The Royal College of
General Practitioners

These brief clinical guidelines and their supporting base of research evidence are intended to assist in the management of acute back pain. It presents a synthesis of up-to-date international evidence and makes recommendations on case management.

Recommendations and evidence relate primarily to the first six weeks of an episode, when management decisions may be required in a changing clinical picture. However, the guidelines may also be useful in the sub-acute period.

These guidelines have been constructed by a multi-professional group and subjected to extensive professional review.

They are intended to be used as a guide by the whole range of health professionals who advise people with acute low back pain, particularly simple backache, in the NHS and in private practice.

Diagnostic Triage

Diagnostic triage is the differential diagnosis between:

• Simple backache (non-specific low back pain)
• Nerve root pain
• Possible serious spinal pathology

Simple backache: Specialist referral not required

• Presentation 20-55 years
• Lumbosacral, buttocks and thighs
• "Mechanical" pain
• Patient well

Nerve root pain: specialist referral not generally required within first 4 weeks, provided resolving:

• Unilateral leg pain worse than low back pain
• Radiates to foot or toes
• Numbness & paraesthesia in same direction
• SLR reproduces leg pain
• Localised neurological signs

Red flags for possible serious spinal pathology: consider prompt referral (less than 4 weeks)

• Presentation under age 20 or onset over 55
• Non-mechanical pain
• Thoracic pain
• Past history - carcinoma, steroids, HIV
• Unwell, weight loss
• Widespread neurological symptoms or signs
• Structural deformity

Cauda equina syndrome: immediate referral

• Sphincter disturbance
• Gait disturbance
• Saddle anaesthesia