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.
The clinical skill is twofold: 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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