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.
- Offer exercise appropriate to needs; manual therapy should be used only in a package including exercise, with psychological treatment for persistent obstacles or high poor-outcome risk.
- If medicine is needed, consider a brief oral NSAID after gastrointestinal, renal, cardiovascular and pregnancy review; paracetamol alone, gabapentinoids, antidepressants and chronic opioids are not recommended.
- Inflammatory clues include onset before 45, over three months of pain, second-half night waking, buttock pain, improvement with movement, rapid NSAID response, psoriasis, uveitis, IBD, enthesitis or family history.
- Use the NICE axial-spondyloarthritis referral combination; normal CRP, normal ESR, negative HLA-B27 or a normal radiograph does not exclude disease.
- Immediate MRI is required for suspected cauda equina or compressive neurological emergency; cancer or infection may require broader spinal coverage than routine lumbar imaging.
Key red flags
New bladder dysfunction, saddle sensory change, bilateral neurological symptoms or progressive motor deficit requires immediate cauda-equina or spinal compression assessment.
Fever, bacteraemia, immunosuppression, injecting drug use, spinal procedure or constant severe pain raises vertebral osteomyelitis or epidural abscess and needs urgent cultures and MRI.
Cancer history, weight loss, progressive night pain or multi-level neurological findings requires an urgent malignant spinal pathway and appropriately timed whole-spine imaging.
Significant trauma, older age with fragility risk, prolonged glucocorticoids or focal percussion tenderness suggests vertebral fracture even after low energy.
Sudden tearing back or abdominal pain, syncope, pulse deficit, hypotension or a pulsatile abdominal mass suggests vascular catastrophe and needs emergency transfer.
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.
- Offer group or individual exercise chosen around capability and preference; consider manual therapy only within a package including exercise.
- For persistent pain or psychosocial obstacles, combine exercise with CBT-informed treatment and address sleep, mood, work and dependence-prone medicines.