Adult Low Back Pain Guidelines

Red Flags/High Complexity

Low Back Pain Pathway

Primary Care Management

Imaging and MRI Guidelines

AQP Manual Therapy

Spinal Interface

Patient Information Leaflets



Please note this guideline is for Lumbosacral Spine conditions only

Cervical and Thoracic cases are excluded and should be referred to Pain Clinic or Neurosurgery Depending On Clinical Requirement


Red Flags/High Complexity


Refer to Emergency Department if structural cause suspected

Discuss with Acute GP Service if metastatic cause suspected


Impending/Established Cauda Equina

  • Low back pain (usually severe)
  • Unilateral or bilateral sciatica
  • Severe or progressive unilateral or bilateral neurological deficit of the legs, such as major motor weakness
  • Recent-onset urinary retention and/or urinary incontinence
  • Recent-onset faecal incontinence
  • Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
  • Unexpected laxity of the anal sphincter
  • Recent-onset erectile dysfunction/reduced sensation pubic area


Conus Medullaris Syndrome

  • Pain usually bilateral and in the perineal region
  • Sudden and bilateral neurological deficit of the legs such as major motor weakness
  • Symmetrical and bilateral perianal numbness
  • Early onset urinary retention, overflow urinary incontinence and faecal incontinence
  • Unexpected laxity of the anal sphincter
  • Recent-onset erectile dysfunction frequently associated


Please note patients can present with a combination of these syndromes


Spinal pathology with significant/rapidly worsening motor/sensory/sphincter disturbance

Severeacute low back pain straight after significant trauma – consider unstable vertebral fracture as cause

Visceral causes: Ruptured AAA, Aortic dissection


Urgent Referral To Neurosurgery/Discuss With On Call Neurosurgery


Primary spinal tumours found on MRI imaging


Low back pain with sustained slowly progressive motor or sensory loss with cauda equina/conus medullaris and red flags excluded


Discuss with Acute GP Service


Suspected Discitis

Suspected Osteomyelitis

Suspected Spinal Abscess


If Vertebral Metastases/Pathological Vertebral Fracture

Suspected Primary Cancer                                              Refer 2WW

Known Primary Cancer and Active Treatment          MDT Cancer Co-ordinator

Unknown Primary Site                                                     Urgent Oncology


Common metastases to bone: Breast, Lung, Thyroid, Renal, Prostate, Melanoma

Myeloma 2WW/Urgent referral depends upon clinical severity



In The Absence Of Red Flags/High Complexity Diagnoses To Consider:


  • Visceral causes/Endocarditis/PE/Shingles/Post herpetic neuralgia/Aortic aneurysm/Metabolic bone disorders







Primary Care Management


Self Help                 

Tailored to individual needs/capabilities information and advice, address

expectations, mobilise, return to work/social/leisure activities as possible



NICE Low Back Pain (Without Radicular Pain) Pharmacological

Recommendations 2016


  • Do not offer paracetamol alone for low back pain
  • Consider NSAIDs taking into account individual risk factors for GI, renal and cardiac toxicity, concomitant medication and co-morbidities, consider gastro protection and ongoing monitoring of risk factors.  Prescribe lowest dose for shortest time possible
  • Consider weak opioids with or without paracetamol if an NSAID is contraindicated, not tolerated or ineffective
  • Do not offer strong opioids, SSRIs, SRNIs or TCAs for managing back pain
  • Do not offer anticonvulsants for back pain where there is no neuropathic component


NICE Recommendations For Neuropathic Pain



The STarT back tool can help identify those at risk of chronic pain


Chronic Pain Management Resources For Patients And Clinicians

Detailed local resources for patients and clinicians on self-management, risks and benefits of drug prescribing and alternatives to medication




Self refer to Occupational Health if restricting/unable to work


NB. Belts, corsets, foot orthotics and rocker sole shoes are not

recommended by NICE




Imaging and MRI Guidelines


In the absence of red flags/suspicion of vertebral fracture, plain X rays

are not routinely indicated.2




See Here




AQP Manual Therapy


Patients with yellow flags often do well with early referral to physiotherapy (Attitudes, beliefs, catastrophisation, psycho-social factors, emotional difficulties, family/work dynamics)


Referral Criteria

Whiplash, stiffness and restricted movement, muscular neck and low back pain +/-  non-progressive mild sensory loss, yellow flags, degenerative pain, postural neck and back pain, cervicogenic headaches



