History and Physical Examination (34 studies)

Basic history (B).
History of cancer/infection (B).
Signs/symptoms of cauda equina syndrome (C).
History of significant trauma (C).
Psychosocial history (C).
Straight leg raising test (B).
Focused neurologic exam (B).

Pain drawing and Visual Analog Scale (D)

Patient Education (14 studies)

Patient education about low- back symptoms (B).
Back school in occupational settings (C).

Back school in nonoccupational settings (C).

Medication (23 studies)

Acetaminophen (C).
NSAIDs (B).

Muscle relaxants (C).
Opioids, short course (C).

Opioids used >2 wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C).

Physical Treatment Methods (42 studies)

Manipulation during first month of low-back pain (B).

Manipulation for patients who have radiculopathy (C).
Manipulation for patients who have symptoms >1 month (C).
Self-application of heat or cold to low back.
Shoe insoles (C).
Corset for prevention in occupational setting (C).

Manipulation for patients who have undiagnosed neurologic deficits (D).
Prolonged course of manipulation (D).
Traction (B).
TNS (C).
Biofeedback (C).
Shoe lifts (D).
Corset for treatment (D).

Injections (26 studies)

Epidural steroid injections for radicular pain to avoid surgery (C).

Epidural injections for back pain without radiculopathy (D).
Trigger point injections (C).
Ligamentous injections (C).
Facet joint injections (C).
Needle acupuncture (D).

Bedrest 4 studies

Bedrest of 2-4 days for severe radiculopathy (D).

Bedrest >4 days (B).

Activities and Exercise (20 studies)

Temporary avoidance of activities that increase mechanical stress on spine (D).
Gradual return to normal activities (B).
Low-stress aerobic exercise (C).
Conditioning exercises for trunk muscles after 2 weeks (C).
Exercise quotas (C).

Back-specific exercise machines (D).
Therapeutic stretching of back muscles (D).

Detection of Physiologic Abnormalities (14 studies)

If no improvement after 1 month:
Bone scan (C).
Needle EMG and H-reflex tests to clarify nerve root dysfunction (C).
SEP to assess spinal stenosis (C).

EMG for clinically obvious radiculopathy (D).
Surface EMG and F-wave tests (C).
Thermography (C).

Radiographs of L-S spine (18 studies)

When Red flags for fracture present (C).
When Red flags for cancer or infection present (C).

Routine use in first month of symptoms in absence of red flags (B).
Routine oblique views (B).

Imaging (18 studies)

CT or MRI when cauda equina, tumor, infection, or fracture strongly suspected (C).
MRI test of choice for patients who have prior back surgery (D).
Assure quality criteria for imaging tests (B).

Myelography or CT-myelography for preoperative planning (D).

Use of imaging test before one month in absence of red flags (B).
Discography or CT-discography (C).

Surgical Considerations (14 studies)

Discuss possible surgical options with patients who have persistent and severe sciatica and clinical evidence of nerve root compromise after 1 month of conservative therapy (B).
Standard discectomy and microdiscectomy of similar efficacy in treatment of herniated disc (B).
Chymopapain, used after ruling out allergic sensitivity, acceptable but less efficacious than discectomy to treat herniated disc (C).

Disc surgery in patients who have back pain alone, no red flags, and no nerve root compression (D).
Percutaneous discectomy less efficacious than chymopapain (C).
Surgery for spinal stenosis within the first 3 months of symptoms (D).
Stenosis surgery justified by imaging test rather than patient's functional status (D).
Spinal fusion during the first 3 months of symptoms in the absence of fracture, dislocation, complications of tumor or infection (C).

Psychosocial Factors

Social economic, and psychological factors can alter patient response to symptoms and treatment (D).

Referral for extensive evaluation/treatment prior to exploring patient expectations or psychosocial factors (D).

Abbreviations: NSAIDs = nonsteroidal anti-inflammatory drugs; TNS = transcutaneous nerve stimulator; CT = computerized tomography; MRI = magnetic resonance imaging; EMG = electromyography.

CATEGORIES OF THE FINDINGS AND RECOMMENDATION STATEMENTS

Recommendations for: If the available evidence (amount A, B, C, D ^* ) indicated potential benefit and outweighed potential harms

Options: If the available evidence (amount A, B, C, D) of potential benefit is weak or equivocal, (some studies for and some against) but potential harms and costs appear small

Recommendations against: If the available evidence (amount A, B, C, D) indicated that there was a lack of benefit, or that potential harms and costs outweighed potential benefits

AMOUNT OF AVAILABLE EVIDENCE AS INTERPRETED BY THE PANEL TO SUPPORT GUIDELINE STATEMENTS

A

Strong research-based evidence ( multiple specific and relevant high-quality scientific studies).

B

Moderate research-based evidence ( multiple adequate ^* or one specific and relevant high-quality scientific study).

C

Some research-based evidence (at least one adequate ^* scientific study).

D

Indirect helpful information that did not meet the inclusion trial criteria on evidence tables.