Low Back Pain — Evidence-Based Clinical Care Standard for Orthopaedic Practice

A concise, AO-style, practical synthesis of NICE NG59 (2016, updated 2020), the ACP 2017 noninvasive-treatment guideline, the WHO 2023 guideline on chronic primary LBP, the Lancet 2018 LBP Series, and the Australian Low Back Pain Clinical Care Standard 2022. Written for the practising orthopaedic surgeon. Treatment recommendations are mapped to high-resource and low-resource pathways.

Quick reference — first 90 seconds at the bedside

• Screen for red flags at every encounter — cauda equina, fracture, infection, malignancy, progressive neurological deficit.
• No routine imaging in the first 6 weeks of non-specific LBP. Image only if a red flag is present or imaging would change management (i.e. surgical/interventional candidate).
• Stay-active advice + reassurance + structured exercise is the foundation. Bed rest is harmful.
• First-line drug: oral NSAID at lowest effective dose, shortest duration. Add PPI if GI risk.
• Paracetamol monotherapy is ineffective for acute LBP (PACE trial, NICE NG59).
• Avoid opioids and benzodiazepines as routine therapy. If used, short course only, with a defined taper.
• Cauda equina syndrome = surgical emergency: urgent MRI, decompression ideally within 48 h of bladder symptoms.

Contents

1. Definitions, epidemiology, classification
2. Clinical assessment: red flags, yellow flags, STarT Back
3. Imaging — structured reporting and indications
4. Non-operative management
5. Pharmacology — drug, dose, route, duration, contraindications
6. Interventional procedures
7. Surgical management — AO-style summary
8. Postoperative rehabilitation — staged protocol
9. Chronic LBP
10. Prevention and lifestyle
11. Pitfalls and complications
12. Multidisciplinary team and follow-up
13. References

1. Definitions, epidemiology, classification

Low back pain (LBP) is pain localised between the costal margin and the inferior gluteal folds, with or without referred leg pain. It is the leading global cause of years lived with disability (Lancet 2018 Series; GBD).

By duration

• Acute: < 6 weeks.
• Subacute: 6–12 weeks.
• Chronic: > 12 weeks.

By presumed aetiology (Lancet 2018 framework)

• Non-specific (mechanical) LBP — ~90–95%. No definable nociceptive structure on imaging.
• Radicular syndromes — disc herniation, foraminal stenosis, spondylolisthesis with nerve-root compression.
• Specific spinal pathology — fracture, infection, malignancy, axial spondyloarthritis, cauda equina syndrome.

2. Clinical assessment

2.1 Red flags — must be excluded actively

Suspected pathology	Key red flags	Immediate action
Cauda equina syndrome	Saddle anaesthesia, urinary retention or incontinence, faecal incontinence, bilateral sciatica, progressive motor weakness	Emergency MRI lumbosacral spine; surgical decompression ideally within 48 h of sphincter symptoms
Vertebral fracture	Significant trauma; minor trauma in older / osteoporotic patient; chronic corticosteroid use; sudden focal pain	Plain radiograph ± CT; consider MRI if neurology or osteoporotic compression with kyphosis
Malignancy	Age > 50, history of cancer, unexplained weight loss, night pain, no relief with rest, raised inflammatory markers	MRI whole spine with contrast; staging; oncology referral
Spinal infection (discitis / vertebral osteomyelitis / epidural abscess)	Fever, IV drug use, immunosuppression, recent bacteraemia or spinal procedure, focal tenderness, raised CRP/ESR	MRI with contrast; blood cultures × 2; CT-guided biopsy before empirical antibiotics if patient stable
Axial spondyloarthritis	Age < 45 at onset, insidious pain > 3 months, morning stiffness > 30 min, improves with exercise, alternating buttock pain	HLA-B27, CRP, MRI SI joints; rheumatology referral
Abdominal aortic aneurysm	Pulsatile abdominal mass, vascular risk profile, sudden tearing back pain	Urgent abdominal ultrasound or CT angiography

2.2 Yellow flags — predictors of chronicity

Catastrophising, fear-avoidance beliefs, depression, anxiety, poor coping, low job satisfaction, secondary gain, and unhelpful pain beliefs predict transition to chronic disabling LBP. Screen and address these from the first visit.

