Back Pain — Acute and Chronic

Safety

Screen for Red Flags — Exclude Serious Spinal Pathology First

Done

Urgently assess for serious pathology, particularly when there are new or progressive symptoms. Red flags should be interpreted in combination with the history, examination and risk context; no single red flag reliably confirms or excludes serious disease. Age modifies suspicion but is not a stand-alone threshold. Check red flags at every consultation — they can develop in a patient with established chronic back pain. Always ask about bladder, bowel, and saddle area.

Cauda Equina Syndrome New urinary retention, impaired flow or loss of bladder sensation, urinary/faecal incontinence, saddle/perineal sensory change, bilateral sciatica or bilateral neurology, progressive weakness or gait disturbance → Immediate ED / acute spinal service (local pathway) — do not arrange outpatient/community MRI; urgent MRI by the receiving service. Document motor, sensory, reflex, gait and bladder findings. Also suspect with difficulty initiating micturition or new urinary incontinence — CES may be incomplete; not all features need be present. Chronic urinary frequency or stress incontinence is not equivalent to CES.

Spinal Cord Compression Progressive bilateral leg weakness, upper motor neuron signs (clonus, hyperreflexia), thoracic pain + neuro symptoms, gait disturbance or falls → Immediate ED / acute spinal; known cancer → MSCC coordinator now Progressive leg weakness, increasing paraesthesia spreading up the leg or loss of reflexes → cord or cauda equina compression → immediate emergency assessment (urgent MRI via the local spinal pathway). Do not wait for symptoms to stabilise.

Malignancy / Spinal Metastases Current or previous cancer, unexplained weight loss, severe progressive/unremitting or night pain, thoracic pain → known cancer without neuro signs: MSCC advice within 24 h; MRI within 1 week (NICE NG234); otherwise NICE NG12 pathway. Spinal metastases (common primaries: prostate, breast, lung, kidney, thyroid, myeloma) → imaging directed by the suspected pathology via the local cancer/MSCC pathway. No generic "cancer screen" — do not order PSA or CA125 routinely for undifferentiated back pain. Older adults with persistent unexplained back/bone pain, weight loss, anaemia, hypercalcaemia, renal impairment or other myeloma features → FBC, calcium, renal function, ESR/CRP, serum protein electrophoresis and serum free light chains (per local laboratory availability); refer urgently if results or findings suggest myeloma or metastatic disease. NICE NG12: persistent unexplained back/bone pain 60+ → urgent FBC, calcium & ESR/PV; plus serum free light chains (urine Bence-Jones protein if free light chain testing is unavailable); results suggesting myeloma → suspected cancer pathway referral (NICE NG12, updated April 2026).

Known Cancer + Back Pain (?MSCC) Neurological symptoms/signs (radicular pain, weakness, sensory level, gait disturbance, bladder/bowel symptoms) → immediately contact the MSCC coordinator/acute oncology; whole-spine MRI as soon as possible and always within 24 h; dexamethasone 16 mg promptly for neurological symptoms/signs, in liaison with the MSCC service (NICE NG234). Suspected spinal metastases without neurological signs → MRI within 1 week; no routine corticosteroids unless severe pain or haematological malignancy. Low threshold to contact the MSCC pathway.

Spinal Infection Severe or progressive spinal pain + systemic illness/fever, immunosuppression, bacteraemia, IV drug use, recent spinal surgery/procedure or another infection source → Same-day hospital assessment if unwell, neuro symptoms or strongly suspected Also consider with diabetes, endocarditis or recent invasive infection (vertebral osteomyelitis/discitis). CRP/ESR are supportive, not diagnostic (normal early markers do not exclude infection); blood cultures if febrile or systemic infection suspected; MRI is the imaging test of choice. Same-day hospital if sepsis, neurological deficit, severe systemic illness or spinal instability suspected.

Severe Unrelenting Night Pain (Not Positional) Cannot find a comfortable position, worse at night — malignancy, infection, or inflammatory (ankylosing spondylitis in younger patients). Investigations directed by the suspected pathology — no routine X-ray or PSA without a specific suspicion.

Vertebral Fracture Significant trauma, or fragility-fracture risk (osteoporosis, prolonged steroids) with minor trauma → Imaging per mechanism, examination & risk; hospital if unstable, neuro deficit or cannot mobilise Consider vertebral fracture in sudden severe focal back pain, particularly after trauma or with osteoporosis, long-term corticosteroid use, frailty or previous fragility fracture. Imaging per clinical assessment and local pathway — X-ray may identify compression fracture; CT or MRI if neurological deficit, suspected malignancy, infection or diagnostic uncertainty. Significant trauma (fall from height, RTA, direct spinal trauma) → X-ray / CT spine; Fracture / cord injury risk — do not mobilise before imaging in major trauma or suspected unstable fracture (not required for every osteoporotic patient with new pain).

Aortic Aneurysm Abdominal pain, collapse, syncope, vascular risk factors, pulsatile abdominal mass, tearing pain radiating to back → 999 — do not delay

Axial Spondyloarthritis Back pain starting before 45 and lasting >3 months, with night waking, buttock pain, improvement with movement or NSAIDs, psoriasis, IBD, uveitis, enthesitis, peripheral arthritis or family history → Rheumatology per NICE NG65 (see Step 3)

Epidural Abscess / Haematoma Severe constant back pain + fever + progressive neurological deficit → Immediate ED / acute spinal service Patient on an anticoagulant + new neurological deficit: Epidural haematoma — spinal cord compression → 999 emergency. Rare — emergency decompression may be needed.

Cauda equina syndrome is the single most important diagnosis to exclude — delayed diagnosis risks permanent bladder, bowel, sexual and lower-limb dysfunction. The GIRFT national suspected cauda equina pathway (2023) requires emergency assessment via the local pathway, with urgent MRI arranged by the receiving service. Malignancy is uncommon in primary-care back pain but delayed diagnosis causes serious harm; in current or previous cancer follow the MSCC pathway (NICE NG234). Spinal infection (discitis/osteomyelitis) is rare but catastrophic if missed: with significant risk of death and permanent neurological deficit without prompt treatment. Aortic dissection/AAA can mimic back pain and is frequently fatal if ruptured — consider in anyone with abdominal pain, collapse, syncope or vascular risk factors. Missing any of these constitutes a patient safety incident.

Cauda equina syndrome (CES) is the most catastrophic missed diagnosis in back pain — it is a spinal surgical emergency. The cauda equina (horse's tail) is the bundle of nerve roots below L1 that innervates the lower limbs, bladder, bowel, and perineum. Compression (most commonly from a large central disc prolapse at L4/5 or L5/S1) causes rapidly progressive neurological deficit. Delay risks permanent bladder, bowel, sexual and lower-limb dysfunction; the timing of surgery depends on neurological status, MRI findings, specialist assessment and local pathways. Suspected CES needs immediate emergency assessment and urgent MRI via the local spinal pathway. The GP's clinical rule: ask every back pain patient about bladder (retention = most specific sign — painless inability to pass urine), bowel, and saddle area sensation at every consultation. A new positive answer to any of these → immediate emergency assessment. CES may be incomplete — not all features need be present; chronic urinary frequency or stress incontinence is not equivalent. Bilateral leg symptoms, even mild, in a back pain patient must also raise concern.

