Back Pain

You may assume that severe back pain always means serious spinal damage, or that a scan is needed to find the cause. Most episodes are not caused by dangerous disease and improve with time, movement and appropriate support. However, a small number arise from nerve compression, fracture, infection, cancer or a condition outside the spine. These require prompt recognition.

Back pain is common and usually not dangerous Back pain can occur anywhere from the neck to the lower spine, but the lower back is affected most often. It may feel aching, sharp, tight, burning, stiff, spasmodic, worse during particular movements, or difficult to localise precisely. Most back pain improves over several weeks, although symptoms can last longer or return. Serious causes such as fracture, infection or cancer are much less common than routine musculoskeletal back pain. Pain does not always identify one injured structure The back contains vertebrae, discs, small joints, ligaments, muscles, tendons, nerve roots, and the spinal cord and lower spinal nerves. Several tissues may contribute to pain at the same time. Pain can also continue after an initial strain has healed because movement, sleep, muscle guarding, stress and sensitivity within the nervous system affect how pain is experienced. A clinician often cannot identify one exact structure responsible for an uncomplicated episode. This is called non specific back pain. The term does not mean that the pain is imaginary or unimportant. It means that no single serious or specific disease has been identified. A mechanical pattern provides clues, not certainty Common back pain may begin after lifting, twisting or unfamiliar activity, start without an obvious trigger, change with position or movement. Feel stiff after remaining in one position, ease or worsen during different activities, include muscle spasm, or limit bending, standing or walking. The word mechanical means that movement, loading or position influences the pain. It does not prove that a disc, joint or muscle has been damaged. Back pain caused by a serious condition can also worsen with movement, so clinicians consider the full pattern rather than one feature alone. Pain severity does not reliably measure damage Back muscles can tighten strongly in response to pain. This protective spasm may make a relatively uncomplicated episode feel severe and make movement temporarily difficult. Conversely, some important conditions begin with moderate pain. Clinicians therefore ask about speed of onset, location, movement and position, leg or arm symptoms, bladder and bowel function, general illness, trauma, previous cancer, medicines and health conditions, and changes over time. A sudden severe change, especially with other warning symptoms, still requires urgent assessment. Sciatica is nerve related leg pain Sciatica describes symptoms caused by irritation or compression of a nerve root in the lower back. Symptoms usually affect the buttock and one leg and may extend into the foot or toes. You may experience sharp, shooting or burning pain, pins and needles, numbness, weakness, or pain worsened by coughing, sneezing or certain movements. Leg pain is often more prominent than the back pain. Back pain without symptoms travelling into the leg is not usually described as sciatica. A "slipped disc" does not literally slip out Discs are strong structures positioned between the vertebrae. A disc can bulge or develop a tear. Disc material may irritate or compress a nearby nerve root, producing sciatica. Disc changes are also frequently found in people without pain. A scan finding therefore needs to match your symptoms and examination before it is treated as the cause. Most episodes of sciatica improve without an operation. Persistent pain, worsening weakness or substantial loss of function may require specialist assessment. Numbness or weakness changes the assessment Pain alone can make movement feel weak. True neurological weakness means that a muscle cannot generate its expected force because nerve signals are impaired. Report a foot that repeatedly catches the ground, difficulty lifting the front of the foot, a leg that gives way, increasing numbness, weakness affecting both legs, new difficulty walking, or loss of hand function with upper back or neck symptoms. Progressive weakness needs prompt assessment. Weakness in both legs or weakness accompanied by bladder, bowel or saddle area symptoms is an emergency. Cauda equina syndrome is a rare emergency The cauda equina is the group of spinal nerves below the end of the spinal cord. These nerves help control leg function, bladder and bowel function, sexual function and sensation around the genitals and anus. Cauda equina syndrome occurs when these nerves are severely compressed. Warning symptoms include: New or rapidly changing numbness between the inner thighs. Numbness around the genitals, buttocks or anus. Altered sensation when wiping after using the toilet. Difficulty starting urination. Difficulty controlling urine flow. Loss of awareness that the bladder is full. Urinary leakage without normal sensation. Loss of bowel control or awareness. Changes in genital sensation. New erectile, ejaculation or orgasm difficulty. Pain, numbness or weakness affecting both legs. This is sometimes called saddle numbness because the affected area is the region that would contact a saddle. Cauda equina syndrome requires immediate hospital assessment because delayed treatment can result in permanent bladder, bowel, sexual or leg dysfunction. Do not wait