2.3 Risk stratification — STarT Back Tool

A 9-item validated questionnaire stratifying patients into low / medium / high risk of poor outcome. Use it to match treatment intensity to risk (Hill et al., Lancet 2011). Recommended by NICE NG59.

• Low risk: education + advice to stay active; brief intervention.
• Medium risk: structured physiotherapy (exercise + manual therapy).
• High risk: combined physical and psychological (CBT-informed) programme from the outset.

2.4 Physical examination

• Inspection: gait, sagittal and coronal balance, scoliosis, list, paraspinal spasm.
• Palpation: spinous processes, paraspinal muscles, sacroiliac joints, sciatic notch, greater trochanters (rule out hip pathology).
• Range of motion: lumbar flexion, extension, lateral bending, rotation; Schober test if spondyloarthritis suspected.
• Neurological exam — L4: knee jerk, tibialis anterior, medial calf sensation. L5: EHL, dorsum of foot, hip abductors. S1: ankle jerk, gastrocnemius, lateral foot.
• Provocation tests: straight leg raise (positive 30–70°, sensitivity ~91%, specificity ~26% for disc herniation); crossed SLR (specificity ~88%); slump test; femoral stretch (L2–L4); FABER and Gaenslen for SI joint.
• Mandatory in suspected cauda equina: perianal sensation, anal tone, post-void residual bladder volume (> 200 mL is concerning).

3. Imaging

Choosing Wisely principle. Imaging within the first 6 weeks of non-specific LBP without red flags does not improve outcomes and is associated with downstream over-treatment, opioid prescription, and surgery (Chou et al., Lancet 2009; Lancet 2018 Series).

3.1 Indications for imaging

• Any red flag.
• Progressive or severe neurological deficit.
• Persistent radiculopathy > 4–6 weeks failing conservative care, where surgical or interventional treatment is being considered.
• Pre-operative planning.

3.2 Plain radiographs (AP, lateral; flexion/extension if instability suspected)

Technique. Standing AP and lateral lumbosacral; coned views of L5–S1 if symptomatic; dynamic flexion–extension for suspected segmental instability (≥ 4 mm translation or ≥ 10–15° angular change between adjacent levels).

Findings to report. Alignment (lordosis, scoliosis, listhesis grade I–IV per Meyerding), disc-space height, endplate sclerosis, osteophytes, pars defects (oblique view — "Scotty dog"), vertebral body height loss (Genant grades), sacroiliac joints.

Impression. Correlate clinically; specify level, grade, and instability if present.

Pitfall. Plain radiographs cannot exclude discogenic, neural, or early infective pathology. Negative film does not equal a benign spine.

3.3 MRI lumbosacral spine — gold standard for soft tissue and neural elements

Technique. Sagittal T1, T2, STIR; axial T2 (and T1 if pathology); contrast (gadolinium) added when infection, tumour, or postoperative scar vs recurrent disc is suspected.

Structured report — what every report should contain:

• Alignment and lordosis; listhesis with grade.
• Disc morphology at every level — bulge / protrusion / extrusion / sequestration (Fardon & Milette nomenclature).
• Modic endplate changes (Type I oedema, Type II fatty, Type III sclerotic).
• Central canal diameter; lateral recess; foraminal stenosis (Lee grade 0–3).
• Nerve-root status — contact, displacement, compression.
• Facet joint hypertrophy / effusion (effusion > 1.5 mm correlates with dynamic instability).
• Conus position (normal terminates L1–L2); cauda equina; filum.
• Paraspinal soft tissues; sacrum and SI joints.

Clinical correlation. Asymptomatic disc bulges occur in ~30% of 20-year-olds and ~84% of 80-year-olds (Brinjikji et al., AJNR 2015). Report incidental degenerative findings as such — do not attribute symptoms without concordant clinical features.

3.4 CT

Reserved for: bone detail (fracture, pars defect, fusion assessment), patients in whom MRI is contraindicated (pacemaker, severe claustrophobia), and pre-operative planning of pedicle screw trajectory. CT myelography when MRI is impossible and neural compression must be defined.

3.5 Other modalities

• Bone scintigraphy / SPECT-CT — occult fracture, active spondylolysis, metastatic survey when MRI not available.
• DEXA — all patients with vertebral fragility fracture, age > 65 (F) / > 70 (M), or chronic glucocorticoid use ≥ 3 months.
• Ultrasound — limited spinal utility; useful for AAA exclusion at the bedside.