Diagnose

Confirm the Diagnosis — Targeted History

Done

Characterise the pain to guide classification and treatment. Use the SOCRATES framework with specific back-pain prompts. Yellow flags predict chronicity more reliably than any imaging finding — consider risk stratification (e.g. STarT Back) at first contact for each new episode (NICE NG59).

Onset & Mechanism

Sudden (trauma, disc prolapse) vs insidious (degeneration, malignancy). Lifting/twisting mechanism common in mechanical LBP. Ask about preceding activity.

Site & Radiation

Localised lumbar → mechanical. Radiation to buttock/thigh → referred. Below knee + dermatomal distribution → radiculopathy (L4/L5/S1). Saddle area → cauda equina.

Character

Aching / stiffness → musculoskeletal. Shooting / burning → neuropathic. Constant / boring / worse at rest → sinister (malignancy, infection).

Severity (NRS 0–10)

Document baseline pain score and function; use them to judge response at review.

Aggravating / Relieving

Worse with movement, better with rest → mechanical. Worse at rest / night → inflammatory or sinister. Better with exercise → inflammatory (AS).

Associated Symptoms

Leg weakness, sensory change, gait disturbance and falls; bladder/bowel symptoms including urinary retention or altered urinary sensation; saddle/perineal symptoms; fever, infection, immunosuppression, IV drug use or recent spinal procedure; history of cancer, unexplained weight loss; steroid use, osteoporosis, significant trauma; renal, abdominal, pelvic or vascular symptoms. Each alters the differential and urgency.

Psychosocial (Yellow Flags)

Fear-avoidance beliefs, catastrophising, low mood, workplace stress, previous sick leave for back pain — use STarT Back or another validated risk-stratification tool where available to inform shared decision-making — it informs, not replaces, clinical assessment. Also ask about sleep, mood and work concerns.

Occupation & Function

Manual labour vs sedentary. Time off work already taken. Ability to perform ADLs (dress, walk, stairs). Fit-note decisions depend on function, safety and occupation.

Duration

Acute <6 weeks · subacute 6–12 weeks · chronic >12 weeks — duration directs the pathway (Step 3). Persistent pain → chronic pathway (Steps 9–11).

Yellow flags — Beliefs

"My back is damaged and fragile" · "Pain means harm" · "I'll never get better" · "Only surgery/injection will fix me." These beliefs are the strongest predictors of disability. Address with validating language: "The pain is real, but pain does not always indicate ongoing tissue damage."

Yellow flags — Emotions

Distinguish psychological distress from a diagnosis of depression or anxiety; use PHQ-9/GAD-7 when depression or anxiety is clinically suspected, and treat it actively. Fear-avoidance behaviour: fear of movement (kinesiophobia) → reduced activity → deconditioning → more pain. Tampa Scale for Kinesiophobia.

Yellow flags — Behaviours

Prolonged rest (bed rest is harmful and counterproductive — NICE NG59 advises encouraging people to continue normal activities; movement is medicine). Passive coping (waiting for someone else to fix the pain). Repetitive healthcare seeking without self-management engagement. Medication over-reliance.

Yellow flags — Work & Social

Work dissatisfaction → poor outcomes. Manual or heavy labour with no modified duties available → barrier to return to work. Low socioeconomic status. Social isolation. Medicolegal involvement (compensation claim) → prolongs disability even with treatment.

The STarT Back Screening Tool (Keele) is named as an example risk-stratification tool in NICE NG59 and stratifies patients into low / medium / high risk of chronicity. High-risk patients (psychosocial subscale ≥4; medium = total ≥4 with subscale ≤3) need early, active attention to those factors — explanation, graded exercise, return-to-work planning, and treatment of any co-existing depression or anxiety — not just analgesia. Since July 2026 NICE NG59 no longer routes high-risk patients to psychological or combined physical and psychological programmes (recommendations withdrawn; partly based on retracted evidence). Yellow flags (psychosocial risk factors) are stronger predictors of disability at 1 year than the severity of the initial pain.

The STarT Back Tool (Keele University) is the risk-stratification tool named as an example in NICE NG59 for stratified care in non-specific LBP. It identifies patients at high risk of chronicity due to psychosocial factors (the high-risk group), who warrant closer follow-up and active attention to catastrophising, fear-avoidance and work barriers. The large RCT by Hill et al. (2011, Lancet) demonstrated that STarT Back-stratified care produced better outcomes and was more cost-effective than undifferentiated usual care. NICE NG59 recommendations on psychological therapy using a CBT approach and on combined physical and psychological programmes (1.2.13 and 1.2.14) were withdrawn on 29 July 2026 because they were partly based on retracted evidence, and psychological therapy was removed from the risk-stratification and manual therapy recommendations — keep exercise, self-management and return-to-work central (ACT/CBT under NG193 applies to chronic primary pain). The tool takes 2 minutes to complete and is available online. NICE NG59 suggests considering it at first contact for each new episode.

Diagnose

Classify the Back Pain — Subtype & Duration

Done

Classify by cause and duration — this drives the entire treatment pathway. Most is non-specific low back pain.

Non-specific LBP (mechanical)

Pain without features suggesting a specific spinal, neurological, systemic, abdominal or vascular cause; related to posture/movement. Acute <6 weeks · Subacute 6–12 weeks · Chronic >12 weeks. This is the vast majority of presentations.

Radiculopathy (sciatica)

Nerve root compression — typically L4 (medial calf), L5 (dorsum foot), S1 (lateral foot/heel). Pain radiates below the knee in dermatomal pattern. A positive straight leg raise supports the diagnosis. Sensory, motor, and reflex changes may be present. L4: medial calf, weakness of knee extension. L5: lateral calf + dorsum of foot, weakness of great toe extension (EHL). S1: posterior calf + sole + small toe, absent ankle jerk, weakness of plantar flexion. A positive straight leg raise supports nerve-root irritation but is not diagnostic alone.

Inflammatory (Axial SpA / AS)

Consider when back pain began before age 45 and has lasted over 3 months, particularly with night waking, buttock pain, improvement with movement or NSAIDs, psoriasis, inflammatory bowel disease, uveitis, enthesitis, peripheral arthritis or a first-degree relative with spondyloarthritis. Refer to rheumatology if four or more NICE NG65 referral features are present. If exactly three are present, perform HLA-B27 if available and refer if positive. Do not exclude axial SpA because HLA-B27 or inflammatory markers are negative. Do not use ASAS classification criteria as a diagnostic test or request MRI sacroiliac joints in primary care.

