GPAtlas🧭 When to suspect
Low back pain is one of the commonest presentations in UK general practice, and the first task is always triage, not diagnosis.
• The great majority is non-specific (mechanical) low back pain – pain, stiffness or soreness in the lumbar region that varies with posture or activity, where serious pathology has been excluded.
• A smaller proportion is sciatica (lumbar radiculopathy), in which leg pain (often worse than the back pain) follows a nerve-root distribution.
• A small but critical minority harbour serious pathology: cauda equina syndrome (CES), spinal fracture, malignancy or metastatic spinal cord compression (MSCC), spinal infection, or inflammatory back pain.
Actively exclude red flags at first contact, then for everyone else stratify the risk of a poor outcome and match the intensity of care to it.
• The STarT Back risk stratification tool (a brief 9-item questionnaire) sorts patients into low, medium or high risk of persistent disabling pain and directs management accordingly.
• Imaging has no role in non-specific low back pain in primary care.
| Presentation | Typical features | Initial action |
|---|---|---|
| Non-specific low back pain | Lumbar pain ± stiffness, mechanical (varies with posture/movement), no red flags, little or no leg pain | Reassure, keep active, STarT Back stratification, self-management |
| Sciatica (lumbar radiculopathy) | Leg pain often > back pain, dermatomal radiation, ± paraesthesia, weakness or positive straight leg raise | • As above • Most settle conservatively • Specialist referral if not improving |
| Serious pathology (red flags) | Features of CES, fracture, malignancy/MSCC, infection, or inflammatory back pain | Urgent or emergency referral per the red-flag pathway |
Source: NICE NG59 · Keele STarT Back
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