Diagnosis and Treatment of Low Back Pain

Evidence-Based Clinical Guidelines for

Multidisciplinary Spine Care:

Diagnosis & Treatment of Low Back Pain

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www.spine.org

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Diagnosis & Treatment of Low Back Pain | Preface

Recommendations were developed based on a specic denition, inclusion/exclusion criteria, and the resulting literature which excluded conditions

such as presence of a neurological decit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec-

ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a xed

treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should

not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same

results. The ultimate judgment regarding any specic procedure or treatment is to be made by the physician and patient in light of all circumstances

presented by the patient and the needs and resources particular to the locality or institution.

Authors & Contributors

Evidence-Based Guideline Development

Committee Co-Chairs

D. Scott Kreiner, MD

Paul Matz, MD

Diagnosis Section

Section Chair:

Daniel K. Resnick, MD, MS

Authors:

Norman B. Chutkan, MD, FACS

Adam C. Lipson, MD

Anthony J. Lisi, DC

Tom E. Reinsel, MD

Robert L. Rich Jr, MD, FAAFP; Stakeholder

Representative, American Academy of Family

Physicians (AAFP)

Contributor:

Robert C. Nucci, MD

Imaging Section

Section Co-Chairs:

Charles H. Cho, MD, MBA

Gary Ghiselli, MD

Authors:

Sean D. Christie, MD

Bernard A. Cohen, PhD

S. Raymond Golish, MD, PhD, MBA

Murat Pekmezci, MD

Walter S. Bartynski, MD; Stakeholder Representative,

American Society of Spine Radiology (ASSR)

Medical & Psychological Treatment Section

Section Chair:

Christopher M. Bono, MD

Authors:

Paul Dougherty, DC

Gazanfar Rahmathulla, MD, MBBS

Christopher K. Taleghani, MD

Terry Trammell, MD

Randall P. Brewer, MD; Stakeholder Representative,

American Academy of Pain Medicine (AAPM)

Ravi Prasad, PhD; Stakeholder Representative, American

Academy of Pain Medicine (AAPM)

Contributor:

John P. Birkedal, MD

Physical Medicine & Rehabilitation Section

Section Chair:

Charles A. Reitman, MD

Authors:

R. Carter Cassidy, MD

Dennis E. Enix, DC, MBA

Daniel S. Robbins, MD

Alison A. Stout, DO

Ryan A. Tauzell, PT, MA, MDT

Contributor:

William L. Tontz, Jr., MD

Interventional Treatment Section

Section Chair:

John E. Easa, MD, FIPP

Authors:

Jamie Baisden, MD, FACS

Shay Bess, MD

David S. Cheng, MD

David A. Provenzano, MD; Stakeholder Representative,

American Society of Regional Anesthesia and Pain

Medicine (ASRA)

Yakov Vorobeychik, MD, PhD; Stakeholder

Representative, Spine Intervention Society (SIS)

Contributors:

Michael P. Dohm, MD

Thomas J. Gilbert, MD

Joseph Gjolaj, MD

Matthew Smuck, MD, Stakeholder Representative,

American Academy of Physical Medicine and

Rehabilitation (AAPM&R)

Diagnosis & Treatment of Low Back Pain | Preface

Recommendations were developed based on a specic denition, inclusion/exclusion criteria, and the resulting literature which excluded conditions

such as presence of a neurological decit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec-

ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a xed

treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should

not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same

results. The ultimate judgment regarding any specic procedure or treatment is to be made by the physician and patient in light of all circumstances

presented by the patient and the needs and resources particular to the locality or institution.

Surgical Treatment Section

Section Chair:

William C. Watters III, MD, MS

Authors:

Thiru M. Annaswamy, MD

Steven W. Hwang, MD

Cumhur Kilincer, MD, PhD

RJ Meagher, MD

Anil K. Sharma, MD

Kris E. Radcli, MD; Stakeholder Representative,

American Academy of Orthopaedic Surgeons (AAOS)

Contributor:

Jordan Gliedt, DC

Cost-Utility Section

Section Chair:

Zoher Ghogawala, MD, FACS

Authors:

Simon Dagenais, PhD, MSc, DC

Jerey A. King, DC, MS

Paul Park, MD

Daniel R. Perry, MPT, MDT

Jonathan N. Sembrano, MD

John E. O’Toole, MD, MS; Stakeholder Representative,

American Association of Neurological Surgeons

(AANS)

