Red Flags
- Cauda equina syndrome (saddle anaesthesia, urinary retention or incontinence, faecal incontinence, bilateral leg pain or weakness) — emergency MRI same-day; emergency surgical decompression[1]
- Suspected infection (fever, IV drug use, immunosuppression, recent procedure, severe pain at rest) — investigate spinal abscess/discitis; urgent MRI and ID[1]
- Suspected malignancy (age >50, history of cancer, weight loss, severe progressive pain unrelieved by rest, night pain) — urgent MRI and oncology[1]
- Suspected fracture (trauma, severe osteoporosis, prolonged steroid) — radiograph or MRI; spine immobilisation if unstable[1]
First-line treatment
Interventions
- Reassurance, education, encourage activity[1]Most non-specific LBP improves within 6 weeks with normal activity; written information; avoid bed rest; address yellow flags (fear-avoidance, depression, work issues)
- Group exercise programme[1]Biomechanical (back-specific), aerobic, or mind-body (yoga, tai chi) approaches; tailor to ability and preference; equivalent benefit between modalities; combine with self-management education
- Manual therapy (manipulation, mobilisation, soft tissue) — only as part of package[1]Component of multimodal package alongside exercise; not a stand-alone treatment; physiotherapy or osteopathy / chiropractic per local pathway
- Psychological therapies with cognitive behavioural approach[1]Component of multimodal package for chronic LBP and high-risk patients on STarT Back; address fear-avoidance, mood, sleep, function
- Avoid ineffective interventions[1]Do NOT offer belts, corsets, foot orthotics, rocker sole shoes, traction, acupuncture, ultrasound, PENS, TENS, or interferential therapy for LBP
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Ibuprofen or naproxen (NSAID)[1] | Cyclooxygenase inhibitor | Ibuprofen 400 mg PO TDS-QDS PRN; naproxen 250–500 mg PO BD PRN | Ibuprofen 7–10 mg/kg/dose | First-line analgesic for LBP and sciatica when pain limits function; lowest effective dose, shortest duration; co-prescribe PPI if risk; avoid in CKD, peptic ulcer, severe HF, anticoagulation |
| Paracetamol (limited evidence in LBP)[1] | Analgesic | 1 g PO QDS PRN, max 4 g/day | 15 mg/kg/dose, max 60 mg/kg/day | Limited evidence in non-specific LBP per recent reviews; useful adjunct or alternative when NSAIDs contraindicated |
| Codeine or weak opioid (selected, short-term)[1] | Weak opioid | Codeine 30–60 mg PO QDS PRN, max 240 mg/day | — | Reserve for moderate-severe acute pain unrelieved by NSAID/paracetamol; short course only; constipation, dependence; avoid for chronic LBP |
| Diazepam or short-acting muscle relaxant (severe spasm)[1] | Benzodiazepine — short-acting | Diazepam 2–10 mg PO BD-TDS for ≤7 days | — | Severe acute muscle spasm; do not use long-term; sedation, dependence; avoid driving |
| Amitriptyline or duloxetine (chronic LBP with neuropathic component)[1] | TCA / SNRI | Amitriptyline 10–25 mg PO night, titrate to 75 mg; duloxetine 30–60 mg PO daily | — | Chronic LBP with neuropathic features; not for acute LBP; specialist initiation; review at 8 weeks |
Ibuprofen or naproxen (NSAID)[1]
Cyclooxygenase inhibitor
- Adult
- Ibuprofen 400 mg PO TDS-QDS PRN; naproxen 250–500 mg PO BD PRN
- Paediatric
- Ibuprofen 7–10 mg/kg/dose
First-line analgesic for LBP and sciatica when pain limits function; lowest effective dose, shortest duration; co-prescribe PPI if risk; avoid in CKD, peptic ulcer, severe HF, anticoagulation
Paracetamol (limited evidence in LBP)[1]
Analgesic
- Adult
- 1 g PO QDS PRN, max 4 g/day
- Paediatric
- 15 mg/kg/dose, max 60 mg/kg/day
Limited evidence in non-specific LBP per recent reviews; useful adjunct or alternative when NSAIDs contraindicated
Codeine or weak opioid (selected, short-term)[1]
Weak opioid
- Adult
- Codeine 30–60 mg PO QDS PRN, max 240 mg/day
- Paediatric
- —
Reserve for moderate-severe acute pain unrelieved by NSAID/paracetamol; short course only; constipation, dependence; avoid for chronic LBP
Diazepam or short-acting muscle relaxant (severe spasm)[1]
Benzodiazepine — short-acting
- Adult
- Diazepam 2–10 mg PO BD-TDS for ≤7 days
- Paediatric
- —
Severe acute muscle spasm; do not use long-term; sedation, dependence; avoid driving
Amitriptyline or duloxetine (chronic LBP with neuropathic component)[1]
TCA / SNRI
- Adult
- Amitriptyline 10–25 mg PO night, titrate to 75 mg; duloxetine 30–60 mg PO daily
- Paediatric
- —
Chronic LBP with neuropathic features; not for acute LBP; specialist initiation; review at 8 weeks
Safety-net
- Most low back pain settles within 6 weeks with continued normal activity — bed rest delays recovery[1]
- Loss of bladder or bowel control, saddle anaesthesia, severe progressive weakness, or fever with back pain — emergency department same-day[1]
- Avoid prolonged opioid use; if needed for >2 weeks, tapering plan and review for chronic pain alternatives[1]
Referral criteria
- Cauda equina syndrome, suspected infection, malignancy, or fractureEmergency department / spinal surgery same-day[1]
- Persistent radicular pain, weakness, or sensory loss ≥6 weeks despite optimal conservative careSpinal surgical assessment or radiology-guided injection[1]
- Suspected axial spondyloarthritis (inflammatory pattern <40 years)Rheumatology with HLA-B27 and SI joint MRI[1]
- High STarT Back risk, chronic disabling pain, or significant psychosocial factorsMultidisciplinary pain rehabilitation programme[1]
Clinical summary
Risk-stratified assessment, exercise, and multimodal management of low back pain and sciatica in adults ≥16 years.