Specific structural cause

Spinal stenosis (bilateral leg claudication, relieved by sitting/leaning forward), fracture, spinal infection, malignancy/MSCC, myeloma, inflammatory disease. Consider according to the presentation; image when serious disease is suspected or the result will change management.

Spinal stenosis

Neurogenic claudication — bilateral leg pain/heaviness/weakness brought on by walking, relieved by sitting or leaning forward (flexing the spine increases canal space). Age >60. Canal narrowing from OA, facet joint hypertrophy, thickened ligamentum flavum. Conservative first (exercise, physio); MSK/spinal referral for severe neurogenic claudication — routine MRI is not a primary-care requirement. Do not use epidural injections for neurogenic claudication due to central canal stenosis (NICE NG59).

Referred pain

Renal disease/colic, AAA/aortic dissection, pancreatitis, pelvic disease, herpes zoster. No spinal tenderness. Pain not altered by spinal movement. Investigate accordingly.

STarT Back Risk

Low risk (score 0–3): simple advice + analgesia. Medium risk (score 4+ but psychosocial <4): physiotherapy. High risk (psychosocial subscale ≥4): physiotherapy/exercise with closer follow-up, addressing fear-avoidance and work barriers within the exercise and self-management plan, and treating co-existing low mood or anxiety in its own right (e.g. NHS Talking Therapies); NICE NG59 no longer recommends psychological or combined programmes for this group (withdrawn July 2026). The tool informs, not replaces, clinical judgement. 9-question tool (0–9 score; psychosocial subscale questions 5–9, 0–5): low risk = total 0–3 → reassurance + advice + remain active; medium risk = total ≥4 with psychosocial subscale ≤3; high risk = psychosocial subscale ≥4 (Keele scoring rule). Available free at keele.ac.uk/startback.

Duration pathway

Acute (<6 weeks): reassure, stay active, NSAID if safe — Steps 6–8. Subacute (6–12 weeks): reassess if not improving as expected; STarT Back-directed physiotherapy; address yellow flags. Chronic (>12 weeks): chronic pathway — Steps 9–11. Reassess if symptoms change.

Accurate classification prevents over-investigation and under-treatment. Radiculopathy with a significant but stable motor deficit needs urgent specialist assessment, and a severe or progressive deficit needs same-day emergency spinal assessment; imaging is arranged where it will guide intervention. Axial SpA diagnosis is often delayed, causing significant morbidity — early rheumatology referral changes disease trajectory. Non-specific LBP in low-risk patients does NOT benefit from early imaging — X-ray/CT adds no diagnostic value, increases radiation exposure, and paradoxically increases disability by medicalising a self-limiting condition (NICE NG59, Lancet 2018).

Diagnose

Targeted Examination — Spine, Neurology, Abdomen

Done

Focus on neurological examination and compare sides — findings change urgency and management plan.

Gait & Posture

Antalgic gait, inability to weight-bear → significant pathology. Observe lumbar lordosis, scoliosis, spasm.

Range of Motion

Flexion (finger-to-floor distance), extension, lateral flexion. Global restriction → degenerative. Asymmetric pain on extension → facet joint. Schober testing is not a routine primary-care test for axial spondyloarthritis — if suspected, use an inflammatory back-pain history and refer per the local rheumatology pathway.

Palpation

Midline spinous process tenderness → vertebral fracture/infection (significant finding). Paraspinal muscle spasm → mechanical. Sacroiliac joint tenderness → axial SpA.

Straight Leg Raise (SLR)

If radiculopathy is suspected: reproduction of radiating leg pain supports L4/5/S1 radiculopathy. Compare sides. A positive SLR supports nerve-root irritation but is not diagnostic alone; crossed SLR may be more specific but is not required at every consultation.

Neurological Lower Limbs

L4: knee extension, knee reflex, medial calf sensation. L5: big toe extension (EHL), dorsum foot sensation. S1: ankle plantar flexion, ankle reflex, lateral foot sensation. Document any deficit formally and compare sides. Also hip flexion (L2/3). Essential when there are neurological symptoms, sciatica, progressive pain or red flags (not needed at every review for stable uncomplicated mechanical pain); document for deterioration tracking. New objective motor deficit → urgent specialist assessment; severe or progressive deficit → same-day emergency spinal assessment.

Perianal Sensation

If bladder, bowel or saddle symptoms → assess saddle/perianal sensation; loss = cauda equina until proven otherwise → immediate ED/acute spinal transfer. A normal perianal examination does not exclude cauda equina. A bladder scan/post-void residual may help if urinary symptoms are present, but must not delay referral or falsely reassure.

Abdominal Examination

Pulsatile epigastric mass with pain, collapse or syncope → suspected ruptured AAA → 999. Check peripheral pulses where indicated. Renal angle tenderness → pyelonephritis / ureteric colic. Absent bowel sounds + peritonism → emergency.

Vital Signs

Observations including temperature where infection is possible — fever or systemic illness with severe spinal pain raises concern for spinal infection or pyelonephritis (a normal temperature does not exclude it). HR/BP if haemodynamic compromise suspected. In a patient with cancer and concerning symptoms, a normal examination does not exclude MSCC.

Neurological examination determines urgency: motor weakness in the lower limbs indicates significant nerve root compression requiring urgent specialist assessment. Absent ankle reflexes plus sensory loss in a dermatomal pattern confirms radiculopathy and guides referral (NICE NG59 advises against gabapentinoids and other antiepileptics for sciatica). Saddle anaesthesia is an indication for immediate emergency transfer (urgent MRI by the receiving service) — this is the single most time-critical physical finding in back pain. Documenting findings formally protects both patient and clinician.

Axial spondyloarthritis is identified mainly from an inflammatory back-pain history (onset before 45, >3 months, night waking, buttock pain, improvement with movement or NSAIDs, extra-spinal features) — Schober testing, CRP and HLA-B27 cannot exclude it, so refer using NICE NG65 criteria. It affects young adults of both sexes, and causes irreversible spinal fusion if untreated — but often responds to NSAIDs and specialist biologic therapy. Diagnostic delay is common and preventable.

Diagnose

Investigations — Order Only What Changes Management

Done

Do not routinely request imaging for non-specific low back pain or uncomplicated sciatica in primary care. Imaging is requested when serious disease is suspected or when the result is likely to change (specialist) management (NICE NG59). Order blood tests according to the suspected condition — there is no routine red-flag panel.

Do NOT routinely request

⚠ Avoid Plain X-ray (low-sensitivity for disc/nerve pathology, radiation, increases medicalisation). MRI or CT for uncomplicated non-specific LBP; MRI for uncomplicated sciatica at the first consultation (NICE NG59).

