Reviewed on : 14 Feb 2023

Reviewed by : Gurpreet Singh Advanced Practitioner Physio & Prof Christopher Newton

Expires : 14 Feb 2025

Spinal Pathways Summary for Back Pain

Acute back pain is defined as < 6 weeks

Chronic back pain > 6 weeks

Low Back Pain without Radiculopathy

This guidance refers to patients ≥ 16 years old who present with low back pain (i.e. pain below the costal margin and above the inferior gluteal folds) without leg pain.

Managing low back pain

DO’s:

As part of a person-centred approach to shared decision-making assess:

• Pain and function
• Emotional health
• Social and work status
• Lifestyle factors (including sleep, weight, physical activity)
• What matters to the person, including their values and preferences regarding appropriate treatment options. Consider using relevant clinical decision support tools.

Pathways for Back Pain

Use the STarT Back screening tool:

This stratifies patients into risk groups predictive of future disability and work absenteeism, providing a basis for targeted care – follow link for more details

For all patients

Tailor advice and education to the person and promote self-management and lifestyle

Consider reassurance and explaining that improvement and recovery (for the majority of people) is likely within 6-12/52.

Offer further review (2-4/52) if not settling/worsening.

Offer appropriate pharmacological treatments. Consider NSAIDs (at the lowest effective dose for the shortest possible period of time); or weak opioids (+/- paracetamol) only if an NSAID is contraindicated, not tolerated or has been ineffective. Consider the addition of a gastroprotective treatment.

For low risk (total 3 or less) patients, with low levels of pain, disability and distress:

If they require ongoing support/guidance on returning to normal activities (including work) and flare up management offer an FCP review.

Also consider directing to appropriate services and self-management resources.

For medium risk (score of 4 or more plus sub-score of 3 or less) patients, with moderate levels of pain, disability and distress:

If they require ongoing support/guidance on returning to normal activities (including work) and flare up management offer an FCP review or referral to physiotherapy. Also consider directing to appropriate services and self-management resources.

For high-risk patients (score of 4 or more plus subscore of 4 or more), with high levels of pain, disability and distress:

If they require ongoing support/guidance on returning to normal activities (including work) and flare up management offer a referral to MSK Triage for consideration of a low intensity Combined Physical Behavioural Physiotherapy programme. Also consider directing to appropriate services and self-management resources.

Provide information and advice for supported self-management

• Facts about Back pain  
• Self-management tips
• Useful websites and resources
• Information on lifestyle management local and online support

Do NOT offer routine imaging for back pain in the absence of red flags

It is important to note routine imaging is NOT warranted for back pain with or without radicular pain in a non-specialised setting, unless serious underlying pathology is suspected and may lead to worse outcomes.

Abnormal imaging findings are poorly correlated with back pain symptoms and very common in people without pain. These findings increase with age and always need to be interpreted in the context of a clinical assessment.

Prevalence of findings on MRI in asymptomatic populations by age range (Brinjikji et al. 2015)

Role for imaging:

• X-ray is NOT indicated for back pain unless an osteoporotic fracture is suspected.
• MRI is indicated for those with significant neurological deficit (<3/5 power) or worsening neurology.
• MRI is indicated for suspected malignancy and infection.
• Whole MRI spine (AS protocol) and pelvic x-rays with sacro-iliac joint views may be indicated, but are not essential for referral to Rheumatology for suspected Axial spondyloarthropathy see GP Gateway Back Pain Suspected Ankylosing Spondylitis Spondyloarthritis.
• All MRIs (via PACS) are accessible across the West Midlands.
• An appropriate Clinician can view a scan performed at UHCW, GEH (Nuneaton), SWFT (Warwick), Worcester Royal Hospital and Alexandra Hospital (Redditch).

Do NOT offer:

• Paracetamol alone
• Opioids for managing persistent low back pain
• Selective serotonin reuptake inhibitors (e.g., fluoxetine, sertraline)
• Serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants
• Anticonvulsants including gabapentinoids

Avoid using:

• Fear inducing language or advice eg. don’t bend, lift, exercise, only sit upright

Consider alternative diagnosis if features do not fit with low back pain:

Serious spinal pathology is found in around 1% of consultations

Patients with suspected serious pathology (red flags) inclusive of a suspected fracture, progressive or sudden neurological deficit, cancer, metastatic cord compression, cauda equina syndrome or infection.