Suspected serious pathology, under 16, women over 35 weeks pregnant, patients not registered with a GP in locality

Patients who at initial assessment have little or no potential for further or sustained improvement through undertaking a course of treatment

Housebound patients

Patients with widespread or chronic (>1 year) musculoskeletal pain

Patients with a primary peripheral limb problem with secondary back and neck pain eg. Hip or shoulder problems, foot or gait abnormalities

Patients already seen by AQP in the preceding 12 month period (unless it can be justified that the initial package of care should be re-opened) 












Spinal Interface

Spinal Interface is a single point of access assessment service for all referrals.

Following assessment patients can be:

  • Provided advice, education and physiotherapy
  • Directly listed for spinal injection if meets specific criteria
  • Discussed in MDT for:
    • Direct listing for spinal injection
    • Consultant Pain Clinic Appointment
    • Nurse Pain Clinic Appointment
    • Referred for neurosurgery

Please note all low back pain referrals for further intervention require assessment at Spinal Interface first.  Direct low back pain referrals for Spinal MDT, Spinal Injection/Intervention, Pain Clinic or Spinal Surgery will NOT be accepted.

Referral Criteria

  • Mild to moderate spinal and/or radicular pain
  • WITH/WITHOUT non-progressive mild sensory loss not responding to appropriate tailored medication, self care AND AQP manual therapy for at least 6 weeks
  • Moderate to severe spinal and radicular pain
  • WITH/WITHOUT non-progressive mild to moderate power loss
  • WITH/WITHOUT moderate sensory loss
  • Diagnosis uncertain, but serious pathology not suspected
  • Severe/worsening yellow flags or persistent yellow flags not responding to initial primary care management/manual therapy
  • Previous spinal surgery input and has been discharged from surgical follow up


  • Cauda equina/conus medullaris syndrome
  • Red flag pathology
  • Rapidly deteriorating neurology
  • Proven neoplasm
  • Under 18 years
  • Recent spinal surgery in the same region and has not been discharged from surgical follow up
  • Recent Spinal Cord Stimulator in the same region and not been discharged from Pain Services
  • Cervical pathology or thoracic pathology – refer these to Pain Clinic or Spinal Surgery depending upon clinical need
  • Widespread inflammatory disease
  • Coccydynia
  • Lumps/bumps


If an MRI has been performed prior to referral to Spinal Interface, please attach a copy of the report to the referral



Patient Information

British Association of Spinal Surgeons (BASS) patient information leaflets on invasive interventions from facet joint injections to surgical procedures



NHS Choices Lumbar Decompression Surgery patient information leaflet











Dr. Natalie Dawes, GP and CCG Lead Orthopaedics

Janine Kennedy, Extended Scope Spinal Physiotherapist, Spinal Interface

Steve Iliffe, Extended Scope Spinal Physiotherapist, Spinal Interface

Dr. Robert Searle, Consultant Anaesthetist, Pain Clinic, Royal Cornwall Hospitals NHS Trust

Dr. Tom Sulkin, Consultant Radiologist, Royal Cornwall Hospitals NHS Trust

Mr. Andrew Clarke, Consultant Orthopaedic Spinal Surgeon, Royal Devon and Exeter

Dr. Rebecca Hopkins, GP and RMS Guidelines Lead Orthopaedics




  1. Integrated Spinal Pain and Non Spinal Triage Service, Neurosurgery, Derriford
  2. Low Back Pain and Sciatica In Over 16s Guideline.  National Institute of Clinical Excellence. November 2016
  3. National Low Back and Radicular Pain Pathway 2017.  NHS England 20 February 2017
  4. Opioids Aware, Faculty of Pain Management
  5. Drug Driving And Medicine: Advice For Healthcare Professionals.  Department of Transport 2014
  6. SB Tool Online.  STaRT Back Tool, Keele University, 2007
  7. MRI Guidelines
  8. Spinal Injections In Pain Clinic.  Royal Cornwall Hospital Truro, December 2015
  9. What The Pain Clinic Offers. Kernow Referral Management Service Pain Clinic Guidance
  10. Patient Information Booklets.  British Association Of Spinal Surgeons 2017
  11. Lumbar Decompression Surgery. NHS Choices, 2015