Padma Gulur, MD; Stakeholder Representative, Ameri-

can Society of Anesthesiologists (ASA)

Contributors:

Darren R. Lebl, MD (Cost-Utility Section)

Alex Seldomridge, MD, MBA (Cost-Utility Section)

Participating Societies

(does not necessarily imply endorsement)

 American Academy of Family Physicians (AAFP)

 American Academy of Orthopaedic Surgeons

(AAOS)

 American Academy of Pain Medicine (AAPM)

 American Association of Neurological Surgeons

(AANS)/Congress of Neurological Surgeons (CNS)

 American Society of Anesthesiologists (ASA)

 American Society of Regional Anesthesia and Pain

Medicine (ASRA)

 American Society of Spine Radiology (ASSR)

 Spine Intervention Society (SIS)

Contributing Societies

(does not necessarily imply endorsement)

 American Academy of Physical Medicine and

Rehabilitation (AAPM&R)

 American Physical Therapy Association (APTA)

Diagnosis & Treatment of Low Back Pain | Preface

Recommendations were developed based on a specic denition, inclusion/exclusion criteria, and the resulting literature which excluded conditions

such as presence of a neurological decit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec-

ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a xed

treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should

not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same

results. The ultimate judgment regarding any specic procedure or treatment is to be made by the physician and patient in light of all circumstances

presented by the patient and the needs and resources particular to the locality or institution.

Financial Statement/

Disclosures

This clinical guideline was developed and funded

in its entirety by the North American Spine Society

(NASS) with the exception that stakeholder societies

provided representatives and paid for the travel

and accommodation of their representatives to

recommendation meetings. All participating

authors have disclosed potential conicts of interest

consistent with NASS’ disclosure policy (http://

www.spine.org/DisclosurePolicy). Disclosures of all

authors and contributors are listed in the Technical

Report associated with this document.

Comments

Comments regarding this guideline may be submitted

to the North American Spine Society at guidelines@

spine.org and will be considered in development of

future revisions of the work.

Endorsements

Letters of endorsement from external societies can

be found in the Technical Report associated with this

document.

Diagnosis & Treatment of Low Back Pain | Preface

Recommendations were developed based on a specic denition, inclusion/exclusion criteria, and the resulting literature which excluded conditions

such as presence of a neurological decit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec-

ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a xed

treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should

not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same

results. The ultimate judgment regarding any specic procedure or treatment is to be made by the physician and patient in light of all circumstances

presented by the patient and the needs and resources particular to the locality or institution.

Table of Contents

I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

II. Guideline Development Methodology and Process ..................................8

III. Glossary and Acronyms .............................................................12

IV. GuidelineDenitionandInclusion/ExclusionCriteria ...............................16

V. Summary of Recommendations ..................................................... 17

VI. Recommendations for Diagnosis and Treatment of Low Back Pain ..................40

A. Diagnosis .......................................................................40

B. Imaging .........................................................................60

C. Medical and Psychological Treatment ...........................................69

D. Physical Medicine & Rehabilitation .............................................101

E. Interventional Treatment .......................................................158

F. Surgical Treatment .............................................................190

G. Cost-Utility ....................................................................198

VII. Appendices ........................................................................213

A full bibliography and technical report, including the literature search parameters and evidentiary tables

developed by the authors, can be accessed at https://www.spine.org/Research-Clinical-Care/Quality-

Improvement/Clinical-Guidelines.

Diagnosis & Treatment of Low Back Pain | Introduction

Recommendations were developed based on a specic denition, inclusion/exclusion criteria, and the resulting literature which excluded conditions

such as presence of a neurological decit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec-

ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a xed

treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should

not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same

results. The ultimate judgment regarding any specic procedure or treatment is to be made by the physician and patient in light of all circumstances

presented by the patient and the needs and resources particular to the locality or institution.

Objective

The objective of the North American Spine Society

(NASS) Clinical Guideline for the Diagnosis and Treat-

ment of Low Back Pain is to provide evidence-based

recommendations to address key clinical questions

surrounding the diagnosis and treatment of adult

patients with nonspecic low back pain. This guide-

line is based upon a systematic review of the evidence

and reects contemporary treatment concepts for

low back pain as reected in the highest quality clin-

ical literature available on this subject as of February

2016. The goals of the guideline recommendations are

to assist in delivering optimum, ecacious treatment

and functional recovery from nonspecic low back

pain.

