Back pain - low (without radiculopathy)
Exam Tips
- In OSCEs, always demonstrate a structured red-flag screen before labeling pain as non-specific.
- State clearly that routine spinal imaging is not indicated in uncomplicated low back pain and can lead to overdiagnosis.
- Use the biopsychosocial model: ask about mood, sleep, function, work, and fear-avoidance, not just pain score.
- For prescribing stations, prioritise short-course oral NSAID + safety checks + PPI when needed; avoid long-term opioids.
- If any cauda equina features are present, this is same-day emergency referral (do not delay for community imaging).
- For revision diagrams, use a lumbar dermatomes/myotomes figure and a cauda equina red-flag pathway figure from your core MSK text.
Definition
Low back pain without radiculopathy is pain localised mainly to the lumbosacral region (typically between the 12th ribs and gluteal folds) without clinical evidence of nerve root compression. In most primary care presentations it is non-specific/mechanical, meaning no single serious structural cause is identified after appropriate assessment, and it is classified as acute (<3 months) or chronic (>=3 months).
Pathophysiology
Non-specific low back pain is usually multifactorial, involving nociceptive input from intervertebral discs, facet joints, ligaments, paraspinal muscles, and thoracolumbar fascia, with pain modulation influenced by psychosocial context. Recurrent or persistent symptoms are linked to central sensitisation (often described as nociplastic mechanisms), where pain amplification and altered processing can persist despite limited ongoing tissue injury. Functional deconditioning, fear-avoidance behaviours, poor sleep, and mood disorders can maintain a pain-disability cycle. (For visual revision, see a standard lumbar spine anatomy figure showing discs, facets, nerve roots, and paraspinal muscles.)
Risk Factors
- Obesity
- Physical inactivity and deconditioning
- Occupational loading (repetitive lifting, bending, twisting, prolonged static postures)
- Psychological distress (anxiety, depression, stressful life events)
- High baseline pain/disability and symptoms persisting beyond 12 weeks
- Maladaptive coping (catastrophising, fear-avoidance)
- History of chronic pain syndromes or substance misuse
Clinical Features
Symptoms
- Localised low back pain, often mechanical (worse with movement, variable with posture/time)
- Stiffness and reduced tolerance for sitting, standing, lifting, or sleep disruption
- Recurrent episodes ('acute on chronic' pattern) common
- Usually no dermatomal leg pain, no focal neurological deficit, and no true radicular pattern
- Screen for red-flag symptoms: urinary retention/incontinence, saddle sensory change, bilateral progressive leg symptoms, constitutional symptoms, unexplained weight loss, fever, night pain, major trauma
Signs
- Antalgic movement or altered posture; reduced lumbar range of motion
- Paraspinal tenderness/spasm without focal neurological loss
- Normal lower limb power, reflexes, and sensation in uncomplicated non-radicular cases
- No objective nerve root tension signs expected (e. g, straight leg raise not typically radicular)
- Red-flag signs if present: vertebral point tenderness/deformity, objective motor deficit, perianal sensory loss, reduced anal tone, fever/systemic illness
Investigations
Management
Lifestyle Modifications
- Provide clear reassurance: pain is common and often improves, but recurrence can occur
- Advise continuation of normal activities and early return to work/study where possible
- Offer structured exercise (strengthening, flexibility, aerobic, or combined programmes)
- Address psychosocial drivers (fear-avoidance, mood, sleep, stress) and use risk-stratified care
- Consider manual therapy only as part of a broader package including exercise (not stand-alone long term)
- Avoid prolonged bed rest; encourage pacing and graded activity
Pharmacological Treatment
Oral NSAIDs (first-line medicine when needed)
- Ibuprofen 400 mg orally three times daily with food (max 2.4 g/day)
- Naproxen 250-500 mg orally twice daily (max 1 g/day)
Use lowest effective dose for shortest duration; check GI, renal, and cardiovascular risk. Co-prescribe gastroprotection when appropriate (e. g, omeprazole 20 mg once daily). Avoid/seek specialist advice in active peptic ulceration, severe heart failure, significant CKD, NSAID hypersensitivity, and pregnancy from 20 weeks onward (contraindicated in 3rd trimester).
Weak opioid (short rescue course only if NSAIDs contraindicated/not tolerated/ineffective)
- Codeine phosphate 30-60 mg orally every 4 hours as required (max 240 mg/day) for brief use only
Avoid routine use, especially in chronic low back pain; counsel on constipation, sedation, nausea, falls risk, and dependence. Review early and stop promptly.
Medicines generally not recommended for routine non-specific low back pain
- Paracetamol monotherapy (not effective as sole treatment)
- Benzodiazepines, gabapentinoids, and long-term opioids
Avoid due to limited benefit and potential harms (sedation, misuse, dependence, cognitive adverse effects).
Complications
- Reduced function in daily activities, study/work, and sleep
- Psychological morbidity (anxiety, depression, pain-related distress)
- Work absence, reduced productivity, and potential job loss
- Physical deconditioning and reduced mobility (higher falls risk, especially in older adults)
- Transition to persistent/chronic pain and recurrent flares
Prognosis
Most episodes improve within weeks and are self-limiting, but recurrence is common. Recovery of function often precedes complete pain resolution, and a significant minority develop persistent symptoms beyond 3 months, especially with psychosocial risk factors, high baseline disability, and maladaptive coping.
Sources & References
✅NICE Guidelines(1)
- Back pain - low (without radiculopathy)[overview]