Acute low back pain only with spasm

• back education program

• strict rest lying on a firm surface for 2 days 8 (keep the spine as straight as possible)

• regular simple analgesics with review as the patient mobilises

• cold or hot compresses to the painful area

• simple mobilisation exercises as tolerated

• muscle energy therapy

• consider trigger point injection of local anaesthetic

• relaxant, e.g. diazepam (if appropriate) for 4-5 days

When the acute phase settles, treat as for uncomplicated low back pain. Sciatica with or without low back pain

Sciatica is a more complex and protracted problem to treat, but most cases will gradually settle within 12 weeks.

Acute

• strict bed rest for 2-3 days (keep the spine straight—avoid sitting in soft chairs and for long periods)

• regular non-opioid analgesics with review as the patient mobilises

• NSAIDs for 10-14 days, then cease and review

• back education program

• resume normal activities as soon as possible

• exercises—straight leg raising exercises to pain tolerance

• traction (a trial of intermittent traction is worthwhile)

• weekly or 2 weekly follow up

Chronic

• continue physiotherapy with possible traction

• reassurance that problem will subside (assuming no severe neurological defects)

• consider epidural anaesthesia (if slow response)

General guidelines for surgical intervention

• bladder/bowel disturbance

• progressive motor disturbance, e.g. significant foot drop, weakness in quadriceps

• severe prolonged pain

• failure of conservative treatment with persistent pain (problem of permanent nerve damage)

Note: An important controlled prospective study comparing surgical and conservative treatment in patients with sciatica over 10 years showed that there was significant relief of sciatica in the surgical group for 1 to 2 years but not beyond that time. At 10 years both groups had the same outcome including neurological deficits. 15

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