Bloods — directed by suspected condition

Possible infection: FBC CRP / ESR Renal function Blood cultures. Suspected myeloma: FBC Calcium ESR / plasma viscosity Serum protein electrophoresis Serum free light chains. Other tests directed by the presentation; PSA only if prostate cancer is clinically suspected (it is not a myeloma test) — guided by symptoms and prostate cancer risk, with shared decision-making.

HLA-B27 (axial SpA)

If axial SpA suspected with exactly 3 NICE NG65 additional features: HLA-B27 if available — refer if positive. ≥4 features → refer without waiting for tests. A negative HLA-B27 or normal CRP/ESR does not exclude axial SpA.

MSU (urine dipstick / MC&S)

If renal angle pain, fever, dysuria → exclude pyelonephritis and renal calculi. Dipstick positive for blood → urine M,C&S and consider ultrasound / urology referral.

MRI lumbar spine

Not routine for sciatica. Usually arranged via MSK interface, spinal service or an agreed local pathway where it will guide intervention. Suspected cauda equina/cord compression → emergency transfer; MRI by the receiving service. Suspected MSCC → whole-spine MRI as soon as possible and within 24 h; suspected spinal metastases without MSCC → within 1 week (NICE NG234). MRI is preferred for suspected infection, malignancy, MSCC, CES or significant neurological deficit (via emergency/specialist pathway); persistent radiculopathy → specialist/MSK interface arranges imaging (no universal 6-week MRI rule). Check your ICB/local pathway.

X-ray lumbar spine

Not routine. Suspected fracture: imaging depends on mechanism, examination and fracture risk; CT is generally more useful than plain radiography when significant vertebral fracture is suspected — follow local radiology pathways. Hospital assessment if unstable fracture, neurological deficit or inability to mobilise. No routine X-ray for night pain without a specific suspicion.

Myeloma / cancer (NICE NG12)

Age 60+ with persistent bone pain (particularly back pain) or unexplained fracture: FBC Calcium ESR / plasma viscosity SPEP Serum free light chains (or urine Bence–Jones) — refer via suspected cancer pathway if results suggest myeloma. Age 60+ with weight loss and back pain → consider urgent direct-access CT for pancreatic cancer, assessing abdominal, bowel and systemic symptoms.

Routine imaging in non-specific LBP does not reduce pain or disability and is associated with increased healthcare utilisation and paradoxically worse outcomes (Foster et al., Lancet 2018). Incidental findings (disc bulges, Modic changes) are common in asymptomatic individuals and lead to unnecessary anxiety and further investigations. Order blood tests when the clinical picture warrants, and do not let a normal result override clinical suspicion. Reserve MRI for cases where the result will change management, not as reassurance.

Refer

Referral Criteria — Who, When, and How Urgently

Done

Most back pain is managed in primary care. Refer when neurological findings, red flags, or failure to respond to treatment indicate specialist input.

Immediate Emergency

Immediate transfer to ED/acute spinal services: new urinary retention or markedly altered urinary sensation; new faecal incontinence with neurological symptoms; saddle or perineal sensory loss; bilateral or progressive leg weakness; rapidly progressive neurological deficit; suspected spinal cord compression; suspected unstable vertebral fracture with neurological compromise; suspected ruptured AAA, aortic dissection or another acute abdominal/vascular emergency (999). Do not delay transfer to arrange community imaging. Suspected CES: any of the features — not all need be present. Also: suspected MSCC (contact MSCC coordinator immediately; whole-spine MRI within 24 h); spinal infection with systemic illness or neurological signs; suspected epidural haematoma (anticoagulated + new neurological deficit); unstable trauma or fracture.

Same-day Urgent

Consider same-day hospital assessment: fever or systemic illness with severe spinal pain; suspected spinal infection; new significant motor deficit (foot drop, quadriceps weakness); severe pain with inability to mobilise or self-care; suspected vertebral fracture needing urgent assessment; known cancer with symptoms suggestive of spinal metastases or MSCC.

NICE NG12 Suspected Cancer

NICE NG12: age 60 and over with weight loss and back pain → consider urgent direct-access CT (within 2 weeks) for pancreatic cancer; age 60 and over with persistent bone pain, particularly back pain → myeloma blood tests (FBC, calcium, ESR or plasma viscosity, serum protein electrophoresis, serum free light chains or urine Bence–Jones) and refer on the result. Current or previous cancer (NICE NG234): neurological symptoms/signs of cord or cauda equina compression → contact the MSCC coordinator immediately; spinal pain suggestive of metastases without neurological signs → MSCC advice within 24 hours. Use the current local MSCC pathway and document the advice received. Persistent thoracic pain without a mechanical cause → urgent assessment and imaging.

Urgent MSK / spinal

Persistent or severe radicular pain despite non-surgical care — MSK/spinal referral (epidural local anaesthetic + steroid injection is a specialist option for acute severe sciatica). Progressive neurological deficit → same-day/emergency route above. Suspected spinal metastases → MSCC pathway (NICE NG234). Most uncomplicated sciatica is managed conservatively first. Refer if progressive or significant motor deficit; severe persistent pain or functional limitation despite appropriate treatment; symptoms persist and surgery may be considered; or imaging is likely to alter management (usually arranged by the specialist/MSK interface). Severe neurogenic claudication (spinal stenosis). Known cancer + new back pain → low threshold to contact the MSCC pathway.

Routine Neurosurgery / Ortho

Sciatica where non-surgical treatment has not improved pain or function — spinal decompression considered when radiological findings are concordant (NICE NG59). Spinal stenosis with claudication limiting quality of life.

Routine Rheumatology

Back pain starting before 45 and lasting >3 months with ≥4 NICE NG65 additional features, or exactly 3 features + positive HLA-B27. Do not use ASAS classification criteria as a diagnostic test in primary care. A negative HLA-B27 or normal CRP does not exclude. Also RA with spinal involvement; psoriatic arthritis with axial disease.

MSK / Physiotherapy

Medium/high STarT Back score — refer to musculoskeletal physiotherapy service directly. High psychosocial risk — physiotherapy/exercise with closer follow-up; NHS Talking Therapies for co-existing depression/anxiety (NICE NG59 psychological and combined programme recommendations withdrawn July 2026). All non-specific chronic LBP: offer exercise as first line (NICE NG59). STarT Back low risk: advice + leaflet + encourage activity.