for every warning symptom to appear. Spinal cord compression can occur higher in the spine Compression of the spinal cord may cause weakness, altered sensation, unsteadiness, difficulty walking, changes in bladder or bowel function. A band like pain around the chest or abdomen, symptoms affecting both legs, or symptoms affecting arms and legs when the neck is involved. Spinal cord compression may result from cancer, infection, trauma or another structural problem. New neurological symptoms affecting several limbs or walking require urgent assessment. Cancer related spinal pain needs prompt recognition Cancer can spread to the bones of the spine. This is called spinal metastasis. The cancer can weaken a vertebra or compress the spinal cord or nerve roots. Concerning pain characteristics in someone with current, previous or suspected cancer include: Severe, unremitting pain. Progressively worsening pain. Pain disturbing sleep. Localised spinal tenderness. Pain worsened by coughing, sneezing, straining or bowel movements. Pain influenced by standing, sitting or moving. Nerve pain extending into a limb or around the chest or abdomen. Bladder or bowel dysfunction, walking difficulty, weakness, numbness or altered sensation in someone with cancer may indicate metastatic spinal cord compression. An oncological emergency. If you have current or previous cancer, report new or changing back pain promptly. Back pain does not usually mean cancer Most people with back pain do not have cancer. Concern increases when pain is accompanied by current or previous cancer, unexplained weight loss, persistent night pain, progressive symptoms, unexplained fatigue, localised bone tenderness, unexplained fracture, or neurological loss. In people aged 60 or over, blood tests to assess for myeloma are recommended when persistent bone pain, particularly back pain, or an unexplained fracture is present. These investigations look for an explanation. They do not mean cancer is already diagnosed. Spinal infection is uncommon but serious An infection can affect a vertebra, disc or the tissues around the spinal cord. Possible warning features include fever, sweats or shivering, feeling generally very unwell, severe localised back pain, rapidly worsening pain, recent serious infection, recent spinal procedure or surgery, immunosuppression, injecting drug use, or new neurological symptoms. Fever is not present in every spinal infection. Risk factors and the overall pattern remain important. Urgent assessment is needed when severe back pain occurs with fever, systemic illness or significant infection risk. A vertebral fracture may occur after trauma A spinal fracture may follow a road traffic collision, a fall from height, a direct blow, or a forceful injury. A weakened vertebra may fracture after a smaller movement or fall when you have osteoporosis, long term corticosteroid use, cancer affecting bone, advanced age or frailty, or a previous fragility fracture. Possible features include sudden localised pain, spinal tenderness, reduced movement or a visible change in back shape. Back pain after a serious accident requires emergency assessment. Sudden pain after a smaller injury may also require urgent review when your bones may be fragile. Inflammatory back pain has a different pattern Some inflammatory conditions affect the joints of the spine and pelvis. Features that may prompt assessment include: Back pain beginning at a younger age. Symptoms lasting more than several weeks. Marked morning stiffness. Improvement with movement. Pain that does not improve with rest. Waking during the second half of the night. Alternating buttock pain. Psoriasis. Inflammatory bowel disease. Eye inflammation. A close relative with related inflammatory disease. No one feature confirms inflammatory spinal disease. Persistent symptoms with this pattern should be discussed with a GP. Pain may be referred from outside the spine Pain felt in the back does not always begin in the back. Possible non spinal sources include kidney infection, kidney stones, gallbladder or pancreatic disease, lung or pleural disease, pelvic conditions, abdominal blood vessel emergencies, or shingles before a rash appears. Clues may include urinary symptoms, fever, abdominal pain, vomiting, breathlessness, chest pain, a rash or pain that does not change with spinal movement. Sudden severe abdominal or back pain with collapse, faintness, sweating or cold clammy skin may indicate a major blood vessel emergency and requires 999. Most uncomplicated back pain does not need a scan Routine imaging is not recommended for low back pain with or without sciatica in non specialist settings. Imaging may be considered in specialist care when the result is likely to change treatment. For example, when there is concern about cauda equina syndrome, spinal cord compression, cancer, infection, fracture, progressive neurological loss, or persistent sciatica being considered for an invasive treatment. Not ordering an immediate scan does not mean your pain is being dismissed. It may mean that your symptom pattern and examination do not suggest a condition for which imaging would alter the plan. X rays and MRI answer different questions An X ray mainly shows bones and may help assess some fractures or structural changes. An MRI gives more detail about discs, nerves, the spinal cord, infection, tumours and soft tissues. MRI is the key test when cauda equina syndrome or spinal cord compression is suspected, and is recommended as soon as possible and within 24 hours when metastatic