Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Early management of persistent non-specific low back pain: summary of NICE guidance

BMJ 2009; 338 doi: (Published 04 June 2009) Cite this as: BMJ 2009;338:b1805

Rapid Response:

When is Low Back Pain Non-specific?

As defined by NICE in the Low Back Pain Guidelines published “Non-
specific low back pain is tension, soreness and/or stiffness in the lower
back region for which it is not possible to identify a specific cause of
the pain. Several structures in the back, including the joints, discs and
connective tissues, may contribute to symptoms”.

So the authors agree that in addition to malignancy, infection,
fracture, ankylosing spondylities and other inflammatory disorders as
mentioned in the guidelines there are several other structures in the
back, including the joints, discs and connective tissues that may
contribute to low back pain. So pain arising from these structures cannot
be labelled as non specific unless specific causes have been excluded. In
the past we did not have the capability of diagnosing low back pain and
patients with low back pain were conveniently dumped into a group called
“mechanical low back pain” or “non specific low back pain”. In recent
years there have been publications describing the neuroanatomy of the
spine which has improved our understanding of the innervation of the
different structures in the lower back which could be the source of pain
(1,2). Simultaneously various techniques have been validated to precisely
identify which structure in the lower back could be the source of patients
pain thus providing the patient with an objective diagnosis and the
possibility of logical, specific treatment. With the information we
gather from clinical consultation, imaging studies and precision
diagnostic techniques we can diagnose approximately 70% of low back pain
(3 – 6). In our opinion our patients deserve to be given an opportunity
of a diagnosis and treatment where possible rather than just acupuncture
and manipulation which have weak evidence and (by guideline definition)
must be applied to non-diagnosed patients. We feel it is ethically and
morally wrong to not give the patient an opportunity to identify the cause
of their pain until one year and keep trying one treatment after the other
by which time the chances of the patient recovering are likely to be
significantly reduced.

In order to make a diagnosis patients need an MRI scan and specific
nerve blocking or structure stimulating techniques, all of which have very
high quality evidence and yet are specifically banned under the new
Low back pain is a complex problem and the treatment has to be tailored to
patient’s needs and prescriptive guidelines promoting “one size fits all”
is not acceptable.

The NICE guideline on low back pain does a great disservice to our
patients and represents several steps backwards in the management of low
back pain. This is also emphasised by the fact that the two major pain
organisations, The British Pain Society which is a multidisciplinary
organisation and the Faculty of Pain Medicine of the Royal College of
Anaesthetist, London have asked for withdrawal of the guidelines.

1.Groen GJ, Baljet B, Drukker J. Nerves and nerve plexuses of the human
vertebral column. Am J Anat 1990; 188: 282-296.

2.Bogduk N. The inneravtion of the lumbar spine. Spine 1983; 8: 286-

3.Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic
low back pain. Spine 1995; 20: 31-37.

4.Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value
of history and physical examination in diagnosing sacroiliac joint pain.
Spine 1006; 21: 2594-2602.

5.Schwarzer AC, Wang S, Bogduk N, et al. Prevalence and clinical
features of lumbar zygapophysial joint pain: a study in an Australian
population with chronic low back pain. Ann Rheum Dis 1995; 54: 100-106.

6.An algorithm for the investigation of low back pain. In: Practice
Guidelines- Spinal Diagnostic and Treatment Procedures. Ed: Bogduk N.
International Spinal Intervention Society, California, USA, 2004, pp 87-

Competing interests:
Dr Sanjeeva Gupta and Dr Jonathan Richardson are both Consultant Pain Specialists

Competing interests: No competing interests

15 June 2009
Dr Sanjeeva Gupta
Consultant Pain Specialist
Dr Jonathan Richardson, Consultant Pain Specialist, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ.
Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Beadford, BD9 6RJ