Please refer to the appropriate speciality following the emergency or urgent pathway listed below (also available on GP Gateway): 

• Suspected Cauda Equina Syndrome or MSCC refer immediately to A&E.
• Suspected malignancy refer via 2WW pathway.
• History of significant fracture or possible unstable fracture following trauma refer immediately to A&E.
• Suspected pathological fracture x-ray the affected area and seek advice and guidance.
• Suspected infection refer urgently to Neurosurgery or Trauma and Orthopaedics Spine Service or A&E.
• Sudden or progressive neurological deficit refer urgently to Neurosurgery or Trauma and Orthopaedics Spine Service.

UHCW Urgent Contacts:

If you need to discuss a patient, please call the Neurosurgery registrar on bleep 2300

On a Wednesday please call the T&O registrar on bleep 1436 until 20:00 then 2699 or via switchboard.

Axial Spondyloarthropathy

For patients who you suspect Axial spondyloarthropathy please click here for guidance

Symptoms of Suspected Cauda Equina Syndrome

• Bilateral sciatica
• Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
• Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible damage
• Urinary retention with overflow urinary incontinence
• Loss of sensation of rectal fullness, if untreated this may lead to irreversible
• Faecal incontinence
• Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
• Laxity of the anal sphincter

To download the flashcard and see this information in another language click here 

Consider sharing this video on when and how soon to seek medical advice for back pain:

When should you seek urgent help for your backpain? (macpweb.org)

Symptoms of Suspected Malignancy

• Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain
• Localised spinal tenderness
• No symptomatic improvement after four to six weeks of conservative low back pain therapy.
• Unexplained weight loss
• Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasise to the spine

Symptoms of Suspected Spinal Fracture

• Sudden onset of severe central spinal pain which is relieved by lying down.
• There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids.
• Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
• There may be point tenderness over a vertebral body.

Symptoms of Suspected Infection

• Fever
• Tuberculosis, or recent urinary tract infection
• History of intravenous drug use
• HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised

Specific pathology accounts for up to 4% of consultations (low back pain with sciatic symptoms)

Low back pain with radicular pain

• Can occur at any age; often insidious
• may be accompanied by low back pain
• Progresses to pain being referred down the posterior aspect or the posterolateral aspect of the leg (below the knee).
• Commonly unilateral leg pain, occasionally bilateral
• Symptoms may be related to or triggered by a particular movement/position or it may be spontaneous
• Neurological examination may be normal

Low back pain with radiculopathy  

There may be the presence of at least one of the following:

• Leg pain > back pain
• Myotomal weakness
• Sensation loss
• Reduced reflexes
• Provocative SLR

Spinal stenosis

There may be the presence of at least one of the following:

• Myotomal weakness.
• Sensation loss.
• Hyporeflexia stenosis.
• >48 years of age.
• Often increased BMI.
• Gradual onset of unilateral or bilateral leg pain.
• Worse with standing/walking.
• Eased with sitting/leaning forward.
• Consider vascular cause: check peripheral pulses, will only get symptoms when walking not when standing.
• Neurogenic claudication: Better up hill.
• Vascular claudication: Worse up hill.
• Managing low back pain with sciatic symptoms (radicular pain/radiculopathy)

DO’s:

• If prescribing NSAIDs for sciatic symptoms consider the risk factors and side effects and use the lowest effective dose for the shortest possible period of time
• Offer evidence-based information click here
• Note: most sciatic symptoms will settle within 6-12 weeks

Consider referral to T&O or neurosurgery if persistent pain despite first line management: 

• Severe pain limiting function and activities of daily living
• Neurological deficit of <3/5 power on muscle testing
• Progressive neurological deficit (power, sensation, reflexes and function)
• Sciatic symptoms not responding to analgesia and patient would consider further intervention such as injection or surgery

Do NOT Offer:

• Gabapentinoids, oral steroids, benzodiazepines or opioids for acute or chronic sciatica
• Do not use opioids for chronic sciatica (>12 weeks)
• Explain the risk of ongoing use of these medications if people are already taking them