Non-specific back pain (6 weeks to 12 months) i.e. Non-specific as described in NICE CG 88 i.e. which is not caused by malignancy, infection, fracture and inflammatory disorders e.g. Ankylosing Spondylitis.

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:

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:

GP / Primary Clinician

Consider diagnosis (discuss within peer review):

  • Screen for red flags suggestive of serious specific causes.
  • Screen for inflammatory back Pain (separate pathway).
  • Undertake a bio-psychosocial assessment.
  • Relevant blood and urine tests if serious pathology suspected.


  • Distress, Depression, Disability, Drug escalation/dependency - or Diagnostic uncertainty
  • Sleep hygiene (strategy).
  • Relaxation.
  • Review analgesia and adherence.
  • Support the patient to self-manage.
  • Address expectations about investigations and 'quick fix cure'.



  • Consider self-referral or referral to Physiotherapy for an exercise programme, a course of manual therapy (+/- adjuvant acupuncture as part a package of care).
  • Medium and high risk groups discuss sleep hygiene, relaxation and compliance with medication and possible need for social support.
  • High risk groups consider referral to an informed Physiotherapy Service or Interface Team or Pain Service with the skills to provide a comprehensive biopsychosocial assessment and management plan.
  • If anxious or depressed consider referral or self referral to “Let’s Talk”.


  • Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
  • Do not offer an MRI scan for non-specific low back pain unless taking the rare decision to refer for an opinion on spinal fusion.

Consider guidelines in previous section.

  • Undertake bio-psychosocial assessment / Diagnosis.
  • Advice, information promoting self-management and reassurance  ‘Hurt does not equal harm ‘.
  • Encourage early return to activity, consider community based and lifestyle programmes of exercise.
  • Encourage early return to work : consider Fit Note .
  • Offer an appropriate package of care per NICE CG88 .
  • Core treatments include: Exercise programme (often in groups) , a course of manual therapy (or rarely acupuncture as part a package of care promoting self management) .

If not responding consider referral to Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management.
  • Undertake comprehensive bio-psychosocial assessment.
  • If not responding re-consider impact of symptoms on lifestyle.
  • Motivational interview/lifestyle/health and weight reduction .
  • Review conservative management   if comprehensive.
  • Reconsider psychosocial barriers to self-care (5 D’s) - Distress, Disability, Drug escalation, Dependency, Diagnostic Uncertainty.
  • Consider referral to Pain Clinic or Pain Management Program for anyone if fitting the criteria, with distress.
  • Consider if fits surgical criteria and Individual Funding Request and if appropriate refer.


  • Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
  • Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion.
Pain Clinic Criteria
  • Absence of Rheumatology referral criteria e.g. systemic malaise, inflammatory presentation.
  • Absence of specific cause of back pain amenable to surgical criteria.
  • Presence of significant risk factors of poor health outcomes (yellow flags).
  • Presence of psychosocial barriers to self –care (i.e. 5 Ds:- distress, disability, diagnostic uncertainty, drug escalation and dependency).
  • Strong opioids are being considered.
  • Invasive treatment not normally offered under 12 months  (NICE CG88).
Pain Clinic
  • Definitive medical diagnosis.
  • Assessment for most effective analgesic and Pain management options.
  • Invasive treatment not normally offered under 12 months  (NICE CG88).
  • Referral to Referral to Pain Self-Management Service / CBT.
Surgical Criteria

No referrals to secondary care orthopaedics for acute back pain of less than 12 months duration, unless:

  • No improvement despite 3-6 months of comprehensive conservative management in Core Physiotherapy


  • Low intensity CPP Programme (locally known as Back to Fitness) has failed


  • The patient has shown commitment to weight reduction through active participation in a weight management programme if the patient's BMI is >30


  • Review by Interface suggests patient likely to benefit from further opinion/management/surgery by an orthopaedic consultant or referral to a secondary care pain clinic.


Individual Funding Requests

Surgical treatment for non-specific low back pain is considered to be a procedure of low clinical priority and is listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please the attached link for details of access criteria and funding arrangements.

  • Invasive treatment not normally offered under 12 months (NICE CG88).
  • See other spinal pathways for over 12 months and specific conditions.