Non-specific low back pain without red flags or radiculopathy; 90% improve within 6 weeks.
History taking
- • Onset (acute / subacute), trigger (lifting, posture)
- • Site, radiation, severity, what makes it better/worse
- • Red flags: night pain, weight loss, fever, neurological deficit, bladder/bowel symptoms
Examination
- • Inspection: posture, scoliosis
- • Palpation: paraspinal spasm, midline tenderness
- • Range of movement
- • Neurological screen lower limbs
- • SLR (positive at <60° suggests radiculopathy)
- • Saddle sensation + anal tone if cauda equina concern
Red flags
- • Age <20 or >55, trauma, cancer history
- • Thoracic pain, night pain, systemic features
- • Saddle anaesthesia, bladder/bowel dysfunction (cauda equina — emergency MRI)
- • Bilateral neurology, progressive weakness
Differential diagnosis
- • Disc prolapse with radiculopathy
- • Spinal stenosis
- • Vertebral fracture
- • Ankylosing spondylitis (inflammatory features)
- • Malignancy / infection
Recommended investigations
- • No imaging in first 6 weeks if no red flags
- • MRI lumbar spine if red flags or radiculopathy >6 weeks
- • Bloods (FBC, CRP, ALP, myeloma screen) if systemic features
Diagnosis
- • Clinical: mechanical pattern, no red flags, no neurology
Initial treatment / management
- • Stay active — bed rest worsens outcomes
- • Heat / cold packs, posture advice
- • Physiotherapy if persistent >2 weeks
- • Stepped analgesia
Drug therapy
- • Paracetamol + topical NSAID first line
- • Add oral NSAID (ibuprofen 400 mg TDS or naproxen 250–500 mg BD) with PPI cover
- • Short course weak opioid (codeine 30 mg QDS) if needed
- • Avoid benzodiazepines and routine muscle relaxants
Lifestyle advice
- • Maintain activity, ergonomic advice
- • Lose weight if BMI elevated
- • Smoking cessation
Prescription examples
- • Ibuprofen 400 mg PO TDS × 7 d + omeprazole 20 mg OD
- • Paracetamol 1 g PO QDS PRN
- • Physiotherapy referral
Follow-up advice
- • Review in 2–4 weeks; sooner if red flags emerge
- • Re-evaluate work modification, mental health
Patient counselling
- • Reassure: most resolve in 6 weeks
- • Importance of returning to normal activity
- • Avoid passive treatments alone (manipulation, traction without exercise)
Referral criteria
- • Urgent MRI / neurosurgery: cauda equina syndrome, progressive neuro deficit, suspected malignancy / infection
- • Pain clinic / spinal surgery if persistent >12 weeks
Clinical pearls
- • Yellow flags (fear avoidance, low mood, work issues) predict chronicity — address early
References
- • NICE NG59 Low back pain 2016/2020
- • BMJ Best Practice
Educational outpatient guide — verify against local guidelines before clinical use.