4. Non-operative management

For non-specific acute or subacute LBP, the cornerstone is reassurance, education, advice to remain active, and supervised exercise. Pharmacology is adjunctive.

4.1 Patient education and self-management

• Explicitly state that most non-specific LBP resolves substantially within 4–6 weeks.
• Discourage bed rest beyond 1–2 days; encourage early return to normal activity and work, with modification if needed.
• Re-frame imaging findings — degenerative changes are common and often unrelated to current pain.
• Provide a written exercise plan and a clear escalation pathway.

4.2 Exercise therapy — strongest evidence in chronic LBP

Exercise therapy reduces pain and disability in chronic LBP (Hayden et al., Cochrane 2021). No single modality is consistently superior; match to patient preference and adherence.

• Motor-control / core-stabilisation exercises — transversus abdominis and multifidus activation, bird-dog, dead-bug.
• General aerobic conditioning — walking, cycling, swimming, 150 min/week moderate intensity.
• Pilates and yoga — supported by moderate-quality evidence (ACP 2017).
• McKenzie method (MDT) — directional preference for centralising radicular symptoms.
• Progressive resistance training — added once acute pain settles.

4.3 Manual therapy

Spinal manipulation and mobilisation produce small short-term benefits in acute and chronic LBP; offer only as part of a package that includes exercise (NICE NG59). Avoid in suspected fracture, malignancy, infection, severe osteoporosis, or radiculopathy with motor deficit.

4.4 Non-pharmacological adjuncts

• Superficial heat — moderate-quality evidence for short-term relief in acute LBP (ACP 2017).
• Acupuncture — modest benefit, may be considered in chronic LBP.
• Massage — short-term benefit only.
• TENS, ultrasound, traction, lumbar supports — not recommended as primary therapy (NICE NG59).

4.5 Psychological therapy

Cognitive behavioural therapy, mindfulness-based stress reduction, and acceptance and commitment therapy reduce pain and disability in chronic LBP and are strongly recommended for STarT Back high-risk and chronic patients (ACP 2017; WHO 2023).

5. Pharmacology

Guiding principles. Lowest effective dose, shortest necessary duration, single-agent before combination, reassess at 2 weeks. Document indication, target, exit criteria. Avoid polypharmacy.

5.1 Acute / subacute non-specific LBP

Agent	Dose, route, frequency	Duration	Notes / contraindications
Ibuprofen (first-line)	400 mg PO every 6–8 h (max 2400 mg/day)	5–10 days, then reassess	Take with food; co-prescribe PPI if age > 65, prior PUD, anticoagulation, or steroid use
Naproxen	500 mg PO twice daily (max 1000 mg/day)	5–10 days	Lowest cardiovascular risk among non-selective NSAIDs
Diclofenac	50 mg PO three times daily; or 75 mg IM every 12 h for ≤ 48 h in severe acute pain	Oral 5–7 days; IM ≤ 2 days then switch oral	Avoid in established cardiovascular disease (highest CV risk in class)
Meloxicam	7.5–15 mg PO once daily	Up to 14 days	Preferential COX-2; favourable GI profile
Celecoxib (COX-2 selective)	200 mg PO once daily (max 400 mg/day)	Up to 4 weeks	Preferred in GI-risk patients with controlled CV disease; avoid in active CAD/stroke
Proton-pump inhibitor	Omeprazole 20 mg PO once daily	Duration of NSAID course	Co-prescribe in patients with GI risk
Paracetamol	1 g PO every 6 h (max 3–4 g/day)	As adjunct only	Monotherapy ineffective for acute LBP (PACE trial, Lancet 2014); use only as add-on or when NSAIDs contraindicated
Tizanidine (short course)	2–4 mg PO at night, titrate to 8 mg three times daily	Maximum 7 days	Sedation; check LFTs if continued; avoid with strong CYP1A2 inhibitors (ciprofloxacin, fluvoxamine)
Tolperisone (centrally acting muscle relaxant, available in EU/Ukraine)	50–150 mg PO three times daily	Up to 14 days	Better tolerated than benzodiazepines; rare hypersensitivity reactions reported
Tramadol (rescue only)	50–100 mg PO every 4–6 h (max 400 mg/day)	≤ 7 days, with taper plan	Avoid with SSRIs/SNRIs (serotonin syndrome), seizure disorders, and in older adults; not first-line per NICE NG59

Agents to avoid as routine.