Pain Management

Chronic back pain (>3 months) not responding to first-line management — consider pain service referral. Do not offer opioids for chronic LBP or chronic sciatica. NICE NG193 applies only to chronic primary pain (>3 months with significant distress or functional disability not better explained by another condition) — not to all chronic LBP. For chronic primary pain: supervised group exercise, consider ACT or pain-focused CBT, a limited course of acupuncture/dry needling, or an antidepressant after discussing benefits and harms; do not initiate gabapentinoids or other antiepileptics. Referral is individualised (no fixed 12-week rule) — based on diagnosis, functional impairment, failure of appropriate conservative management, medication complexity/dependence and local MSK and pain service pathways. Radiofrequency denervation only in carefully selected patients (specialist). Spinal cord stimulation (NICE TA159, 2008: an option for chronic neuropathic pain, including failed back surgery syndrome, persisting at least 6 months despite conventional management, after a successful trial). Pain service assessment where indicated (chronic primary pain → NICE NG193). The NICE NG59 combined physical and psychological programme recommendation was withdrawn in July 2026.

Occupational Health

Prolonged or at-risk work absence. Workplace assessment and reasonable adjustments. Phased return to work. Fit note guidance: GP should specify modifications not just "unfit for work" — per DWP fit note guidance.

Cauda equina requires emergency assessment and decompression to reduce the risk of permanent bladder/bowel dysfunction. Significant or progressive motor deficit needs prompt specialist assessment. Delayed referral for axial SpA remains a known quality-of-care failure in UK primary care — NICE NG65 (2017) supports rheumatology referral when its spondyloarthritis criteria are met. NICE NG59 advises against opioids for chronic LBP; its combined physical and psychological programme recommendation was withdrawn in July 2026 (partly based on retracted evidence).

Malignant cord compression (MSCC) from vertebral metastases is a spinal emergency that requires urgent MRI of the whole spine. NICE NG234 (Spinal metastases and MSCC, 2023) asks for MRI as soon as possible and always within 24 hours for suspected MSCC, and 16 mg dexamethasone promptly for people with neurological symptoms or signs of MSCC, continued while awaiting surgery or radiotherapy — in liaison with the MSCC service, not GP-initiated prolonged dexamethasone; no routine corticosteroids for suspected spinal metastases without neurological signs unless severe pain or haematological malignancy; spinal pain suggestive of metastases without suspected MSCC still needs MRI within 1 week via the acute oncology/MSCC service. GPs should have a low threshold for suspecting MSCC in any back pain patient with a history of cancer — the primary cancer may have been diagnosed years previously. Common primaries: prostate (sclerotic lesions), breast, lung, kidney, thyroid, myeloma. The outcome of MSCC depends critically on the patient's neurological status at the time of decompression — so act before deficits progress.

Treat

Analgesic Ladder & Pharmacological Treatment

Done

Tailor analgesia to pain type (nociceptive vs neuropathic), severity, and comorbidities. Always combine with exercise and self-management — drugs alone are insufficient. Doses shown are clinical-practice examples; follow the local formulary.

Mechanical / Nociceptive

Oral NSAID 1st line

NICE NG59: consider an oral NSAID at the lowest effective dose for the shortest possible duration (e.g. ibuprofen 400mg TDS with food or naproxen 500mg BD), after assessing GI, renal, hepatic and CV risk; offer gastroprotection by individual risk and local formulary; do not offer paracetamol alone. Topical diclofenac is not an NG59 recommendation — local formulary/product information only, not an evidence-equivalent first line.

Radiculopathy / Neuropathic

No neuropathic agents for sciatica Do not offer

NICE NG59: do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for sciatica, and do not offer SSRIs, SNRIs or tricyclics for low back pain. For persistent radicular pain use NSAID, physiotherapy and specialist spinal assessment (epidural or surgery if severe and persistent). Be aware NSAIDs have limited benefit and potential harm in sciatica. Do not offer opioids for chronic sciatica. These medicines are not recommended for sciatica in primary care — there is no routine "neuropathic agent" step.

Muscle spasm

Benzodiazepines Do not offer

NICE NG59: do not offer benzodiazepines for sciatica — lack of benefit and evidence of harm. Manage spasm with movement, graded activity and an NSAID where appropriate.

Step 1Self-management and staying active first. Do not offer paracetamol alone (NICE NG59). Topical NSAID only per local formulary (not an NG59 recommendation) — evidence is stronger for localised superficial conditions and benefit for deep spinal pain is uncertain; if offered, explain this and assess NSAID contraindications. Review as needed.

Step 2Consider oral NSAID — e.g. ibuprofen 400mg TDS with food, or naproxen 500mg BD; lowest effective dose, shortest possible duration. Assess GI, renal, hepatic and CV risk; check anticoagulants, antiplatelets, corticosteroids and SSRIs/SNRIs. Gastroprotection by overall GI risk and the chosen NSAID (local formulary), not age alone. Review if symptoms persist or the NSAID is ineffective. In chronic pain: a short trial if safe — naproxen 500 mg BD may suit some adults (not a universal regimen); also assess age/frailty, hypertension, heart failure and pregnancy. Paracetamol may sometimes be an adjunct, but benefit should not be assumed.

Step 3 (neuropathic)NICE NG59: do not offer antidepressants (SSRIs, SNRIs, tricyclics such as amitriptyline) for low back pain, or gabapentinoids/antiepileptics for low back pain or sciatica. Treat co-existing depression in its own right (duloxetine is an option there). Consider MSK/spinal referral for persistent or severe radicular pain.

Step 4Weak opioid (NICE NG59: acute pain only, if an NSAID is contraindicated, not tolerated or ineffective; with or without paracetamol) — e.g. codeine phosphate 30–60mg QDS — smallest appropriate quantity, assess dependence risk, review promptly with a clear stop plan. Counsel driving, sedation, constipation (laxative), falls and respiratory risk, alcohol/benzodiazepine/sedative interaction; mind total daily paracetamol dose. Do not offer opioids for chronic LBP or chronic sciatica. Do NOT combine with tramadol.

Step 5 (specialist)Do not offer opioids (weak or strong) for chronic non-specific LBP or chronic sciatica (NICE NG59). Persistent pain → MSK/spinal or pain service. No benefit vs harm in chronic LBP (Cochrane 2023).

Oral Corticosteroids

Not recommended: NICE NG59 advises against oral corticosteroids for sciatica, and they have no role in mechanical LBP. Limited evidence; significant side effects. Severe persistent radicular pain → specialist spinal assessment (epidural steroid injection is a specialist option for acute severe sciatica).

Topical Capsaicin (neuropathic only)

Not part of the mechanical low back pain ladder. Capsaicin cream is an option only for localised neuropathic pain — follow the local neuropathic pain guidance.

NSAIDs — Contraindications

Avoid or seek advice: previous or active ulceration or GI bleeding; significant renal impairment (renal risk is clinical and dose-related — not a single eGFR cut-off); heart failure or significant CV disease; uncontrolled hypertension; concomitant anticoagulant, antiplatelet, corticosteroid or SSRI/SNRI; NSAID hypersensitivity; pregnancy (particularly from 20 weeks; contraindicated in the third trimester).

