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Health condition · Clinically reviewed

Back pain, the red flags, the scans that matter and the treatments that work.

Most back pain is not dangerous and settles within weeks. This guide covers what to watch for, when to scan, and the stepped UK approach from physiotherapy to surgery.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE NG59, BASS and peer-reviewed spine society sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance including stratified care with the STarT Back tool and combined physiotherapy plus CBT programmes.

Key facts

Back pain at a glance.

The essentials, in plain English. What it is, the categories that matter, and how it is assessed and treated in the UK today.

  • What it is

    Pain anywhere from the base of the skull to the tailbone. The commonest musculoskeletal complaint seen in UK primary care.

  • Most common cause

    Non-specific mechanical back pain accounts for around 85 to 90 per cent of episodes and settles within six weeks in most people.

  • Specific causes

    Disc prolapse, sciatica, spinal stenosis, spondylolisthesis, inflammatory spondyloarthritis, osteoporotic fracture, infection and malignancy.

  • Referred pain

    Back pain can arise from the kidneys, aorta, pancreas or pelvic organs. History and examination will steer these apart.

  • Imaging

    Not routine for non-specific pain under six weeks. MRI is used when red flags, radiculopathy or persistent symptoms suggest a specific cause.

  • Foundation of care

    Reassurance, staying active, physiotherapy, graded exercise and a biopsychosocial approach. Injections and surgery are reserved for specific indications.

Why this guide matters

A stepped plan, not a rush to scan.

Back pain is common, usually not sinister and almost always improves. The three points below shape everything else on this page.

  • Most pain is mechanical and self-limiting

    Around 85 to 90 per cent of episodes are non-specific mechanical pain that settles within six weeks with sensible activity.

  • Red flags are rare but must not be missed

    Cauda equina, cord compression, fracture, infection and malignancy are uncommon, but each has clear features that warrant urgent action.

  • The biopsychosocial approach wins

    Beliefs, mood, sleep and work matter as much as tissue. Combined physiotherapy and CBT programmes outperform any single tool.

How the diagnosis is made

From first consultation to a clear plan.

The steps a UK GP, physiotherapist or spinal specialist will normally follow, in order, in line with NICE NG59.

  1. 01

    Assessing

    Structured history and red flag screen

    Onset, pattern, night pain, neurology, systemic features, cancer history, trauma, weight loss, fever, steroid use and bladder or bowel symptoms.

  2. 02

    Assessing

    Examination and neurological screen

    Spinal movement, tenderness, straight-leg raise, femoral stretch, dermatomes, myotomes, reflexes, gait and saddle sensation.

  3. 03

    Assessing

    STarT Back stratification

    A brief questionnaire that sorts people into low, medium or high risk of persistent disabling pain and shapes the intensity of care from the start.

  4. 04

    Assessing

    Psychosocial (yellow flag) review

    Beliefs, fear-avoidance, low mood, work factors and sleep. These predict recovery as strongly as any imaging finding.

  5. 05

    Confirming

    Blood tests when indicated

    FBC, ESR, CRP, calcium and PSA or myeloma screen when infection, inflammatory disease or malignancy is on the list.

  6. 06

    Confirming

    MRI for red flags or radiculopathy

    Same-day or within 24 hours if cauda equina or cord compression is suspected. Elective MRI for persistent radiculopathy or suspected specific pathology.

  7. 07

    Onward

    Rheumatology or spinal surgery referral

    Rheumatology if inflammatory spondyloarthritis is suspected. Spinal surgery for refractory radiculopathy, stenosis or progressive neurology.

Typical timeline: a first assessment to a settled plan within one to two visits.

Symptoms

What back pain can look like.

A wide spectrum, from a straightforward mechanical ache to nerve-root pain, inflammatory disease and pain referred from other organs.

  • Non-specific mechanical pain

    Diffuse ache in the lower or mid back, worse with certain movements or postures, better with gentle activity. The commonest picture by far.

  • Radicular pain and sciatica

    Sharp, shooting pain down the leg with pins and needles or numbness in a nerve-root pattern. Often from a disc prolapse.

  • Neurogenic claudication

    Bilateral leg heaviness and pain on walking that eases with sitting or leaning forward. The classic story of lumbar spinal stenosis.

  • Inflammatory back pain

    Younger adult, morning stiffness over 30 minutes, wakes in the second half of the night, eases with activity. Think spondyloarthritis.

  • Thoracic and postural pain

    Pain between the shoulder blades linked to desk work, kyphosis or, less often, an osteoporotic fracture.

  • Facet and axial pain

    Focal, one-sided pain worse with extension and rotation. Often responds to facet joint injection, medial branch block or radiofrequency ablation.

  • Referred visceral pain

    Renal colic, aortic aneurysm, pancreatitis or pelvic disease can all present as back pain. History and examination pick these up.

  • Red flag features

    Saddle anaesthesia, bladder or bowel dysfunction, progressive weakness, fever, unexplained weight loss or night pain that wakes you up.

Treatment

How back pain is treated in the UK.

Reassurance and active self-management first. Physiotherapy, psychological support and simple analgesia next. Injections and surgery for specific indications.

  • Self-management and reassurance

    Explanation, pacing and staying active. Bed rest slows recovery. Most non-specific pain settles within six weeks with sensible activity.

  • Simple analgesia

    NSAIDs at the lowest effective dose for the shortest time, with paracetamol as an adjunct. Weak opioids only briefly and only when NSAIDs are unsuitable.

  • Physiotherapy and exercise

    Graded return to activity, core stability, stretching, yoga, Pilates or tai chi. Exercise type matters less than doing something you will keep up.

