GP triage – Spinal Menu
Common Spine Problems
Mechanical Spinal Pain
+/- Mild-moderate Radicular pain without neurological deficit

Affected Area
- Pain between the bottom of the rib cage and the buttock, plus or minus leg
- Aggravated by specific positions/activities
- May have somatic leg pain (no loss of nerve function and no positive nerve tension signs eg SLR)
- Pain varies
- Sleep may be disturbed
- Education & advice
- Encourage normal activity
- Avoid bed rest
- Gentle exercise
- Advice and reassurance
- Refer to physiotherapy
- Analgesia: NSAIDS (+PPI for>45 years) Paracetamol (do not offer paracetamol alone)
- Weak opioids if the above not helpful Muscle relaxants, eg diazepam
- Review 2 weeks after onset
- Consider use of STaRT Back tool to guide onward referral www.keele.ac.uk/sbst
- Routine imaging not required
- Consider onward referral if conservative treatment unsuccessful
- Patient is functionally limited in ADLs and wants to consider surgery/injection.
Severe Lumbar Nerve Root Pain
with/ without neurological deficit

Affected Area
- Pain
- Radicular pain or nerve root pain tends to be in the distribution of a nerve root
- Pain can vary in nature radiating to below the knee often in the foot and/or toes
- May be associated with muscle weakness, numbness, or tingling and change in reflexes
- Pain on movement
- May have night pain
- +VE with SLR/Femoral Nerve tension test
- Analgesia
- NSAIDs
- Paracetamol
- Neuropathic pain medication
- Refer physiotherapy
- Advice and information
- Stay active where possible-modify activity if pain too severe
- Consider MRI if:
radicular pain is present and not controlled by medication at 4-6 weeks
neurology is progressive and pain uncontrolled
- Refer to MSK service – No response to conservative treatment.
- Refer to physiotherapy – Struggling with ADLs/ work/ conservative treatments.
Red Flags
Cancer/ Infection/ Fracture/ Inflammatory disease

Affected Area
- Individually, red flag symptoms have weak predictive value due to a high false positive rate. Red flags in combination may increase their predictive value.
- Cancer:
- History of previous cancer (lung, breast, prostate most common)
- Consider new onset if the patient:
- is older than age 55 years (with increasing suspicion with increasing age)
- Unexplained weight loss
- Constant progressive non mechanical pain
- Thoracic pain (two out of three spinal metastases are in the thoracic region)
- Infection:
- History of fever/ systematically unwell
- Intravenous drug misuse
- Recent infection
- Fracture:
- Suspect if: history of trauma or Osteoporosis
- Structural deformity on examination
- Inflammatory disease:
- Younger age
- Awakening in the second part of night
- Alternating buttock pain
- Morning stiffness (typically longer than 30 minutes)
- Pain improves with exercise
- Consider serious pathology in patients at particular risk:
- People younger than age 20 years
- Immunocompromised people, including patients on immunosuppressive medications, eg corticosteroids
- Back pain is common in people older than age 55 and therefore is a weak red flag in isolation
- An acute episode of spinal pain in a person older than age 70 years is predictive of osteoporotic collapse
- Low back pain affecting activity in a person younger than age 16 years is a strong red flag for cancer, as back pain is less common in this age group
- Erythrocyte Sedimentation Rate (ESR) more than 50mm/h with packed cell volume (PCV) less than 30% is useful for predicting cancer.
- Continue treatment for low back pain if the tests prove negative
- Cancer:
- Blood tests:
- FBC
- ESR
- CRP
- Bone profile
- PSA
- Prot EP
- Bence Jones s protein
- Serum light chain protein
- MRI
- Infection:
- blood tests:
- FBC
- ESR
- CRP
- MRI
- Spinal fracture:
- X-ray
- MRI
- Inflammatory disease:
- FBC and ESR
- CRP and HLA-B27
- MRI
- X-ray
- Immediate referral to A&E or orthopaedics for suspected cauda equina syndrome, fracture, or infection.
- Urgent or 2 week referral to oncology for suspected cancer.
- Consider urgent referral to Rheumatology for stable osteoporosis vertebral collapse.
Cauda Equina Syndrome

Affected Area
- Back pain-(usually but not always)
- plus one or more of:
- Erectile dysfunction
- Problems with ejaculation
- Loss of vaginal sensation
- Loss of bowel control
- Laxity of anal sphincter tone
- Urinary retention, frequency or incontinence
- Saddle anaesthesia or paraesthesia
- Severe or progressive neurological deficit in the lower extremities or gait disturbance
- Immediate referral by telephone to Orthopaedics / Neurosurgery on call Registrar
- Urgent MRI
- Immediate referral by telephone to Orthopaedics / Neurosurgery on call Registrar