified management.
1.1.3Based on risk stratification, consider:

• simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and
have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)

• more complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor
outcome (for example, exercise programmes with or without manual therapy or using a psychological approach).4
Lumbar muscular Subjective Objective Differential
strain/sprain Presentation examination Diagnosis

The exact cause of pain Pain, stiffness, benign physical

is often impossible to and/or soreness of examination,
identify precisely, but the lumbosacral diagnosis is one of
arises from any region lasting <4 exclusion
combination of weeks (acute), 4 to
pathology involving 12 weeks
discs, vertebrae, facet (subacute), or >12
joints, ligaments, and/or weeks (chronic)
muscles

Herniated nucleus • persistent low • Restriction in

back pain lumbar motion
pulposus (HNP) • radicular leg • positive
pain straight leg
A complex, multi-
• activity-related raise (SLR)
factorial, clinical symptoms • neurological
condition characterised • increasing deficit (leg
by low back pain with or
age weakness,
• genetic sensory loss,
without the concurrence influence
of radicular lower limb • occupation
symptoms in the (excessive
axial loads,
presence of vibrations
radiologically-confirmed
degenerative disc from
transportation)
disease. The pain is • tobacco
exacerbated by activity, smokin
but may be present in •

certain positions, such

as sitting.

Spinal stenosis intermittent pain patients walk with a

radiating to the thigh or forward flexed gait;
Lumbar spondylosis
legs, worse with patients with vascular
refers to degenerative
prolonged standing, claudication have
conditions of the lumbar
activity, or lumbar diminished pulses and
spine that narrow the
extension; pain is typical skin changes,
spinal canal, lateral
typically relieved by such as mottled
recesses, and neural
sitting, lying down, discolouration, thinning
foramina. Facet joint and
and/or lumbar flexion; and shiny skin
ligamentous
patient may describe
hypertrophy, • pain radiating
intermittent burning, down the leg
intervertebral disc
numbness, heaviness, • bladder or
protrusion, and
or weakness in their bowel
spondylolisthesis may all dysfunction
legs, unilateral or
contribute to the • muscle
bilateral radicular pain, weakness or
stenosis, and symptoms
motor deficits, bowel wasting
result from neural
and bladder
compression of the
cauda equina, exiting dysfunction, and back
nerve roots, or both. and buttock pain with
Patients present with standing and
symptoms of neurogenic ambulation.
claudication or
• age >40 years
radiculopathy • manual labour
• previous back
surgery

Compression Postmenopausal tenderness to It is important to

fracture women and patients palpation over the exclude the possibility
taking long-term midline; increased of pathological fracture
Most are isolated
corticosteroid therapy kyphosis, normal due to malignancy or
fractures of the anterior
are most susceptible. neurological infection
spinal column related to
examination unless
low bone mineral Typically history of
there is retropulsion of
density. trauma, although acute
bone into the neural
event not always
due to a combination of elements, such as in
recalled; pain at rest
flexion and axial burst fractures
and at night, previous
compression loading.
history of fractures
Rarely, osteoporotic (e.g., distal radius, hip
compression fractures
can also involve the or other vertebral
middle and/or posterior compression fractures)
spinal columns, in
addition to the anterior
column. This type of
fracture is potentially
unstable and requires
surgical intervention.

Degenerative disc pain is reproduced

with flexion in
disease or facet discogenic pain and
arthropathy extension with facet
arthropathy
A multi-factorial clinical
condition characterised • restriction in
by low back pain with or
lumbar motion
• positive
without the concurrence straight leg
of radicular lower limb raise (SLR)
symptoms in the • neurological
deficit (leg
presence of weakness,
radiologically confirmed sensory loss,
degenerative disc bladder and
bowel
disease.
symptoms)
Degenerative disc
disease leads to
abnormal loading
patterns of the motion
segment. Progression of
disc degeneration may
lead to additional painful
manifestations, including
loss of disc height and
facet joint arthrosis, disc
herniation and nerve
root irritation, and
hypertrophic changes
resulting in spinal
stenosis.

Spondylolysis and/or Most are exaggerated

spondylolisthesis asymptomatic; pain in lordosis, heart-
the lower back with shaped buttock, or
occasional radiation to midline step-off of
the posterior thigh and the spinous
 aggravated by processes may be
extension present; pain with
single-leg
hyperextension test
may be present (this
test should not be
relied on because it
has been shown to
have low sensitivity
and specificity; a
combination of
findings are required
for diagnosis).

Vertebral Patients with a history generalised

discitis/osteomyelitis of fever, weight loss, appearance of
and non-mechanical malaise; fever;
Osteomyelitis is an
back pain (i.e., pain localised tenderness
infection of the bone that
that occurs even presents particularly
presents a variety of
without motion, with percussion;
challenges to the
particularly at rest and neurological findings
physician. The severity
at night); hx of absent
of the disease is staged
intravenous drug use,
depending on the
immunosuppression,
infection's aetiology,
pathogenesis, extent of or diabetes. In addition
bone involvement, and penetrating injuries,
duration, and host Surgical
factors particular to the contamination, HIV.
individual patient.
Osteomyelitis may be
either haematogenous
or caused by a
contiguous spread of
infection.
Staphylococcus
aureus is the most
common organism
isolated.

Inflammatory male predominance in Stiffness of spine with

spondylo- ankylosing spondylitis, kyphosis, limited range
arthropathy early-morning of movement of lower
stiffness, nocturnal spine, tenderness on
Ankylosing spondylitis
back pain, fatigue, palpation; extra-
(AS) is a chronic
weight loss, diffuse articular signs (e.g.,
progressive
non-specific pain psoriasis, uveitis).
inflammatory
radiating bilaterally to
arthropathy
buttocks; pain
predominantly affecting
the spine and sacroiliac improves after physical association with the
joints. activity; may have FHx gene HLA-B27
of arthritis or psoriasis;
A diagnosis of
hx of inflammatory
established AS requires
bowel disease may be
definitive evidence of
suggestive of
sacroiliitis on plain
enteropathic arthritis.
radiographs
A positive response to
non-steroidal anti-
inflammatory drugs
(NSAIDs) is
characteristic of most
patients.

extra-articular sites
such as the eye and
bowel are frequently
affected. Levels of
disability are
comparable with those
who have rheumatoid
arthritis.