  • Manual therapy

    Spinal manipulation, mobilisation or massage as an adjunct to an exercise programme rather than as a stand-alone fix.

  • Psychological therapy

    CBT, pain neuroscience education or ACT for persistent pain. A biopsychosocial approach outperforms any single tool.

  • Combined physiotherapy and CBT

    NICE recommends combined programmes for people with persistent back pain and higher risk on the STarT Back tool.

  • Interventional pain procedures

    Facet joint injection, medial branch block, radiofrequency ablation, epidural steroid or spinal cord stimulator for carefully selected patients.

  • Spinal surgery

    Discectomy, laminectomy, fusion or disc replacement for cauda equina, progressive neurology, refractory radiculopathy, stenosis or spondylolisthesis.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or spinal specialist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Low back pain and sciatica in over 16s: assessment and management (NG59).

  • NICE. Spondyloarthritis in over 16s: diagnosis and management (NG65).

  • British Association of Spine Surgeons (BASS). Standards for spinal surgery and cauda equina.

  • Faculty of Pain Medicine and British Pain Society. Guidance on interventional pain procedures.

  • Royal College of Radiologists. iRefer guidance on imaging for back pain.

Red flags

When back pain needs urgent attention.

Most back pain is not sinister. These are the situations that need same-day or urgent specialist review rather than watchful waiting.

  • Cauda equina syndrome

    Saddle anaesthesia, new bladder or bowel dysfunction, bilateral leg weakness or sexual dysfunction. Same-day emergency MRI and spinal surgery review.

  • Spinal cord compression

    Progressive weakness, sensory level, hyper-reflexia or ataxia. Urgent neurosurgical or oncology assessment within 24 hours.

  • Malignancy

    History of cancer, unexplained weight loss, night pain, age over 55 with new pain or a rising PSA. Needs urgent imaging and specialist review.

  • Spinal infection

    Fever, IV drug use, immunosuppression, recent bacteraemia or a rising CRP. Discitis, osteomyelitis or epidural abscess must be excluded.

  • Osteoporotic vertebral fracture

    Sudden pain in an older adult, on steroids or with known osteoporosis, especially after a minor fall. Consider imaging and a DEXA scan.

  • Inflammatory spondyloarthritis

    Younger adult, morning stiffness over 30 minutes, alternating buttock pain, better with activity, worse with rest. Rheumatology referral.

  • Significant trauma

    High-energy injury, or lower-energy injury in an older or osteoporotic patient. Needs prompt imaging to exclude fracture.

  • Progressive neurological deficit

    Worsening weakness, numbness or reflex changes over days or weeks. Escalate urgently rather than watch and wait.

  • Abdominal aortic aneurysm

    Older adult with sudden severe back or flank pain, hypotension or a pulsatile abdominal mass. A time-critical vascular emergency.

Living with it

A common condition, with a clear ladder.

Four things that make the biggest difference day to day. Gentle movement, a calmer relationship with pain, everyday habits and knowing when to escalate.

A quiet reminder

Consistency beats intensity, every time.

Small, steady habits kept up for months do more than a heroic week that does not last.

  1. 01 Movement

    Keep moving, gently

    Bed rest slows recovery. Short walks, gentle stretching and a graded return to normal activity are the fastest route back.

  2. 02 Mindset

    Hurt does not mean harm

    A sensitised nervous system can produce real pain without ongoing tissue damage. Understanding this reduces fear and speeds recovery.

  3. 03 Habits

    The everyday levers

    Sleep, weight, smoking, workstation setup and stress all shift pain thresholds. Small, steady changes add up.

  4. 04 Escalate

    Know when to seek help

    New neurology, bladder or bowel changes, fever or pain that will not settle after six weeks all deserve a face-to-face review.

Frequently asked

Everything we get asked about back pain.

Quick answers on scans, red flags, bed rest, injections and surgery.

  • What causes most back pain?

    Around 85 to 90 per cent of back pain is non-specific mechanical pain from muscle, ligament, facet or disc structures. It settles within six weeks in most people with sensible activity and simple treatment. A smaller proportion is due to specific causes such as disc prolapse, sciatica, spinal stenosis, spondylolisthesis, inflammatory disease, fracture, infection or malignancy.

  • Do I need a scan for back pain?

    Not usually. NICE guidance is clear that imaging is not routine for non-specific back pain under six weeks with no red flags. MRI is used when there are red flags, a suspected specific cause, persistent radiculopathy or if surgery or an injection is being considered. Cauda equina or cord compression needs urgent MRI within 24 hours.

  • What are the red flags I should not ignore?

    Saddle anaesthesia, new bladder or bowel dysfunction, bilateral leg weakness or sexual dysfunction all suggest cauda equina and need same-day emergency review. Fever, unexplained weight loss, night pain that wakes you, a history of cancer, progressive weakness, significant trauma or new pain in an older adult also need prompt medical assessment.

  • Is bed rest a good idea?

    No. Prolonged bed rest slows recovery and stiffens the spine. Staying gently active, pacing yourself and returning to normal activities as pain allows leads to better outcomes than resting until the pain has gone.

  • When do injections or surgery help?

    Interventional procedures such as medial branch block, radiofrequency ablation, epidural steroid or a spinal cord stimulator are reserved for carefully selected patients. Surgery is used for cauda equina, progressive neurology, refractory radiculopathy, symptomatic stenosis or spondylolisthesis, not for non-specific back pain.

  • What is the STarT Back tool?

    A short questionnaire that sorts people into low, medium or high risk of developing persistent disabling back pain. It shapes stratified care: low-risk patients get reassurance and simple advice, while higher-risk patients are offered combined physiotherapy and psychological support earlier.

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