• Strong opioids (morphine, oxycodone, fentanyl patches) — no evidence of benefit over NSAIDs in non-specific LBP; significant harm. Reserve for severe pain refractory to all alternatives, ≤ 3 days, with explicit taper.
• Diazepam and other benzodiazepines — no clinically meaningful benefit over placebo for acute LBP (Friedman et al., Annals Emerg Med 2017); dependence and falls risk. Not recommended.
• Systemic corticosteroids — ineffective for acute non-radicular LBP (Goldberg et al., JAMA 2015).
• SSRIs — not effective for LBP.

5.2 Radicular pain / sciatica

Agent	Dose, route, frequency	Duration / titration	Notes
Gabapentin	Start 300 mg PO at night; titrate by 300 mg every 3 days to 900–1800 mg/day in 3 divided doses (max 3600 mg/day)	Trial 4–8 weeks; taper over 1–2 weeks if discontinuing	Evidence for radicular pain is weak (Mathieson et al., NEJM 2017 — pregabalin failed). Use is pragmatic, not guideline-mandated. Renal dose adjustment
Pregabalin	75 mg PO twice daily; titrate to 150 mg twice daily (max 600 mg/day)	Trial 4–8 weeks	Same caveat as gabapentin; consider abuse potential
Amitriptyline (off-label)	10 mg PO at night; titrate to 25–50 mg	Trial 6–8 weeks	Anticholinergic effects; avoid in elderly, glaucoma, cardiac conduction disease; nortriptyline 10–25 mg better tolerated
Duloxetine	30 mg PO once daily for 1 week, then 60 mg once daily	Long-term in chronic LBP	FDA-approved for chronic musculoskeletal pain including chronic LBP; monitor BP and hepatic function; avoid with MAOIs

5.3 Low-resource setting — minimum effective formulary

• Ibuprofen 400 mg PO 8-hourly + omeprazole 20 mg daily.
• Paracetamol 1 g PO 6-hourly as adjunct only.
• Amitriptyline 25 mg at night for chronic / neuropathic component.
• Diclofenac IM 75 mg 12-hourly for ≤ 48 h in severe acute pain.
• Structured exercise sheet, hot-pack instruction, written reassurance.

6. Interventional procedures

Honest evidence position. Interventional therapies for LBP show modest short-term benefit at best. They are adjuncts to active rehabilitation, never substitutes.

6.1 Epidural steroid injection (ESI)

Indications. Radicular pain from disc herniation or lateral-recess stenosis, refractory to 4–6 weeks of conservative care.

Approach. Transforaminal (most selective), interlaminar, or caudal. Always under fluoroscopic guidance with contrast confirmation.

Drug. Dexamethasone 8–10 mg (non-particulate — preferred at cervical and high-risk lumbar levels) or methylprednisolone 40–80 mg, combined with lidocaine 1% or bupivacaine 0.25%.

Regimen. Single injection; repeat at 2–4 weeks only if partial benefit; maximum 3 per year.

Evidence. Short-term (2–6 week) reduction in radicular pain and disability; no demonstrable effect on surgery rates at 1 year (Friedly et al., NEJM 2014; Pinto et al., Ann Intern Med 2012).

Complications. Dural puncture, infection, transient hyperglycaemia, vasovagal events; rare catastrophic embolic events (use non-particulate steroid at upper levels).

6.2 Facet joint and medial branch interventions

Diagnostic medial branch block with bupivacaine 0.5% confirms facet-mediated pain (≥ 80% pain relief, ideally with double block to reduce false positives).

Therapeutic intra-articular injection: triamcinolone 20–40 mg or methylprednisolone 40 mg with local anaesthetic.

6.3 Radiofrequency denervation of medial branches

Indications. Chronic axial LBP with positive dual diagnostic medial branch blocks.

Evidence. Effect size is contested. The MINT randomised trials (Juch et al., JAMA 2017) showed no clinically meaningful benefit over an exercise programme at 3 months. Counsel patients accordingly.

