• Work Loss Data Institute. Low back - lumbar & thoracic (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Jul 5. 393 p. [543 references]

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Identify Radicular Signs

• First visit: may be with Primary Care Physician MD/DO (50%), Orthopedist (33%), or Chiropractor (17%)
• Determine presence or absence of radiculopathy:
  • Medical history
  • Sensation: Feeling pain radiating below the knee (calf or lower), not just referred pain (pain radiating to buttocks or thighs), and dermatological sensory loss
  • Straight leg raising test (sitting and supine), productive of leg pain
  • Motor strength and deep tendon reflexes
  • Document flexibility/range of motion (ROM) (fingertip test), muscle atrophy (calf measurement), local areas of tenderness, visual pain analog, sensation alternation
  • Note: Radiculopathy is often over-diagnosed. For unequivocal evidence of radiculopathy, refer to the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, 5^th Edition, page 382-383.
• Rule out "red flag" diagnoses, including diagnostic studies, for specialist referral:
  • Cauda Equina Syndrome (Schedule emergency procedure) (Refer to the original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)
  • Fracture, Compression fracture, Dislocation, Wound
  • Cancer, Infection
  • Dissecting/Ruptured Aortic Aneurysm
  • Others (prostate problems, endometriosis/gynecological disorders, urinary tract infections, and renal pathology)
  • Note: This guideline should not be used to suggest appropriate procedures for other conditions or comorbidities. When the treating doctor suspects any other diagnosis, they may decide what necessary testing should be performed, which may include laboratory tests such as erythrocyte sedimentation rate (ESR), complete blood count (CBC), and urinalysis (UA) to screen for nonspecific medical diseases (especially infection and tumor) of the low back.

Without Radiculopathy (90% of cases)

• Also first visit (day 1):
  • Prescribe decreased activity, if necessary, based on severity and difficulty of job, limited passive therapy with heat/ice (3 to 4 times/day), stretching/exercise (training by physical therapist OK), appropriate analgesia (i.e., acetaminophen) and/or anti-inflammatory (i.e., ibuprofen) [Benchmark cost: $14], back to work except for severe cases in 72 hours, possibly modified duty. Avoid bed rest.
  • No x-rays unless significant trauma (e.g., a fall)
  • If muscle spasms, then consider muscle relaxant with limited sedative side effects [Benchmark cost: $44]

    (Note: The purpose of muscle relaxants is to facilitate return to activity, but muscle relaxants have not been shown to be more effective than non-steroidal anti-inflammatory drugs [NSAIDs].)

  • REASSURE PATIENT: patient education - common problem (90% of patients recover spontaneously in 4 weeks)

• Second visit (day 3 to 10 - about 1 week after first visit or sooner because delayed treatment is not recommended)
  • Document progress (flexibility, areas of tenderness, motor strength, straight leg raise--sitting and supine).
  • If still 50% disabled then consider referral for exercise/instruction/manual therapy [Benchmark cost: $250]: Options are physical therapist, chiropractor, massage therapist, or occupational therapist (3 visits in first week), or by treating DO/MD (Choose providers supporting active therapy and not just passive modalities. The focus of treatment should not be symptom reduction, but improving function with a goal to return to work.) Consider screening for psychosocial symptoms in cases with expectations of delayed recovery.
  • Discontinue muscle relaxant.

• Third visit (day 10 to 17 - about 1 week after second visit)
  • Document progress.
  • Prescribe muscle-conditioning exercises.
  • At this point 66% to 75% should be back to regular work.
  • While not indicated in the absence of red flags, if still disabled, then consider imaging study (anterior-posterior [AP]/lateral 2-view x-ray of lumbar) [Benchmark cost: $150] to rule out tumor, fracture, osteoporosis, myelopathy
  • Maintain therapy, continue focus on active therapy and not passive modalities, 2 visits in next week, teach home exercises
  • End manual therapy at 4 weeks (1 visit in last week)

With Radiculopathy (10% of cases)

• Also first visit (day 1)
  • Same as non-radicular

• Second visit (day 3-10 - about 1 week after first visit)
  • Same as non-radicular, but
  • Reassure, but if increased numbness or weakness of either leg, get back to provider in one day
  • Consider referral to nonsurgical musculoskeletal physician (Orthopedist/Physical Medicine/Sports Medicine).
• Third visit (day 10 to 17 - about 1 week after second visit)
  • Same as non-radicular, but
  • About 50% can be back at modified duty.
  • If improvement, then add strengthening exercises, increased activity
• Fourth visit (day 21 to 28 - about 1 to 2 weeks after third visit)
  • Document, if no improvement then:
  • First magnetic resonance imaging (MRI) (about 3% of total cases, or 30% of radicular cases) to confirm extruded disk with nerve root displacement (>1 month conservative therapy) [Benchmark cost: $1,600]
  • MRI or computed tomography (CT) not indicated without obvious clinical level of nerve root dysfunction, clear radicular findings, or before 3 to 4 weeks
  • EMGs (electromyography) may be useful to obtain unequivocal evidence of radiculopathy, after 1-month conservative therapy, but EMGs are not necessary if radiculopathy is already clinically obvious.
  • Consider an epidural steroid injection (ESI) for severe cases hoping to avoid surgery [Benchmark cost: $676] (Note: The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs, but this treatment alone offers no significant long-term functional benefit.)
  • If psychological factors retarding recovery are suspected, possibly refer to psychologist for testing. [Benchmark cost: $540]
  • Education: Consider back school as an option, if available
  • If no improvement 7 to 14 days after the first ESI, consider prescribing 2nd ESI [Benchmark cost: $615]; there should be a maximum of two ESIs, and the second ESI can be 7 to 14 days after the first, depending upon the patient's response and functional gain.

• Surgery (three months or more -- after appropriate work-up and consultation, concordance between radicular findings on radiologic evaluation and physical exam findings) (about 2% of total cases, or 20% of radicular cases) (See also ODG Indications for Surgery™ -- Discectomy in the Procedure Summary of the original guideline document). Unequivocal objective findings are required based on neurological examination and testing.
  • Refer to fellowship trained Spine Surgeon: Neurosurgeon (50%), Orthopedist (50%)
  • Before surgery, screen for psychological symptoms that could affect surgical outcome (e.g., substance abuse, child abuse, work conflicts, somatization, verbalizations, attorney involvement, smoking).
  • Review options/outcomes with patient, let patient be part of decision making.
  • Simple discectomy/laminectomy, minimally invasive [Benchmark cost: $17,400]
  • Post-operative pain, walking exercises, physical therapy

• Failure to recover: See the Procedure Summary (in the original guideline document) for options that may be available, along with links to the medical evidence. Also see the Chronic Pain Chapter.

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

• Work Loss Data Institute. Low back - lumbar & thoracic (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Jul 5. 393 p. [543 references]

Not applicable: The guideline was not adapted from another source.

2003 (revised 2007 Jun 12)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI on March 28, 2005, January 3, 2006, April 11, 2006, November 10, 2006, and March 30, 2007. This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug advisory on Colchicine. This NGC summary was updated by ECRI Institute on August 28, 2007. This summary was updated by ECRI Institute on October 31, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.