Pain localised below costal margin and above gluteal folds; most cases mechanical and self-limiting.
History taking
- • Onset, duration, mechanism, radiation, aggravating/relieving factors
- • Red flags: age <20 or >55, trauma, weight loss, fever, neurological symptoms, steroid use, malignancy
- • Bladder/bowel disturbance, saddle anaesthesia (cauda equina)
Examination
- • Posture, gait, range of motion, paraspinal tenderness
- • SLR test, neurological exam of lower limbs, perianal sensation
- • Hip and SI joint exam to exclude other causes
Red flags
- • Cauda equina syndrome (urgent surgical emergency)
- • Progressive neurological deficit
- • Suspected malignancy/infection
Differential diagnosis
- • Mechanical low back pain, lumbar disc prolapse, spinal stenosis, spondylolisthesis
- • Ankylosing spondylitis, vertebral fracture, pyogenic spondylodiscitis, malignancy
Recommended investigations
- • No imaging in acute mechanical back pain <6 weeks
- • X-ray, MRI if red flags, progressive deficit, suspicion of serious pathology
- • CBC, ESR, CRP if infection/malignancy suspected
Diagnosis
- • Clinical; classify as non-specific, radicular, or serious pathology
Initial treatment / management
- • Stay active, avoid bed rest >2 days
- • NSAIDs first-line; short course muscle relaxant
- • Physiotherapy after 2 weeks; cognitive behavioural therapy for chronic pain
- • Avoid opioids long-term
Prescription examples
- • Tab Diclofenac 50 mg PO TDS x 5 d (with PPI cover)
- • Tab Tizanidine 2 mg PO TDS x 3 d
- • Tab Paracetamol 1 g PO QID PRN
Follow-up advice
- • Review in 2 weeks; refer if no improvement
- • Encourage return to work and graded exercise
Patient counselling
- • Reassure about benign nature in most cases
- • Stay active, posture correction, weight management, core strengthening
Referral criteria
- • Red flags, refractory >6 weeks, suspected radiculopathy
Clinical pearls
- • Imaging in non-specific back pain leads to over-diagnosis and unnecessary surgery
- • Cauda equina is a surgical emergency — refer immediately
References
- • NICE NG59: Low Back Pain and Sciatica
- • ACP Guideline on Noninvasive Treatments for Low Back Pain 2017
Educational outpatient guide — verify against local guidelines before clinical use.