Duration of benefit, when achieved. 6–12 months; nerve regeneration permits repeat procedure.

6.4 Spinal cord stimulation

Reserved for failed back surgery syndrome with predominant neuropathic leg pain after multidisciplinary evaluation. Requires successful percutaneous trial before permanent implantation.

7. Surgical management — AO-style summary

7.1 Indications

Pathology	Indication for surgery	Timing
Cauda equina syndrome	Saddle anaesthesia, sphincter dysfunction, bilateral neurological deficit confirmed on MRI	Emergency — decompression ideally within 48 h of sphincter symptoms; sooner if incomplete CES
Acute disc herniation with progressive motor deficit	MRC grade ≤ 3 motor power, or progressive worsening	Within days–2 weeks
Acute disc herniation with intractable radicular pain	Concordant imaging, failure of 6–12 weeks of structured conservative care	Elective — earlier surgery (within 6 months) gives faster relief; long-term outcomes converge with conservative care (SPORT trial, Weinstein et al., NEJM 2006, JAMA 2006; 8-year outcomes 2014)
Lumbar spinal stenosis with neurogenic claudication	Walking distance limitation, failure of conservative care, MRI-confirmed central / lateral recess stenosis	Elective
Degenerative spondylolisthesis with instability or stenosis	Clinical instability symptoms + ≥ 4 mm translation on dynamic imaging, or concurrent symptomatic stenosis	Elective
Vertebral fracture	Burst fracture with neurological deficit, kyphosis > 30°, ≥ 50% height loss, or progressive deformity. Osteoporotic compression — vertebroplasty/kyphoplasty for refractory pain > 4–6 weeks (controversial; VERTOS IV positive, VAPOUR positive, but Buchbinder/Kallmes negative trials)	Per AO Spine algorithm (TLICS / AOSpine TLICS)
Spinal infection	Neurological deficit, epidural abscess, failure of antibiotic therapy, mechanical instability, deformity	Urgent
Spinal tumour	Cord compression, instability (SINS), refractory pain — apply NOMS framework	Per oncological MDT

7.2 Surgical options

Microdiscectomy (open or tubular)

• Goal: decompress affected nerve root, preserve facet and lamina.
• Outcomes: ~85–90% short-term relief of radicular pain in well-selected patients.
• Recurrence: 5–15% reherniation at the same level within 2 years.
• Pitfalls: wrong-level surgery (always intraoperative fluoroscopic confirmation), incidental durotomy (repair primarily, bed rest 24–48 h), incomplete fragment retrieval.

Decompressive laminectomy ± medial facetectomy / foraminotomy

• Goal: relieve central and lateral stenosis.
• Outcomes: significant improvement in claudication and leg pain; back pain less reliably relieved.
• Decision point: add fusion only when overt instability exists. The SPORT and SLIP-II trials (Försth et al., NEJM 2016) showed no benefit of adding fusion to decompression in degenerative stenosis without instability.

Lumbar interbody fusion (TLIF / PLIF / ALIF / LLIF)

• Indications: symptomatic spondylolisthesis with instability, recurrent disc herniation requiring discectomy, iatrogenic instability, isthmic spondylolisthesis.
• Goal: restore disc height, indirect decompression, segmental stability.
• Complications: pseudarthrosis (5–15%), adjacent-segment disease (~3% per year), implant failure, dural injury, vascular injury (ALIF), retrograde ejaculation (ALIF in males).

Vertebral augmentation (vertebroplasty / kyphoplasty)

• Indication: refractory pain from osteoporotic compression fracture > 4–6 weeks despite analgesia and bracing; ideally fracture < 6 weeks old with bone-marrow oedema on STIR MRI.
• Evidence: heterogeneous; VAPOUR (2016) and VERTOS IV (2018) positive in selected acute painful fractures; earlier blinded trials (Kallmes 2009, Buchbinder 2009) negative.
• Complications: cement leakage (mostly asymptomatic), adjacent-level fracture, rare pulmonary cement embolism.

