Defined as multi-level degenerative change to bones, disc, ligaments and joints considered to be largely age related rather than specific other diagnosis - includes Spinal Stenosis and Neurogenic Claudication.

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.
  • Examine to exclude widespread neurological disorder, more than one nerve root, or cord compression or myelopathic features.
  • Consider other vascular causes e.g. Peripheral Vascular Disease and manage appropriately.
  • Screen for related sources for pain e.g. Hips for lower limbs
  • Relevant blood and urine tests if serious pathology suspected.

Consider features of spinal stenosis:

  • Painful parathesiae in legs on walking (can be standing) often bilateral legs but can be one.
  • Can have unilateral foraminal stenosis.
  • Symptoms classically eased rapidly by flexion of spine e.g. sitting or bending forward
  • Classically they have no pain in legs at rest.
  • May or may not have accompanying odd heavy weak legs.
  • Often there is NO sensory or motor deficit.
  • Negative SLR.
  • Severe cases may have features of  cord Compression, myelopathy  e.g. UL grip weakness and loss and LL gait disturbance, bladder and bowel disturbance.


  • Consider congenital narrow / trefoil canal.
  • Consider tethered cord syndrome.

Undertake bio-psychosocial assessment:

  • Review analgesia and adherence.


  • Mild cases reassure often slow to progress.
  • Optimal analgesia/ NSAID.
  • Consider Tricyclic antidepressants.
  • Smoking Cessation advice.
  • Encourage physical activity with lifestyle advice e.g. cycling maybe manageable or pool exercise.
  • Weight management advice.
  • Consider self-referral or refer to Physiotherapy for mild or moderate symptoms or co-existing degenerative back pains and / or degenerative hip symptoms.
  • Cross refer with Spondylolysis and Spondylolisthesis pathways.


  • Consider MRI when a diagnosis of serious spinal pathology is suspected e.g.  malignancy, infection, fracture, cauda equina syndrome.
  • MRI scan is is indicated if any worrying features exist e.g. severe or progressive neurological deficits exist).
  • Primarily a clinical diagnosis therefore MRI is not routinely indicated.
  • MRI is indicated  prior to considering referral for surgery.
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice/ Lifestyle advice.
  • A multi-modal package of care including: Aerobic Exercise, spinal flexion - rotation mobility exercises/ manual therapy as part a package of care promoting self management.
  • Active self-management with aerobic exercise / lifestyle advice.
  • Severe consider walking aid – flexed rolator type frame to function.

If not responding consider referral to Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management.
  • Specifically review conservative management and Physiotherapy.
  • Detailed advice/ Lifestyle advice.
  • Review adherence to optimal analgesia.
  • Consider referral to Surgeon for opinion if fits criteria.

 If patient fits criteria consider referral to Pain Clinic / Pain Medicine.


  • XR Standing Lumbar AP and Lateral for suspected bony pathology and degenerative spondylolisthesis and deformity.
  • MRI as a second line investigation.
  • MRI scan is not routinely required but is indicated if any worrying features exist e.g. severe or progressive neurological deficits exist or myelopathy.
  • MRI is indicated prior to considering referral for intervention such as injections or surgery.
Pain Clinic Criteria

Consider referral where:

  • Intrusive pain not improved by an optimal multi-modal package of care, including appropriate exercise programme

AND optimal analgesia.

  • Patient fits the above and is not fit for surgery or has chosen not to undergo surgery.
  • Presence of significant risk factors of poor health outcomes (yellow flags).
  • Presence of psychosocial barriers to self –care (i.e. 5 Ds:- distress, depression, disability, diagnostic uncertainty, drug escalation/dependency)
  • Strong opioids are being considered.
Pain Clinic
  • Definitive medical and pain diagnosis.
  •  Assessment for most effective analgesic and Pain management options.
  • Diagnostic and therapeutic injections e.g. nerve root block, epidural as part of a package of care.
Surgical Criteria

No referrals to secondary care orthopaedics unless:

  • Patient experiences intrusive pain despite 6 months of comprehensive conservative management


  • Patient has demonstrated motivation and adhered to rehabilitation and advice


  • 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


  • Surgical option has been discussed and the patient has confirmed they want explore surgery and understand the risks and benefits


  • 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
  • Combinations of diagnostic and therapeutic spinal injections (root canal or epidural nerve root blocks etc).
  •  Surgical spinal canal decompression +/- fusion.