Most low back pain in primary care is non-specific and settles with advice to stay active. Imaging early does not improve outcomes and can lead to unnecessary procedures.
The job in the consultation is to find the few patients who need more. Ask about saddle anaesthesia, new bladder or bowel dysfunction and bilateral leg symptoms, which point to cauda equina syndrome and need same-day referral. Ask about cancer history, unexplained weight loss and night pain that does not ease with rest. Ask about fever, injection drug use, recent infection or immunosuppression for spinal infection. Consider fracture after trauma or in older patients on steroids or with osteoporosis.
In India, consider spinal tuberculosis in a patient with persistent back pain, constitutional symptoms or local tenderness.
- Ask every patient with back pain about saddle numbness and bladder or bowel change
- Refer suspected cauda equina syndrome the same day
- Image only when red flags or progressive neurological signs are present
- Consider spinal tuberculosis with fever, weight loss or a gibbus
Why it matters
A short, structured history protects the rare serious case and spares the rest unnecessary scans.
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