8. Postoperative rehabilitation — staged protocol

Phase	Timeframe	Goals	Permitted activities	Progression criteria
Phase 1 — protection	0–2 weeks	Pain control, wound healing, neural quiescence, prevent VTE	Walking from day 1; log-roll transfers; isometric core activation; no bending, lifting > 5 kg, twisting; thromboprophylaxis (LMWH 7–14 days) per risk profile	Wound clean, pain controlled on oral analgesia, independent ambulation
Phase 2 — early mobility	2–6 weeks	Restore neutral spine control, walking tolerance 30 min	Walking programme, hip and hamstring mobility, transversus abdominis and multifidus activation, stationary cycle without resistance	Pain < 3/10 with activity; 30-min continuous walking; independent ADLs
Phase 3 — strengthening	6–12 weeks	Core endurance, hip and gluteal strength, return to light occupational duty	Progressive resistance training, bridging, bird-dog, plank progressions, swimming, light cardiovascular work	McGill core endurance tests within 70% of age-norm; pain-free flexion to mid-shin
Phase 4 — functional restoration	3–6 months	Return to manual work, sport-specific demands	Loaded squats, deadlift mechanics (hip-hinge pattern), sport-specific drills	Symmetrical strength (within 10% side-to-side); pain-free repetitive lifting at job-relevant load; clinician-led return-to-sport criteria for athletes
Maintenance	≥ 6 months	Prevent recurrence	Continued resistance and aerobic training ≥ 3×/week; ergonomic and lifestyle adherence	Long-term ODI < 20%; no recurrent radicular symptoms

8.1 Modifications after instrumented fusion

• Brace (TLSO) optional in modern rigid instrumentation; if used, 6 weeks.
• Avoid bending, lifting > 5 kg, and twisting for 6–12 weeks.
• Radiographic fusion assessment at 3, 6, and 12 months (CT at 12 months if pseudarthrosis suspected — Lenke or Bridwell grading).
• Return to non-contact sport at 6 months; contact sport at 12 months if solid fusion.

8.2 Follow-up schedule

• 2 weeks — wound check, suture removal, neurological re-examination.
• 6 weeks — clinical and functional assessment; standing radiograph after fusion.
• 3 months — ODI, VAS, return-to-work assessment.
• 6 and 12 months — outcomes, fusion radiographs / CT if indicated.
• Annual review for 2 years thereafter.

9. Chronic LBP

Defined as LBP persisting > 12 weeks. Treatment is biopsychosocial and multidisciplinary. Pharmacology is one small lever.

9.1 Core interventions

1. Supervised exercise therapy — first-line. Patient preference dictates modality.
2. Psychological therapy — CBT, ACT, or MBSR. Mandatory for STarT Back high-risk patients.
3. Multidisciplinary biopsychosocial rehabilitation — combines exercise, psychology, occupational input; best evidence for return-to-work outcomes (Kamper et al., Cochrane 2014).
4. Pharmacology — see Section 5; emphasise duloxetine and tricyclics; minimise NSAIDs and avoid opioids long-term.
5. Interventional procedures — only if specific indication and short-term goal.

9.2 What not to do

• Do not order repeat imaging without new red flags or change in management plan.
• Do not escalate opioids.
• Do not perform fusion for non-specific axial chronic LBP without instability — outcomes equivalent to intensive rehabilitation (Fairbank et al., BMJ 2005; Brox et al.; Mannion et al.).

10. Prevention and lifestyle

• Exercise — the only intervention with consistent evidence for primary and secondary prevention of LBP (Steffens et al., JAMA Intern Med 2016). Any modality.
• Weight optimisation — every 5 kg/m² of BMI increases LBP risk.
• Smoking cessation — smoking impairs disc nutrition and surgical bone healing; raises pseudarthrosis risk after fusion ~2-fold.
• Ergonomics and manual handling training — limited isolated benefit; effective only as part of a broader programme.
• Sleep, stress, mental health — address actively.
• Lumbar supports and orthotic insoles for prevention — not supported by evidence.

