Summary of intervention

The evaluation of low back pain by a medical provider should include a complete medical history and examination. It should be established if any “red flag” signs or symptoms are present that could indicate serious underlying pathology.


Serious underlying pathology includes but is not limited to:

  • Infection
  • Suspected cancer
  • Spinal injury
  • Spinal cord compression
  • Inflammatory conditions
  • Patients with cancer and symptoms suggestive of spinal metastases
  • Spondyloarthritis in over 16s
  • Cauda equina syndrome

 This guidance applies to adults aged 19 years and over.


Number of interventions 2018/19




Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica in the absence of red flags, or suspected serious underlying pathology following medical history and examination.


Imaging in low back pain should be offered if serious underlying pathology is suspected. Serious underlying pathology includes but is not limited to: cancer, infection, trauma, spinal cord injury (full or partial loss of sensation and/or movement of part(s) of the body) or inflammatory disease.


Further information can be accessed at the relevant NICE guideline for these conditions.


Patients presenting with low back pain and sciatica should be reviewed in accordance with the low back pain and sciatica guidance [NG59]. Patients presenting with low back pain without sciatica should be reviewed and if none of the above serious underlying pathology are suspected, primary care management typically includes reassurance, advice on continuation of activity with modification, weightloss, analgesia, manual therapy and reviewing patients who are high risk of developing chronic pain (i.e. STaRT Back).


NICE guidelines recommend using a risk assessment and stratification tool, (e.g. STaRT Back), and following a pathway such as the National Back and Radicular Pain Pathway, to inform shared decision making and create a management plan.


Consider a combined physical and psychological programme for management of sub-acute and chronic low back pain (greater than 3 to 6 months duration) e.g. Back Skills Training (BeST). Consider referral to a specialist centre for further assessment and management if required. Imaging within specialist centres is indicated only if the result will change management.


For further information please see the following NICE guidance:

  • NICE. Low back pain and sciatica in over 16s: assessment and management [NG59]
  • NICE. Low back pain and sciatica in over 16s [QS155]


Rationale for recommendation

NICE recommends imaging does not often change the initial management and outcomes of someone with back pain. This is because the reported imaging findings are usually common and not necessarily related to the person’s symptoms. Many of the imaging findings (for example, disc and joint degeneration) are frequently found in asymptomatic people. Requests for imaging by non-specialist clinicians, where there is no suspicion of serious underlying pathology, can cause unnecessary distress and lead to further referrals for findings that are not clinically relevant.


Undertaking imaging when it is not indicated can lead to further additional and unnecessary investigations and treatment, including surgery, increasing the risk of harm to patients and driving up costs.


There is evidence that most patients in whom a serious underlying pathology is not suspected and without red flag symptoms will recover from low back pain within six weeks.


In patients with symptoms suggestive of cauda equina syndrome, imaging should not be delayed. The spinal surgery GIRFT report has recommended there should be a low threshold for investigation and, following urgent referral by a senior clinician, an MRI should be undertaken as an emergency. The decision to perform an MRI does not require discussion with the local spinal services. The MRI must be undertaken as an emergency in the patient’s local hospital and a diagnosis achieved prior to any discussion with the spinal services. The MRI must take precedence over routine cases and any reasons for a delay or a decision not to perform an emergency scan should be clearly documented. Hospitals with MRI facilities that are not providing a 24/7 service (usually due to a lack of radiographer out of hours support) are being encouraged to provide this service.