Scope, Purpose and Intended User

This document was developed by the North American

Spine Society Evidence-Based Guideline Development

Committee with representation from stakeholder or-

ganizations as an educational tool to assist practi-

tioners who treat adult patients with nonspecic low

back pain. The goal is to provide a tool that assists

practitioners in improving the quality and eciency

of care delivered to these patients. The NASS Clinical

Guideline for the Diagnosis and Treatment of Low Back

Pain outlines a reasonable evaluation of patients with

nonspecic low back pain and outlines treatment op-

tions for adult patients with this condition.

THIS GUIDELINE DOES NOT REPRESENT A

“STANDARD OF CARE,” nor is it intended as a xed

treatment protocol. It is anticipated that there will be

patients who will require less or more treatment than

the average. It is also acknowledged that in atypical

cases, treatment falling outside this guideline will

sometimes be necessary. This guideline should not

be seen as prescribing the type, frequency or duration

of intervention. Treatment should be based on the

individual patient’s need and doctor’s professional

judgment and experience. This document is designed

to function as a guideline and should not be used as

the sole reason for denial of treatment and services.

This guideline is not intended to expand or restrict a

health care provider’s scope of practice or to supersede

applicable ethical standards or provisions of law.

Patient Population

The patient population for this guideline encompass-

es adults (18 years or older) with low back pain dened

as pain of musculoskeletal origin extending from the

lowest rib to the gluteal fold that may at times extend

as somatic referred pain into the thigh (above the

knee).

Considerations:WhyThisGuidelineIsDierent

andHowExclusionofLegPainImpactsthe

Recommendations

NASS typically writes clinical guidelines based on di-

agnosis. Due to demand and the expertise of NASS

spine care specialists, NASS, in this single instance,

has opted to address low back pain as a generalized

topic rather than a specic diagnosis or code. As a

multidisciplinary organization for spine care provid-

ers, NASS was uniquely positioned to provide specialty

expertise and a real-world perspective on multidisci-

plinary spine care. It is important to keep in mind that

“low back pain” is no more a diagnosis in the spine

eld than “chest pain” is for cardiology, but rather a

generalized patient complaint that can encompass a

variety of diagnoses.

Recommendations were developed based on a specic

denition, inclusion/exclusion criteria, and the re-

sulting literature which excluded leg pain below the

knee. Leg pain was excluded in order to address treat-

ment of nonspecic low back pain. For many sections,

the inclusion of leg pain in the literature search would

have included many specic causes of back pain, in-

cluding disc herniation and spondylolisthesis, that

would have made the focus on nonspecic low back

pain more dicult and less clear.

Without the inclusion of leg pain, these guideline rec-

ommendations address only a subset of low back pain

and its care. The inclusion and exclusion criteria used

resulted in the removal of multiple articles that may

have inuenced overall recommendations for a par-

ticular treatment or procedure. Evaluation of a par-

ticular treatment or procedure under dierent clinical

circumstances would necessitate a separate evalua-

tion of the evidence.

Diagnosis & Treatment of Low Back Pain | Introduction

Recommendations were developed based on a specic denition, inclusion/exclusion criteria, and the resulting literature which excluded conditions

such as presence of a neurological decit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec-

ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a xed

treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should

not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same

results. The ultimate judgment regarding any specic procedure or treatment is to be made by the physician and patient in light of all circumstances

presented by the patient and the needs and resources particular to the locality or institution.

Due to the time needed to develop a guideline of this

size and breadth, some explanation is needed as to the

why or why not certain items can be found in the con-

tent.

 Although opioids are addressed, it is in a limited

fashion. The opioid crisis as we know it today was

a phenomenon that reached crisis proportions af-

ter the guideline was already in development. In

the future, more substantial attention to this is-

sue will be merited.

 This is the largest clinical guideline NASS has

ever undertaken and four years in the making.

There were 82 clinical questions and the literature

search resulted in more than 45,000 articles. Due

to the high volume of literature and the labor-

intensive nature of the review, literature search

dates are spread out in some instances (although

most were within the same month). In addition,

consideration should be given to the fact that

newer research has been published since the

literature searches have taken place.

 This document is based on the evidence known at

the time of the literature review. However, evi-

dence can be incomplete or immature and recom-

mendations can change in the future where the

current evidence is thin, weak, or evolving. NASS’

future recommendations for research are a valu-

able tool when considering these areas.