11. Key pitfalls and complications

Pitfall	Mitigation
Missed cauda equina syndrome	Document perianal sensation, anal tone, and post-void residual in every patient with bilateral leg symptoms or sphincter complaints; low threshold for emergency MRI
Over-imaging in non-specific LBP	Apply Choosing Wisely; defer MRI until red flag or surgical consideration; explicitly counsel that imaging will not change management in most cases
Attributing pain to incidental imaging findings	Correlate findings with dermatomal pattern, examination, and provocation tests; remember 30–80% asymptomatic disc bulges across the lifespan
Opioid escalation	Avoid initiation for chronic LBP; if used, define exit criteria from day 1 and taper
Wrong-level spinal surgery	Mandatory intraoperative fluoroscopic confirmation against fixed landmark; mark in standing position pre-operatively
Incidental durotomy	Primary watertight repair with 6-0 monofilament; fibrin sealant; flat bed rest 24–48 h; lumbar drain if large defect
Surgical site infection	Prophylactic cefazolin 2 g IV (3 g if > 120 kg) within 60 min of incision, redose every 4 h intra-op; topical vancomycin powder for instrumented fusion (controversial benefit); meticulous closure
VTE	Risk-stratified mechanical ± pharmacological prophylaxis from postoperative day 1; LMWH (enoxaparin 40 mg subcutaneously daily) for 7–14 days in high-risk patients
Pseudarthrosis after fusion	Optimise modifiable risk (smoking cessation, vitamin D, glycaemic control); avoid NSAIDs first 6 weeks post-fusion; CT at 12 months if symptomatic
Failed back surgery syndrome	Patient selection is the strongest predictor of success; do not operate without concordant imaging and clinical findings

12. Multidisciplinary team and escalation

Optimal LBP care is team-based:

• Orthopaedic / spinal surgeon — diagnostic clarification, surgical decision-making.
• Physiotherapist — exercise prescription and graded loading; central to every phase.
• Pain medicine / anaesthesia — interventional procedures, pharmacology stewardship.
• Clinical psychology — CBT, ACT, pain neuroscience education.
• Radiology — imaging strategy, structured reporting, image-guided intervention.
• Infectious diseases — spondylodiscitis, postoperative infection.
• Nursing — wound care, ERAS pathway, patient education.
• Occupational therapy — ergonomics, return-to-work planning.
• Rheumatology — spondyloarthritis and inflammatory back pain.

12.1 Escalation criteria

• Any red flag → same-day specialist referral or emergency department.
• Progressive motor deficit → urgent surgical referral and MRI within 24–48 h.
• Cauda equina suspicion → emergency MRI; surgical decompression ideally within 48 h.
• Persistent radiculopathy > 6 weeks despite optimal conservative care → spine surgery clinic.
• STarT Back high-risk, or chronicity at 12 weeks → multidisciplinary pain programme.

13. References

1. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). 2016, updated 2020. https://www.nice.org.uk/guidance/ng59
2. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514–530. doi:10.7326/M16-2367
3. World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: WHO; 2023. https://www.who.int/publications/i/item/9789240081789
4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–2367. doi:10.1016/S0140-6736(18)30480-X
5. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368–2383.
6. Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. Lancet. 2018;391(10137):2384–2388.
7. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial (PACE). Lancet. 2014;384(9954):1586–1596.
8. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11–21.
9. Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the MINT randomized clinical trials. JAMA. 2017;318(1):68–81.
10. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT). JAMA. 2006;296(20):2441–2450. 8-year outcomes: Spine. 2014.
11. Försth P, Ólafsson G, Carlsson T, et al. A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med. 2016;374(15):1413–1423.
12. Hayden JA, Ellis J, Ogilvie R, et al. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9:CD009790.
13. Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802):1560–1571.
14. Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med. 2017;376(12):1111–1120.
15. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2014;9:CD000963.
16. Steffens D, Maher CG, Pereira LSM, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199–208.
17. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816.
18. Fardon DF, Williams AL, Dohring EJ, et al. Lumbar disc nomenclature: version 2.0. Spine J. 2014;14(11):2525–2545.
19. Australian Commission on Safety and Quality in Health Care. Low Back Pain Clinical Care Standard. Sydney: ACSQHC; 2022. https://www.safetyandquality.gov.au/standards/clinical-care-standards/low-back-pain-clinical-care-standard
20. Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system. Spine. 2013;38(23):2028–2037.
21. North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Clinical-Guidelines
22. Clark W, Bird P, Gonski P, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet. 2016;388(10052):1408–1416.
23. Friedman BW, Irizarry E, Solorzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain. Ann Emerg Med. 2017;70(2):169–176.e1.

Prepared by: Dr Vasyl M. Shlemko, Orthopaedic Surgeon.
This standard is intended as a working clinical tool. Local protocols, drug availability, and individual patient factors must guide final decisions.