What are the red flags for low back pain in urgent care?

Saddle numbness, new bladder or bowel disturbance, bilateral leg symptoms → Cauda equina — emergency MRI pathway; History of cancer, weight loss, night pain → Metastatic spinal cord compression — urgent; Fever, IV drug use, immunosuppression → Spinal infection; Significant trauma or osteoporosis / steroids → Vertebral fracture; Over 50 with new pain, pulsatile mass, collapse → Abdominal aortic aneurysm

Which decision rule is used for low back pain?

STarT Back (risk stratification): Low risk → reassurance, self-management, stay active; Medium / high risk → physiotherapy, consider psychological support. Use to decide on physiotherapy referral (NICE NG59).

What should I prescribe for low back pain?

Ibuprofen (oral NSAID, first line): 400 mg three times a day with food — lowest effective dose, shortest time (Consider a PPI if GI risk; check renal function / risk factors); Codeine 30 mg ± paracetamol: 30 mg four times a day as needed — only if an NSAID is contraindicated or not tolerated (Short course (few days); warn about constipation and drowsiness/driving)

● Urgent care clinic · 30-minute consult

Low back pain

Q: What safety-netting advice should I give for low back pain?

Advise the patient to return or seek help if: Numbness around the bottom or genitals; Problems passing urine, loss of bladder or bowel control, or sexual dysfunction; Weakness or numbness in both legs; Fever, or feeling very unwell.

Non-specific back pain: rule out the red flags, then keep them moving.

Typical consult⏱ 15 min

Investigations🔬 Usually none

Usual outcome💊 NSAID + stay active

0–5Red flags + history5–12Examine12–17Decide17–24Treat + explain24–30Safety-net + document

1Rule out first — red flags

If you find…	…then
Saddle numbness, new bladder or bowel disturbance, bilateral leg symptoms	Cauda equina — emergency MRI pathway
History of cancer, weight loss, night pain	Metastatic spinal cord compression — urgent
Fever, IV drug use, immunosuppression	Spinal infection
Significant trauma or osteoporosis / steroids	Vertebral fracture
Over 50 with new pain, pulsatile mass, collapse	Abdominal aortic aneurysm

4Decide — investigate only if it changes the plan

STarT Back (risk stratification)

Low risk → reassurance, self-management, stay active
Medium / high risk → physiotherapy, consider psychological support

Use to decide on physiotherapy referral (NICE NG59).

Investigation	Only if…
No imaging	Non-specific back pain — imaging doesn’t help and isn’t recommended (NICE NG59)
Urgent MRI	Only for suspected cauda equina, cord compression, infection or cancer

5Treat & send home

Management & advice

Explain: most acute back pain improves within 6 weeks; it isn’t a sign of damage
Stay active, keep working if possible; avoid bed rest
Heat may help; exercise programmes and physiotherapy self-referral
Don’t offer paracetamol alone, opioids for chronic pain, gabapentinoids, benzodiazepines or antidepressants for low back pain

Refer / follow-up

Red flags → ED / urgent pathway
Sciatica not improving at 4–6 weeks or high STarT Back → physiotherapy / GP

℞

Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.

Drug	Dose	Duration / notes
Ibuprofen (oral NSAID, first line)	400 mg three times a day with food — lowest effective dose, shortest time	Consider a PPI if GI risk; check renal function / risk factors
Codeine 30 mg ± paracetamol	30 mg four times a day as needed — only if an NSAID is contraindicated or not tolerated	Short course (few days); warn about constipation and drowsiness/driving

6Safety-net

Say it like this

This is the common kind of back pain. It’s a strain, not damage, and most people are much better within 6 weeks. The best thing is to keep moving and use the anti-inflammatory regularly for a few days. If you ever notice numbness around your bottom or genitals, or problems controlling your bladder or bowels, that’s an emergency: go to A&E straight away, day or night.

Come back / call 111 — or 999 if severe — if:

Numbness around the bottom or genitals
Problems passing urine, loss of bladder or bowel control, or sexual dysfunction
Weakness or numbness in both legs
Fever, or feeling very unwell

7Patient leaflets — scan & go

Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.

Back painnhs.uk/conditions/back-pain

8Document

Low back pain — clinic note

A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.

URGENT CARE — LOW BACK PAIN PRESENTING COMPLAINT: HISTORY Onset, mechanism, duration, radiation to the legs: Cauda equina screen: saddle sensation, bladder, bowel, sexual function, bilateral sciatica: Red flag screen: cancer, weight loss, fever, trauma, steroids, IVDU: Function: work, sleep, mobility; analgesia tried: Yellow flags: fear of movement, low mood, work issues: RED FLAGS (record present / absent) [ ] Saddle numbness, new bladder or bowel disturbance, bilateral leg symptoms [ ] History of cancer, weight loss, night pain [ ] Fever, IV drug use, immunosuppression [ ] Significant trauma or osteoporosis / steroids [ ] Over 50 with new pain, pulsatile mass, collapse PMH: DRUG HISTORY: ALLERGIES: SOCIAL (job / who is at home / driving): OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 ) EXAMINATION Observe gait and posture: Palpate spine for midline tenderness: Straight-leg raise: Lower limb neurology: power, reflexes, sensation (dermatomes): Saddle sensation (if any neuro symptoms) — document clearly: Abdomen and pulses if over 50: DECISION RULE — STarT Back (risk stratification): result ______ INVESTIGATIONS: none required / No imaging, Urgent MRI — result: IMPRESSION: PLAN Treatment / TTO (drug, dose, duration): Advice given: Leaflet given (QR / printed): Back pain Follow-up / referral: SAFETY-NETTING (told to return / call 111 / 999 if): - Numbness around the bottom or genitals - Problems passing urine, loss of bladder or bowel control, or sexual dysfunction - Weakness or numbness in both legs - Fever, or feeling very unwell Patient understands and agrees with the plan: Y / N Seen by: Grade: Date/Time:

✓Guidelines

Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.

More injuries & musculoskeletal

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