Paracetamol alone is not effective for LBP, so NICE NG59 advises against offering it on its own. NSAIDs have the strongest evidence for short-term pain relief in LBP but carry GI, CV and renal risks — use the lowest effective dose for the shortest possible duration. Opioids: systematic reviews show no meaningful benefit over placebo for chronic non-specific LBP, with significant harms (addiction, constipation, falls in elderly, hyperalgesia). NICE NG59 states do NOT offer opioids for chronic low back pain (and NICE NG193 does not recommend them for chronic primary pain). NICE CG173 neuropathic pain recommendations do not apply to sciatica — NG59 advises against gabapentinoids and other antiepileptics, and NG193 advises not initiating them for chronic primary pain. Treat co-morbid depression or anxiety in its own right.

Lifestyle

Non-Pharmacological Treatment — The Most Important Step

Done

NICE NG59 is explicit: exercise and self-management are the primary treatment for back pain. Drugs without these are insufficient. Prescribe activity as medicine.

Stay Active — No Bed Rest Strongly advise to continue normal activity as much as pain allows. Bed rest worsens outcomes and promotes chronicity. "Keep moving" is the single most important message.

Structured Exercise Programme Refer to physiotherapy (NHS or self-refer). Consider an exercise programme suited to the patient's preferences and ability; consider a group exercise programme for a specific episode or flare-up (NICE NG59).

Manual Therapy / Manipulation NICE NG59: consider only as part of a treatment package including exercise. Spinal manipulation (physiotherapist or osteopath), mobilisation, or massage — offer only within a package including exercise — not standalone (psychological therapy removed from this recommendation, July 2026). Do not offer traction.

Heat Application Topical heat (wheat bag, hot water bottle) may give short-term relief as a self-management measure (clinical practice, not an NG59 recommendation).

Weight Management General health advice — offer weight management support (e.g. NHS weight management programme; exercise + dietary support) where appropriate; Tier 3 if BMI >35. Not a core NG59 back-pain recommendation.

Psychological Support NICE NG59 recommendations on psychological therapy (CBT approach) and combined physical and psychological programmes were withdrawn in July 2026 because they were partly based on retracted evidence. Address fear-avoidance within the exercise and self-management plan, and treat co-existing depression, anxiety or distress in its own right (e.g. NHS Talking Therapies). ACT or pain-focused CBT are NG193 options only where pain meets criteria for chronic primary pain.

Smoking Cessation General health advice — refer to NHS Stop Smoking Service or prescribe NRT; varenicline is the most effective pharmacotherapy. Smoking cessation benefits overall health (no guaranteed reduction in back pain). Not a core NG59 back-pain recommendation.

Sleep Hygiene & Ergonomics Poor sleep amplifies pain perception. Offer practical sleep-position advice (e.g. pillow between knees if side-lying) — clinical practice, not an NG59 recommendation. Workplace ergonomics assessment if sedentary/manual work — via occupational health or self-referral.

Return to Work Encourage continuation of normal activities and facilitate return to work or usual roles where feasible. Consider temporary modification of duties, pacing and occupational-health input. Make fit-note decisions according to function, safety and the patient's occupation; there is no universal duration of sickness certification.

Acupuncture NICE NG59 advises not offering acupuncture or traction for low back pain with or without sciatica. Some patients self-fund it; not routinely commissioned nationally.

Exercise is central to NICE NG59 management. NICE NG59 withdrew its psychological therapy (CBT approach) and combined physical and psychological programme recommendations in July 2026 (partly based on retracted evidence); manual therapy remains an option only alongside exercise. Return to work: facilitate return to usual roles where feasible, with temporary adjustments and occupational-health input. Bed rest is actively harmful: the Cochrane review (2010) shows it worsens pain and disability versus staying active. The message to patients: "Your back is not fragile. Movement heals it."

Diagnose

Chronic Back Pain (>12 Weeks) — Reassess & Re-screen

Done

Persistent back pain (>12 weeks): reassess the diagnosis, function, mood and impact. Re-examine for neurology and inflammatory features, and re-check red flags at every consultation (Step 1) — then manage with a biopsychosocial, exercise-led approach (Steps 10–11).

Non-specific CLBP

Most patients seen in primary care, after serious and specific causes have been considered — reassess if symptoms change. Chronic (>12 weeks). No neurological deficit. No red flags. Influenced by psychosocial factors (yellow flags). NICE NG59: do not routinely image in non-specialist settings (specialist imaging only if the result is likely to change management) — imaging rarely changes management and may be harmful (catastrophising, over-medicalisation of normal findings). Exercise is the treatment.

Missed red flags

New neurology, systemic features or new bladder, bowel or saddle symptoms → emergency/urgent pathway (CES, MSCC, infection, fracture) — see Steps 1 and 6.

Inflammatory pattern

Re-screen younger patients if the pattern evolves. Use NICE NG65 referral criteria, not a simplified rule: onset before 45 (before 40 particularly suggestive), symptoms >3 months, improvement with movement, night waking, buttock pain, psoriasis, inflammatory bowel disease, uveitis, enthesitis, family history, good response to NSAIDs. HLA-B27 and CRP may both be negative — do not use them to exclude. Ankylosing spondylitis, psoriatic arthritis, reactive, enteropathic. Rheumatology referral. Refer per NICE NG65 criteria (Step 6).

Distinguish pain types

Non-specific mechanical back pain, radicular pain (sciatica), clearly neuropathic pain (NICE CG173) and chronic primary pain (NICE NG193: >3 months with significant distress or functional disability not better explained by another condition) are managed differently — do not blur them.

Mood (PHQ-9 / GAD-7)

Use when depression or anxiety is clinically suspected — not mandated annually for every patient. Distinguish psychological distress from a diagnosis of depression or anxiety. Treat diagnosed depression/anxiety actively in its own right.

NICE NG59 explicitly states: "Do not offer imaging for non-specific low back pain." This is a major departure from historical practice and is frequently misunderstood by patients and clinicians alike. The evidence base is clear: routine MRI in back pain patients without red flags increases catastrophising, disability, and healthcare utilisation without improving outcomes. Degenerative disc changes (disc bulges, facet joint OA, Modic changes) are common in pain-free adults on MRI — they are radiological variants of ageing, not pathological findings requiring treatment. Telling a patient they have a "bulging disc" or "wear and tear changes" significantly increases their pain beliefs, reduces physical activity, and promotes disability behaviour. The GP communication task is to explain that absence of imaging is the evidence-based approach, and that the spine is strong and movement is healing.

Treat

Chronic Back Pain — Medicines Review & Deprescribing

Done

In chronic back pain, medicines play a limited role. Oral NSAID (short trial if safe) and topical NSAID as in Step 7; review what is already prescribed, rationalise, and keep exercise and self-management central.