spinal cord compression is suspected. A scan result still needs to be interpreted alongside your symptoms and examination. Staying active usually supports recovery For uncomplicated back pain, prolonged bed rest can increase stiffness, weakness and loss of confidence. Try to continue ordinary activities within tolerable limits. Short walks, frequently changing position, gradually resuming household tasks, returning to work with temporary adjustments, breaking larger tasks into smaller parts, or reducing an activity temporarily rather than stopping all movement. Some discomfort during movement does not automatically mean you are damaging your back. However, stop and seek assessment if activity produces new weakness, widespread numbness, bladder or bowel changes, or a rapidly worsening neurological pattern. Pacing differs from complete rest Pacing means balancing activity and recovery so that you avoid repeated cycles of doing too much on a better day and becoming inactive after a flare. You might divide tasks into manageable sections, alternate positions, take planned brief breaks, increase activity gradually, maintain a basic level of movement on difficult days, and review which tasks genuinely aggravate symptoms. Pacing should help you remain engaged in life rather than make activity progressively smaller. Heat, cold and pain medicines require individual assessment A wrapped heat pack may ease stiffness or muscle spasm. A wrapped cold pack may feel useful after a recent strain. Protect your skin and limit exposure. These measures may change comfort but do not treat serious spinal disease. An anti inflammatory medicine may be considered for low back pain, but it is not suitable for everyone. Risk may be higher with a stomach ulcer or previous gastrointestinal bleeding, kidney disease, heart disease, uncontrolled blood pressure, asthma triggered by anti inflammatory medicines, anticoagulant treatment, pregnancy, significant liver disease, or frailty. Oral non steroidal anti inflammatory drugs should be used at the lowest effective dose for the shortest possible period. Paracetamol alone is not recommended as the main treatment for low back pain. Ask a pharmacist or clinician which option is appropriate. Opioids are not a routine long term solution Opioid medicines can cause drowsiness, constipation, nausea, falls, impaired driving, tolerance, dependence, and withdrawal symptoms. Opioids are not recommended for chronic low back pain. A weak opioid may occasionally be considered for acute low back pain when an anti inflammatory medicine is unsuitable, not tolerated or ineffective, but it should not be treated as routine care. Do not increase, stop or combine opioid medicines without clinical advice. For sciatica specifically, gabapentinoids, other antiepileptic medicines, oral corticosteroids and benzodiazepines are generally not advised because overall benefit has not been shown and harms can occur, and opioids are not recommended for chronic sciatica. If you already take one of these medicines, do not stop it suddenly. Exercise should match your needs and capabilities There is no single exercise programme that suits everyone. Options may include walking, strengthening, aerobic exercise, mobility exercises, swimming, yoga or Pilates adapted to your ability, a supervised group programme, or individual physiotherapy. Exercise programmes should be considered according to your needs, preferences and capabilities. Manual therapy may be considered only as part of a wider package that includes exercise, with or without psychological support. Persistent pain may need broader rehabilitation When pain continues, several factors may maintain disability: reduced strength and conditioning, poor sleep, fear of movement, low mood or anxiety. Work or caring pressures, repeated ineffective treatments, unhelpful beliefs that the spine is permanently damaged, social isolation, or medicine side effects. Considering these factors does not imply that the pain is psychological. A combined physical and psychological programme may help when persistent pain has not responded to simpler care or when fear and avoidance are creating additional barriers. Return to work does not require complete absence of pain Remaining connected with work can support recovery when duties are safe and appropriate. Temporary adjustments might include reduced lifting, shorter shifts, more frequent position changes, phased return, temporary alternative tasks, or equipment or workstation review. Your plan should consider the actual demands of your role. Arrange review when recovery is not progressing See a GP or use an NHS musculoskeletal service when pain has not improved after several weeks, pain repeatedly returns, it is preventing usual activities, you are struggling to cope, leg symptoms are persistent, numbness or weakness is developing. Sleep is repeatedly disrupted, pain is mainly in the upper back, you have unexplained weight loss, your back has changed shape or developed a swelling, or pain is worsening rather than gradually settling.

Back pain is assessed by separating three broad patterns: common back pain influenced by movement, muscles and joints without signs of serious disease; nerve related pain, tingling, numbness or weakness travelling into a limb; and possible serious or non spinal pain accompanied by changes in bladder, bowel, sexual or neurological function, major trauma, infection risk, previous cancer or systemic illness. The pattern and associated symptoms determine urgency, not pain intensity alone.