Back Pain

Non-specific low back pain

The commonest by far. It involves muscles, joints, discs, ligaments and the nervous system together — which is precisely why a scan rarely identifies "the" cause, and why looking for one is unhelpful.

Specific causes

• Sciatica — nerve root irritation causing pain down the leg. See our sciatica page
• Spinal stenosis — typically over 60, with leg pain on walking that eases on sitting or leaning forward
• Axial spondyloarthritis — inflammatory, as above
• Vertebral fracture — in osteoporosis, sometimes after minimal trauma or none
• Infection, or cancer spread to the spine — uncommon, and the reason the red flags exist

What increases the risk

• Previous episodes — the strongest single predictor
• Sedentary work and prolonged sitting
• Heavy manual work, lifting and vibration
• Excess weight, and low general fitness
• Smoking
• Poor sleep
• Psychological factors — stress, low mood, and fear of movement. These are among the strongest predictors of pain becoming persistent, and saying so is not the same as saying the pain is imaginary

What matters more than posture

Worth saying, because it removes a lot of unnecessary guilt: there is no single "correct" posture, and sitting badly does not damage your spine. The evidence for posture as a cause of back pain is weak. The best position is the next one — changing position regularly matters far more than holding any particular one.

Why persistent pain is not the same as ongoing damage

In long-standing back pain the nervous system becomes more sensitive — pain signals amplify even after tissues have healed. The pain is entirely real; it is just no longer a reliable measure of harm. This is why gradually increasing activity is safe and helpful even when it hurts, and why understanding it genuinely reduces pain.

Back pain is diagnosed from the history, and a video consultation covers that well. The purpose of assessment is to identify the small number who need something different — not to find a structure to blame.

What we ask

• The cauda equina questions, in every case: bladder, bowel, saddle sensation, both legs, sexual function
• Where the pain is, and whether it goes below the knee
• Morning stiffness — and specifically, how long before it loosens
• Does it improve with movement or with rest?
• Night pain, and whether it wakes you
• Age at onset
• Cancer history, weight loss, fever, steroid use, drug use
• Any leg weakness, numbness or foot dragging
• Work, and what you cannot currently do
• Mood, sleep, and what you are worried it might be — which is a clinically useful question, not a polite one

Imaging — and why we usually will not arrange it

X-rays and MRI scans do not improve outcomes in ordinary back pain, and they carry a genuine downside. Degeneration, disc bulges and "wear and tear" are found in the majority of people who have no pain whatsoever. Being told your spine shows these things measurably increases fear, reduces activity, and worsens outcomes.

Imaging is warranted for: red flags, suspected cauda equina, suspected fracture, suspected infection or cancer, or where surgery is genuinely being considered.

Blood tests

Where inflammatory or serious causes are possible: inflammatory markers, full blood count, vitamin D, calcium, and a PSA in men where the picture warrants it.

What needs in-person assessment

Any red flag, any neurological deficit, and any suspicion of cauda equina — which goes straight to A&E, not to a referral. We will say so immediately and without hedging.

During a flare

• Keep moving. Short walks, gentle movement, changing position regularly
• Anti-inflammatories regularly for a few days rather than sporadically
• Heat packs; a hot shower before moving in the morning
• Sleep however is comfortable — there is no correct sleeping position. A pillow between or under the knees often helps
• Keep going to work if you can, with adjustments
• Expect a flare to settle over days to weeks. Flares are part of the pattern, not a sign of new damage

Preventing the next one

• Regular exercise — the single most effective preventive measure. Any kind, consistently
• Build core and back strength gradually
• Stay at a healthy weight; stop smoking
• Sleep properly — poor sleep amplifies pain measurably
• Break up long periods of sitting; move every 30 minutes or so
• Lift sensibly — close to the body, using your legs. But do not become afraid of bending or lifting; backs are built for it, and avoidance weakens them

Two beliefs worth letting go of

"I have a bad back and must protect it." Avoidance and bracing lead to weaker muscles, more stiffness and more pain. Gradually loading the back is what makes it more resilient.

"My scan shows degeneration, so I am damaged." Those findings are present in most pain-free people of the same age — like grey hair on the inside. They are a poor predictor of pain, and treating them as a diagnosis has been shown to make people worse.

Getting back to activity

Start below what you think you can manage, and build by roughly 10% a week. Some increase in pain during activity is expected and is not damage — what matters is that it settles within a day. Consistency beats intensity by a wide margin.

Know the emergency signs

Worth memorising, because it is the one thing on this page where timing genuinely changes the outcome:

Numbness in the saddle area — difficulty passing urine or losing control — loss of bowel control — numbness or weakness in both legs — new loss of sexual sensation. Any of these: A&E now.

What is the one thing I must not ignore?

Numbness in the saddle area, any change in bladder or bowel control, weakness or numbness in both legs, or new loss of sexual sensation. That combination may be cauda equina syndrome, and it is a genuine emergency — go to A&E immediately, not tomorrow. Delay of hours can cause permanent loss of bladder and bowel function. Everything else on this page can wait for an appointment.

Should I rest?

No — and this is the biggest change from the advice people were given years ago. Bed rest weakens muscles, stiffens joints and prolongs the pain. Keep moving within what you can manage, keep going to work if possible, and change position often. Hurting is not the same as harming.

Shouldn't I have a scan?

Usually not, and it is worth explaining why rather than just refusing. "Disc bulges", "degeneration" and "wear and tear" appear on the scans of most people who have no pain at all — they are like grey hair on the inside. Being told your spine shows them measurably increases fear, reduces activity and worsens outcomes. Scans are for red flags, suspected fracture or infection, or where surgery is genuinely on the table.

Can I have something stronger than ibuprofen?

Almost certainly not codeine or tramadol. Opioids work poorly for back pain, cause dependence and constipation, and prolonged use makes pain worse rather than better — this is national guidance rather than caution on our part. Anti-inflammatories are first-line, and exercise is the treatment with the best long-term evidence. Interestingly, paracetamol alone is not recommended for low back pain.

Is it my posture?

Probably not, and this removes a lot of guilt. The evidence linking posture to back pain is weak, and there is no single correct way to sit. What helps is changing position regularly — the best posture is the next one. Ergonomics are about comfort, not about preventing damage.

Could this be arthritis in my spine?

There is one pattern worth checking. If your back pain started before 45, came on gradually, gives you more than 30 minutes of morning stiffness, improves with exercise rather than rest, and wakes you in the second half of the night — that suggests inflammatory back pain rather than mechanical. It needs blood tests and rheumatology, and the average delay to diagnosis is measured in years, so it is worth raising specifically.

Why does it still hurt when the scan is normal?

Because in persistent pain the nervous system becomes more sensitive, amplifying signals even after tissues have healed. The pain is entirely real — it is simply no longer a reliable measure of damage. That is why gradually increasing activity is safe even when it hurts, and why programmes combining exercise with understanding pain work better than more scans.

Will it come back?

Quite possibly — back pain tends to come in episodes, and a flare is not a sign of new damage. Regular exercise is the single most effective way of reducing how often and how badly they happen. Having a plan for flares — keep moving, anti-inflammatories for a few days, heat, don't panic — makes them considerably shorter.