AmitriptylineAmitriptyline 10–30 mg nocte (low-dose) — not for the back pain itself: NICE NG59 advises against SSRIs, SNRIs and tricyclics for low back pain. Consider only for a separate indication (e.g. chronic primary pain under NICE NG193 after shared decision-making, or a clearly neuropathic condition under CG173) — do not blur these with non-specific mechanical or radicular pain. If used: start at 10 mg, titrate to 30 mg; review at 6 weeks.

DuloxetineDuloxetine 30–60 mg OD — SNRI; not for the back pain itself (NICE NG59 advises against SSRIs, SNRIs and TCAs for low back pain). Use only for co-existing depression or anxiety, treated in its own right, or a separate, clearly neuropathic condition (e.g. painful diabetic neuropathy, NICE CG173) — not for sciatica: CG173 does not cover sciatica, and NICE NG59 (2020 update) makes no antidepressant recommendation for sciatica (research recommendation only), so any trial is a specialist or pain-service decision. Review at 4 weeks for efficacy and tolerability. Maximum 120 mg OD.

GabapentinoidsGabapentin / pregabalin — not recommended for low back pain or sciatica (NICE NG59, 2020 update). If a patient is already taking gabapentin or pregabalin for this indication, plan an individualised withdrawal (particularly after long-term or high-dose use) following dependence/withdrawal guidance — no fixed schedule. NICE NG59: do not offer gabapentinoids or other antiepileptics for low back pain or sciatica. Both are Class C, Schedule 3 controlled drugs (since April 2019). Addiction potential — review regularly and do not prescribe indefinitely without specialist review.

OpioidsNICE NG59: Do NOT use opioids for non-specific chronic low back pain. Weak opioids (codeine, tramadol) have no evidence of long-term benefit and significant harms (dependence, cognitive impairment, falls, hyperalgesia). If already prescribed, agree an individualised tapering plan — assess dependence, withdrawal, mental health, substance use and patient preference; seek specialist pain/addiction advice for complex cases. Strong opioids are not appropriate for CLBP.

Next steps: see Sciatica · Cauda equina syndrome · Metastatic spinal cord compression · Chronic primary pain · Opioids in non-cancer pain · Axial spondyloarthritis

The NICE NG59 recommendation against opioids for non-specific chronic low back pain is based on robust evidence that opioids produce minimal long-term pain reduction while causing significant harms: dependence, opioid-induced hyperalgesia (opioids paradoxically increase pain sensitivity with chronic use), constipation, cognitive impairment, falls (especially in elderly), sexual dysfunction (opioid-induced androgen deficiency), and overdose risk. Many patients on long-term opioids would benefit from an individualised tapering plan combined with exercise-based physiotherapy and support. Opioid tapering for CLBP is an active RCGP GP guidance priority and is specifically tested in SCA examination scenarios. A key phrase for the SCA: "I can help you come off these medications — they may actually be making your pain worse in the long run."

Lifestyle

Chronic Back Pain — Exercise-Led Active Self-Management

Done

Exercise and active self-management are the core treatment for chronic back pain, not an add-on. Manage expectations: function and flare-control rather than a pain-free spine. Weight and smoking advice as in Step 8.

Exercise (NICE NG59 — first line)

Any form of exercise is beneficial — there is no evidence that one type is superior. Aerobic exercise (walking, swimming, cycling), strengthening (core stabilisation, resistance training), yoga, Pilates, tai chi. Choose sustainable activity that is acceptable and achievable; progress gradually and focus on function rather than pain elimination. Consider physiotherapy for a tailored programme.

Physiotherapy

Manual therapy (manipulation, mobilisation, soft tissue) — consider only as part of a treatment package including exercise (NICE NG59), not standalone. Transcutaneous electrical nerve stimulation (TENS) — NICE NG59 advises not to offer it for low back pain, although it is used widely. Heat therapy — temporary relief, adjunct only.

Psychological interventions

NICE NG59: the psychological therapy (CBT approach) and combined physical and psychological programme recommendations were withdrawn in July 2026 (partly based on retracted evidence). NHS Talking Therapies for co-existing depression or anxiety. ACT or pain-focused CBT remains an NG193 option where the pain meets criteria for chronic primary pain.

Acupuncture

NICE NG59: do not offer acupuncture for low back pain. However, NICE NG193 allows consideration of a limited course of acupuncture or dry needling for chronic primary pain under specified conditions — explain the distinction to patients who request it.

Spinal injections

Epidural steroid injection (ESI): NICE NG59 — do not offer spinal injections for low back pain; consider epidural local anaesthetic and steroid only in acute and severe sciatica. Evidence: short-term benefit for radiculopathy only (not non-specific pain). Do not use epidural injections for neurogenic claudication due to central canal stenosis. Facet joint injections are not offered for low back pain. Radiofrequency denervation: consider only in carefully selected patients after a positive diagnostic medial branch block (NICE NG59) — specialist decision.

Movement Is Medicine Key message, in validating language: "The pain is real, but pain does not always mean ongoing damage — movement is safe and helps." Choose sustainable activity that is acceptable and achievable, progress gradually, avoid prolonged bed rest, and focus on function rather than pain elimination.

Posture & Ergonomics No single "correct" posture prevents CLBP — varying position and regular movement breaks matter more than any specific posture. Offer practical lifting, desk and driving advice as needed rather than fixed rules.

Sleep Quality Poor sleep worsens pain perception (increases central sensitisation) — address sleep as part of self-management. Practical sleep-position advice as preferred (e.g. pillow between knees for side sleepers). Treat insomnia actively (CBT-I, sleep restriction therapy via NHS Talking Therapies).

Work & Activity Staying at work or returning to usual roles where feasible is an important outcome in CLBP. Fit note: specify modifications ("can do light duties / avoid heavy lifting / standing breaks") rather than total incapacity where possible. Occupational health referral early.

Pacing & Flare Management Teach activity pacing: do activities in small chunks with scheduled rest — avoids boom-and-bust cycle (overdoing → crash → bed rest → deconditioning). During flares: short course NSAIDs + continue gentle movement + avoid prolonged bed rest. Written flare management plan.

Back Pain Resources NHS Pain Toolkit (paintoolkit.org): free self-management guide. Arthritis UK (arthritis-uk.org): back pain information. MIND back pain and mental health resources. Refer to social prescriber for community activity.

Exercise is a core NICE NG59 treatment for chronic low back pain. The type of exercise is less important than adherence and consistency — patients should be encouraged to choose an activity they enjoy (swimming, walking, yoga, tai chi) rather than a specific "back exercise" programme, because enjoyment predicts adherence and adherence predicts outcome. The neurobiological mechanisms by which exercise reduces chronic pain include: endogenous opioid release, central pain inhibition (reduced central sensitisation), anti-inflammatory cytokine production, improved sleep, and mood enhancement via serotonin/dopamine. The GP's most important CLBP communication task is to explain that movement does not damage the back — the spine is a strong structure designed for movement, and, in validating terms, the pain is real but does not always indicate ongoing tissue damage.

