Back pain with or without leg pain - under 6 weeks which is not caused by malignancy, infection, fracture and inflammatory disorders e.g. Ankylosing Spondylitis.  But may include flare-up of persistent non-specific pain.

Red flags for spinal conditions

Serious pathology in the absence of an obvious cause (eg trauma) is very rare, but be aware of signs suggestive of more serious pathology.

Symptoms suggestive of cauda equina syndrome (compression of the cauda equina):

  • loss of bowel control (faecal or flatus incontinence) and unexpected laxity of anal sphincter
  • loss of bladder control (urinary retention or incontinence)
  • severe or progressive neurological deficit in the lower extremities or gait disturbance
  • saddle anaesthesia or paraesthesia (loss or change of perianal and perineal sensation)

Significant symptoms that may suggest cancer:

  • new onset pain in patient over age 50 years (defined as over age 55 years in some guidelines), or younger than age 20 years
  • incidence of pain in adolescents is becoming increasingly common; epidemiological surveys show point prevalence rates of around 30%
  • history of cancer
  • failure to improve after one month

Other symptoms that may suggest cancer include:

  • persistent night pain (unrelieved by change in position)
  • structural deformity of the spine
  • pain at multiple sites
  • unexplained weight loss

Symptoms that may suggest infection:

  • fevers, chills, rigors
  • immunosuppression
  • intravenous (IV) drug misuse
  • recent bacterial infection
  • penetrating wound

Symptoms that suggest fracture:

  • sudden onset of back pain associated with major trauma or minor trauma in people with osteoporosis or in those taking corticosteroids
  • structural deformity of the spine
  • severe central pain, relieved by lying down

Red flags may also be indicated by:

  • sensory or motor loss
  • history of serious injury
  • in people with or at high risk of osteoporosis
  • other disorders which increase the chance of serious aetiology, eg:
    • substance abuse
    • prolonged use of corticosteroids
    • immunosuppression
    • HIV

NB: Be aware that some red flags have very high false-positive rates and as such have little diagnostic value in primary caresettings. Careful clinical judgment to decide whether to investigate further or refer is needed.

Urgent spinal referral

Patients with any of the following suspected should be sent to A&E:

  • Suspected Cauda Equina Syndrome (not of metastatic origin).
  • Violent trauma
  • Rapid onset of new neurology (upper or lower motor neurone signs).
  • Back pain with fever or raised inflammatory markers (discitis / osteomyelitis)
  • Minor head / neck / spine trauma in known Ankylosing Spondylitis / at risk osteopenic
  • Confirmed metastatic spinal cord compression (MSCC) on imaging (consider direct referral to Oncology).


Consider urgent referral to Consultant Spinal Surgeon Clinic (where certain of malignancy contact Oncology):

  • Back pain in presence of cancer with objective signs of new recent onset neurological deficit (suspicious of tumour or metastasis).
  • Back pain with confirmed presence of spinal cancer on MR imaging.
  • Back pain with constitutional features (loss of weight, fever etc)
  • Constant unrelenting back or neck pain / especially unrelenting night pain
  • Thoracic back pain – suggestive of fracture, tumour, infection
  • Back or neck pain in less than 18 years old
  • Back or neck pain in intravenous drug users; steroid use; HIV; immunocompromised.
  • Progressive or significant neurological loss or more than one nerve root affected (upper or lower limbs), insidious onset.
  • New, worsening or significant structural deformity: Kyphosis, Scoliosis, (including osteoporotic collapse)
  • New onset or progressive myelopathic symptoms and signs
  • Recent surgery 3/12


Urgent referral to Rheumatology Clinics for suspected spondyloarthropathy:

  • See specific Rheumatology pathways
GP / Primary Clinician

Consider diagnosis (discuss within peer review)

  • Screen for red flags and suspicion of serious pathology.
  • Screen for inflammatory back pain (see separate pathway).


  • LBP in pregnancy
  • Relevant blood and urine tests if serious pathology suspected.


  • 70-84% will experience during their lifetime.
  • 20% will consult their GP.
  • 70% who take sick leave will return to work within a week 90% with 2 months.
  • Pain is usually self limiting.
  • High recurrence rate 44-80% within a year.

Risk Factors for back pain:

  • Maintaining same posture long periods of time.
  • Bending, lifting, twisting.
  • Lifting heavy objects.
  • Vibration of whole body  (e.g. driving heavy machinery)
  • Obesity.
  • Psychosocial risk factors e.g. stress and depression.

Recurrent episodes:

  • review psychosocial risk factors and use clinical judgement to determine whether to follow chronic persistent pain pathway.
  • consider nerve root/radiculopathy pathway.


Consider using risk stratification tool -

Key Messages:

  • Advice and reassurance - ‘Hurt does not equal harm’.
  • Optimal analgesia/ NSAIDS.
  • Address expectations about investigations and 'quick fix cure'.
  • Support the patient to self-manage.
  • Encourage early return to activity.
  • Encourage early return to work: consider  “Fit Note”.
  • Discuss weight management and smoking cessation if appropriate.

If not improved at 2-6 weeks:

  • Low risk groups encourage to ‘self-manage’ but consider self-referral to Physiotherapy if not resolved at 6 weeks.
  • Medium and high risk groups discuss sleep hygiene, relaxation and compliance with optimal analgesia.
  • Medium risk group consider self-referral or refer to Physiotherapy.
  • High risk groups consider referral to a Physiotherapy Service, Interface Team or Pain Service with the skills to provide a comprehensive biopsychosocial assessment and management plan.


  • Do not offer X-ray of the lumbar spine for the management of acute non-specific low back pain
  • Do not offer MRI for acute back pain where the suggestion of a serious or specific underlying cause or pathology is absent.
  • Consider guidelines in previous section.
  • Assessment / diagnosis/ detailed advice and reassurance regarding condition.
  • Risk stratification tool -
  • Reinforce helpful attitudes and beliefs supporting self-management.
  • Management of flare-ups.
  • Encourage early return to activity and work and lifestyle modification.
  • Combinations of appropriate multi-modal package of care e.g. supported self -exercise with signposting to community based and lifestyle programmes.
  • High risk - consider referral to a well Physiotherapist with the skills to provide a comprehensive bio-psychosocial assessment and management plan re: pacing and graded activity.

If not responding consider onward referral to Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management.

If not responding consider:

  • Further activity modification.
  • Challenge unhelpful attitudes and beliefs.
  • Support self-management.

If not responding after comprehensive conservative treatments and fits criteria consider referral to surgeon or pain medicine.


Only consider MRI when a diagnosis of spinal malignancy, infection, fracture, cauda equina syndrome or ankylosing spondylitis or another inflammatory disorder is suspected.

Surgical and Pain Medicine Clinic Criteria
  • No referrals to secondary care for acute back pain of less than 6 weeks duration.
  • See separate Radiculopathy / nerve root pathway.
  • See separate Chronic Pain Pathway for persistent recurrent episodes.