Synopsis
Classify low back pain safely, exclude neurological, malignant, infectious, fracture and vascular emergencies, recognise inflammatory patterns, avoid low-value imaging and medicines, and support active recovery through staged biopsychosocial care.
- Screen every new or changed episode for cauda equina, progressive motor loss, infection, cancer, fracture and vascular or visceral causes before calling it non-specific.
- Do not routinely image non-specific low back pain in non-specialist care; incidental degeneration is common and imaging is useful only when it changes management.
- Advise continued ordinary activity, self-management and return to work where feasible; prolonged bed rest weakens muscle and reinforces fear.
Key red flags
New bladder dysfunction, saddle sensory change, bilateral neurological symptoms or progressive motor deficit requires immediate cauda-equina or spinal compression assessment.
Investigation priorities
Classify non-specific, radicular, inflammatory and dangerous patterns and choose emergency care or active conservative management.
Management branches
Assessment finds no serious cause, progressive neurological loss or compelling inflammatory referral pattern.
- Explain favourable natural history, advise normal activity and early work participation within tolerance, and provide return advice for bladder, saddle, weakness, fever, trauma or deterioration.
- Use risk stratification at first contact to match simple self-management to low-risk episodes and intensive physical or psychological support to likely poor recovery.
Key medicines
Naproxen with gastroprotectionUse 250–500 mg orally twice daily with food for the shortest acute course; when gastrointestinal risk warrants, add omeprazole 20 mg orally once daily for the duration.
Codeine phosphate for exceptional acute useUse 30–60 mg orally every four hours when required for only a few days, never exceeding 240 mg in 24 hours, solely when an NSAID is unsuitable; set a stop date.