The "boom-and-bust" cycle is one of the most important concepts in chronic pain self-management — patients with CLBP frequently overdo activities on "good days" (boom), experience a pain flare from overexertion (bust), then rest for days (which deconditions them further). This cycle gradually escalates disability. Pacing (doing a set quota of activity regardless of pain level — not stopping when pain increases, not overdoing when pain is low) breaks this cycle. The concept comes from operant pain management theory (Fordyce, 1976) and is the foundation of all evidence-based pain management programmes. Teaching pacing explicitly in a GP consultation is one of the highest-impact behavioural interventions available in primary care for CLBP. The pain toolkit (paintoolkit.org) is a free resource developed by Pete Moore (a chronic pain patient) that encapsulates all these principles in patient-friendly language.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

Provide clear safety-net instructions at every consultation. Document that you have given them. Follow-up should be individualised according to severity, function, risk stratification, treatment and diagnostic uncertainty rather than fixed review intervals.

Early review

Consider if: high STarT Back risk, acute severe episode, new medication (e.g. weak opioid), or diagnostic uncertainty. Assess: pain score, function, medication tolerance, ability to work. In chronic pain: STarT Back stratification completed? Physiotherapy commenced and engaged? Medication reviewed — escalate or rationalise. Depression/anxiety treated? If opioids prescribed → review tapering plan. New neurological or systemic symptoms? Examine neurology if symptoms are present.

If not improving

Review if pain or function is not improving as expected, symptoms become persistent or recurrent, new neurological findings develop, medication is ineffective or causing adverse effects, or work participation or psychological distress is deteriorating. Reassess the diagnosis and actively look for new or changing symptoms (NICE NG59). Persistent radicular pain → MSK/spinal referral rather than GP-requested MRI.

Persistent (>3 months)

Chronic LBP review. Assess: analgesic appropriateness (opioids should not be continued for chronic LBP), functional improvement, occupational impact, need for pain service referral. Consider medication rationalisation. Later review: Exercise programme sustained? Functional improvement (optionally a patient-reported outcome measure, e.g. Roland Morris or Oswestry). Consider pain service referral based on functional impairment, failure of appropriate conservative management, medication complexity/dependence and local pathways — not a fixed 12-week rule. Opioid tapering progress?

Ongoing

Review long-term medicines as clinically indicated. Ask about mood and anxiety, and treat co-existing depression or anxiety in its own right. In chronic pain, review is individualised by functional impact, treatment response, medication risks, work status, new neurological or systemic symptoms and patient goals. Assess function and activity, work participation, medication benefit and adverse effects, exercise adherence, mood/distress when clinically indicated, and new red flags. Consider stepping down medications if pain stable.

Urgent help if

Safety-net explicitly: go to A&E immediately (call 999 if unable to get there safely) for new urinary retention, loss of bladder or bowel control, saddle numbness, bilateral leg weakness, progressive weakness or inability to walk; seek same-day medical help for fever with severe back pain or rapidly worsening symptoms. Sudden severe "worst ever" back pain with collapse (AAA / aortic dissection) → 999. Also: altered urinary sensation, difficulty starting to pass urine, new incontinence or bilateral leg symptoms → immediate emergency assessment (CES). Sudden severe back pain in known osteoporosis/cancer (vertebral fracture/cord compression).

Same-day GP if

Fever or systemic illness with back pain. New foot drop or rapidly progressive neurological deficit. Severe pain unresponsive to analgesia. Suspicion of vertebral fracture after fall. Unexplained weight loss noted. New or worsening neurological signs (leg weakness, new foot drop, spreading paraesthesia); new fever + back pain (vertebral osteomyelitis); sudden intractable pain in a patient with known cancer.

Fit Note Guidance

Make fit-note decisions according to function, safety and the patient's occupation; there is no universal duration of sickness certification. Use "may be fit for work" with temporary adjustments, phased return or altered duties where feasible. Chronic LBP: review the fit note at every issuing — avoid open-ended fit notes for CLBP. Specify modifications where possible. Describe functional limitations and workplace adjustments — do not promise a phased return by a particular time. Consider occupational health for prolonged absence (the national Fit for Work service closed in 2018).

Medication Review

NSAIDs: lowest effective dose, shortest possible duration — review and stop if ineffective. Opioids (acute pain only): review promptly with a planned stop; do not continue for chronic LBP/sciatica. Gabapentinoids are not recommended for sciatica (Schedule 3 CD if prescribed for another indication). Document review in notes.

Opioid Review

Patients on long-term opioids for CLBP: review regularly. Assess efficacy (functional improvement — not just pain relief), side effects, dependence signs. Agree an individualised taper (no universal rate), assessing dependence, withdrawal, mental health, substance use and patient preference. Seek specialist pain/addiction advice for complex cases; buprenorphine patches are not a routine primary-care bridge.

Safety-netting for cauda equina must be explicit and documented — courts have found GPs negligent for failure to document this warning. Red flags can evolve between consultations — re-ask and document them at every contact. Long-term opioids have no evidence of benefit in chronic LBP — active deprescribing reduces harm. Gabapentinoids became Schedule 3 Controlled Drugs in 2019 due to misuse potential — require monitoring and cannot be issued by repeat prescription without review.

The Oswestry Disability Index (ODI) is the gold standard patient-reported outcome measure (PROM) for low back pain — it is a 10-item questionnaire covering personal care, lifting, walking, sitting, standing, sleeping, social life, travelling, and pain intensity. Scores: 0–20% = minimal disability; 21–40% = moderate; 41–60% = severe; 61–80% = crippled; 81–100% = bedbound. Where useful, documenting ODI at baseline and at review provides an objective functional measure to guide escalation decisions, evidence treatment response, and support referral justification. Significant improvement is defined as ≥10-point reduction. For the SCA examination, being able to name a validated functional outcome measure for back pain and explain its clinical application demonstrates clinical knowledge at examiner-quality level. The Roland Morris Disability Questionnaire (24-item) is an alternative PROM that is simpler to complete.

🦴 Back Pain — Acute and Chronic

Screen for Red Flags — Exclude Serious Spinal Pathology First

Confirm the Diagnosis — Targeted History

Classify the Back Pain — Subtype & Duration

Targeted Examination — Spine, Neurology, Abdomen

Investigations — Order Only What Changes Management

Referral Criteria — Who, When, and How Urgently

Analgesic Ladder & Pharmacological Treatment

Non-Pharmacological Treatment — The Most Important Step

Chronic Back Pain (>12 Weeks) — Reassess & Re-screen

Chronic Back Pain — Medicines Review & Deprescribing

Chronic Back Pain — Exercise-Led Active Self-Management

Follow-Up, Monitoring & Safety-Netting