Recommendations were developed based on a specic denition, inclusion/exclusion criteria, and the resulting literature which excluded conditions

such as presence of a neurological decit or leg pain experienced below the knee, among others. Given the exclusion criteria, these guideline rec-

ommendations address a subset of low back pain care as opposed to low back pain in its entirety. This clinical guideline is not intended to be a xed

treatment protocol; it is anticipated that there will be patients who require more or less treatment than what is outlined. This clinical guideline should

not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same

results. The ultimate judgment regarding any specic procedure or treatment is to be made by the physician and patient in light of all circumstances

presented by the patient and the needs and resources particular to the locality or institution.

Diagnosis & Treatment of Low Back Pain | Development Methodology and Process

Guideline Development

Methodology

Through objective evaluation of the evidence

and transparency in the process of making

recommendations, it is NASS’ goal to develop

evidence-based clinical practice guidelines for the

diagnosis and treatment of adult patients with various

spinal conditions. These guidelines are developed for

educational purposes to assist practitioners in their

clinical decision-making processes.

Multidisciplinary and Multi-Stakeholder

Collaboration

With the goal of ensuring the best possible care for

adult patients suering with spinal disorders, NASS

is committed to multidisciplinary involvement in the

process of guideline development. To this end, NASS

has ensured that representatives from research, both

operative and non-operative, medical, interventional

and surgical spine specialties have participated in the

development and review of NASS guidelines. To en-

sure broad-based representation on this topic, NASS

invited representatives from organizations whose

members are involved in the care of patients with low

back pain to serve on guideline work groups. A more

detailed description of stakeholder involvement is

included under the “Guideline Development Process”

on page 9.

Evidence Analysis Training of all Guideline

Developers

As a condition of participation, all developers com-

pleted NASS’ Fundamentals of Evidence-Based Med-

icine Training prior to participating in guideline de-

velopment. The training includes a series of readings

and exercises to prepare guideline developers for

systematically evaluating literature and developing

evidence-based guidelines. Participants are awarded

CME credit upon completion of the course.

DisclosureofPotentialConictsofInterest

All participants involved in guideline development

have disclosed potential conicts of interest to their

colleagues in accordance with NASS’ Disclosure Pol-

icy (https://www.spine.org/DisclosurePolicy) and

their potential conicts have been documented in the

Technical Report associated with this guideline. NASS

does not restrict involvement in guidelines based on

conicts as long as members provide full disclosure.

Individuals with a conict relevant to the subject

matter were asked to recuse themselves from delib-

eration. Participants have been asked to update their

disclosures regularly throughout the guideline devel-

opment process.

Levels of Evidence and Grades of

Recommendation

NASS has adopted standardized levels of evidence

(Appendix A) and grades of recommendation (Appen-

dix B) to assist practitioners in easily understanding

the strength of the evidence and recommendations

within the guidelines. The levels of evidence range

from Level I (high quality randomized controlled tri-

al) to Level V (expert consensus). Grades of recom-

mendation indicate the strength of the recommenda-

tions made in the guideline based on the quality of the

literature.

Grades of Recommendation:

 A: Good evidence (Level I studies with consistent

ndings) for or against recommending interven-

tion.

 B: Fair evidence (Level II or III studies with con-

sistent ndings) for or against recommending

intervention.

 C: Poor quality evidence (Level IV or V studies) for

or against recommending intervention.

 I: Insucient or conicting evidence not allowing

a recommendation for or against intervention.

Levels of evidence have very specic criteria and are

assigned to studies prior to developing recommenda-

tions. Recommendations are then graded based upon

the level of evidence. To better understand how levels

of evidence inform the grades of recommendation and

the standard nomenclature used within the recom-

mendations see Appendix C.

Guideline recommendations are written utilizing a

standard language that indicates the strength of the

recommendation. “A” recommendations indicate a

test or intervention is “recommended”; “B” recom-

mendations “suggest” a test or intervention and “C”

recommendations indicate a test or intervention “may

be considered” or “is an option.” “I” or “Insucient

Evidence” statements clearly indicate that “there is

insucient evidence to make a recommendation for

or against” a test or intervention. Work group con-

sensus statements clearly state that “in the absence of

reliable evidence, it is the work group’s opinion that”

a test or intervention may be appropriate.