Over 12 months duration 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 red flags / systemic malaise.
  • Screen for inflammatory back pain.
  • Examine for specific back pain causes.

Biopsychosocial assessment and management and consider:

Consider possible associations of anxiety and depression in adults with a chronic physical health problem:

  • If anxious or depressed consider referral or self referral to “Let’s Talk
  • sleep hygiene.
  • relaxation.
  • review compliance with medication .

Use clinical judgement to determine whether to follow this persistent pain pathway or a specific condition pathway.


  • Consider using risk stratification tool -
  • Optimal analgesia/ NSAID.
  • Simple analgesia escalate in a stepwise approach to include weak Opioids and / or Tramadol.
  • Consider Tricyclic antidepressants.
  • Support the patient to self-manage
  • Consider self-referral or referral to Physiotherapy for an exercise programme, a course of manual therapy +/- adjuvant acupuncture.
  • 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.
  • Consider referral to Expert Patient Programme.
  • Consider Community Health Trainers
  • Consider third sector voluntary charitable groups.

Imaging / Bloods

  • Do not routinely offer X-ray of the lumbar spine for the management of non-specific low back pain.
  • GP to consider appropriate investigation according to any concerns from history and examination. Possible tests to include:
    • FBC
    • U&Es
    • LFTs
    • Bone profile
    • Fasting glucose
    • Thyroid Function Tests
    • Inflammatory markers
    • Plasma Viscocity
    • CRP
    • Urine dipstick tests for blood, protein or glucose.
    • Consider Vitamin D with risk factors.
  • Consider and reinforce guidance in previous section.
  • Bio-psychosocial assessment and management.
  • Risk stratification tool -
  • Active self-management with exercise / fitness / lifestyle advice.
  • Ensure fitness programme has been offered / Pacing/ graded exercise / Back to Fitness programme.
  • Explain pain mechanisms (use Pain Toolkit
  • Reinforce optimisation of analgesia (Discuss with GP to consider tricyclic antidepressants).
  • Consider Expert Patient Programme / signposting to other support programmes.
  • High risk group: consider referral to a Physiotherapist within Service if available or to Interface Team or Pain Service with the skills to provide a comprehensive bio-psychosocial assessment and management plan.
  • If not responding consider referral to Interface Team.
Interface Team
  • Review previous assessment, diagnosis and management.
  • Reconsider for a specific cause of back pain and investigations required.
  • Reconsider psychosocial barriers to self-care (5 Ds): Distress, Depression, Disability, Drug escalation/dependency, Diagnostic uncertainty.
  • Advice, information and reassurance and promoting self-care.
  • Challenge unhelpful beliefs and attitudes.
  • Review step-wise analgesia with GP support.
  • Ensure fitness programme and comprehensive conservative management has been offered.

If no major barriers are identified and the GP is seeking reassurance, discharge is warranted at this stage.

Or if barriers identified consider referral criteria below:-

  • Consider referral to Rheumatology if fits criteria.
  • Consider referral to Pain Clinic or Pain Management Programme if fits criteria.
  • Consider if fits surgical and Individual Funding Request criteria and if appropriate refer.

Imaging / Bloods

  • Unlikely but consider Xray of symptomatic joints only to exclude other joint / bone arthropathy or pathology.
  • Liaise with GP to consider appropriate investigations e.g. Bloods : FBC, U&Es, LFTs, Bone profile, fasting glucose, Thyroid Function Tests.
  • Inflammatory markers: Plasma Viscosity and CRP Urine dipstick tests for blood, protein or glucose.
  • Consider Vitamin D with risk factors.
Pain Clinic Criteria
  • Absence of Rheumatology referral Criteria e.g. systemic malaise, inflammatory presentation.
  • Absence of specific cause of back pain amenable to surgery.
  • Presence of significant risk factors of poor health outcomes (yellow flags).
  • Presence of psychosocial barriers to self-care ( ie. 5 D’s:- distress, disability, diagnostic uncertainty, drug escalation and dependency).
  • Strong opioids are being considered.
Pain Clinic
  • Definitive medical diagnosis.
  • Reconsider a specific cause of back pain and investigations required.
  • Assessment for most effective analgesic and Pain management options.
  • Interventions as part of a package of care.
  • Referral to Pain Self-Management Service / CBT.
Pain Self-Management Service
  • Help to come to terms with and cope better with chronic pain
  • Learn skills to manage the pain more effectively
  • Improve quality of life despite pain
  • Support with implementing changes and maintaining them from a multi-disciplinary team

Inclusion criteria for Pain Self-Management Service:

  • Aged 18 years and over.
  • Chronic Pain for 6 months or more arising from diagnoses including musculoskeletal conditions, or where there is no diagnosis despite investigations.
  • Distressed, and /or disabled, or struggling to maintain daily function / work.
  • Appropriately investigated.
  • Maybe still waiting for, or having medical treatment for this problem e.g. injections/acupuncture etc, but not surgery.
  • Patient is open to idea of learning self-management / lifestyle changes, although it is NORMAL for them to be skeptical.

Pain Self-Management referral is not appropriate for people who:

  • Are awaiting further investigation, or possible surgery for this condition.
  • People with red flags who have not been fully investigated.
  • Active inflammatory conditions, or those awaiting investigations to rule this out.
  • Active cancer, or those awaiting investigations to rule this out.
  • People who are adamant that they do not want to find out more about self-management / lifestyle change approaches.
  • People who are adamant that they need MRI / further investigation / further Consultant assessment. Pain clinic referral may well be helpful to enable these patients to become more accepting, and therefore more ready for pain management.

Criteria for urgent referrals to Pain Self-Management Service

  1. Individuals who
  1. display evidence of significantly elevated levels of risk eg. suicide risk
  2. are at risk of losing their job/ struggling to stay in work
  3. are the main carer for dependents and struggling to cope eg. young children/disabled children/elderly relatives
  4. have frequent attendances to acute services/inpt stays
  5. have recent onset chronic regional pain syndrome (less than 6 months)


  1. Armed forces veterans in line with NHS wide policy 


Rheumatology Criteria

Consider referral to Rheumatology (after discussion with GP) if:

  • If symptoms suggestive of inflammatory back pain or connective tissue disease (see inflammatory pathway).
  • If diagnosis is uncertain.
  • If unable to exclude  inflammatory arthropathy or connective tissue disease.

Please follow the resource link below to the Early Inflammatory Arthritis Pathway.

Surgical Criteria

No referrals to secondary care orthopaedics unless:

  • Patient experiences intrusive pain and comprehensive conservative management including physiotherapy, low intensity CCP Programme (known locally as Back to Fitness), psychological management, and weight management 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 management/surgery by an orthopaedic consultant or referral to a secondary care pain clinic


  • Health Care Professional has discussed surgery with the patient who has confirmed they want explore surgery


  • General Health including fitness for anaesthesia has been considered and believed adequate to proceed to potential surgical intervention and it is believed that the patient is likely to derive quality of life benefits from surgery


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.