Back pain

Most back pain is what doctors call non-specific or mechanical back pain. It arises from the muscles, ligaments, discs and small joints of the spine, and often no single structure can be blamed with certainty. An awkward lift, a long journey, a new activity, prolonged sitting or simply a period of being less fit than usual can all set it off, and sometimes it starts for no obvious reason at all. This kind of pain is very common, it is not a sign of serious damage, and the natural course is to settle over days to weeks.

A smaller group of causes behaves differently and deserves to be recognised. Inflammatory back pain, seen in conditions such as axial spondyloarthritis, comes from inflammation in the spine and pelvis rather than strain. In older people, and in anyone who has taken steroid tablets for a long time, a sudden severe pain can come from a vertebra weakened by osteoporosis that has fractured. Back pain can also travel down the leg when a nerve root is irritated, which is what most people mean by sciatica, or it can be one part of a wider picture of aching and fatigue, as in fibromyalgia. Rarely, back pain is caused by infection or cancer, which is why certain warning features are always taken seriously.

Ordinary mechanical back pain tends to follow a recognisable course:

• Pain that varies with position and activity, often easing when you find a comfortable position
• Aching or stiffness across the lower back, sometimes spreading into the buttock or thigh
• Pain that is worse after prolonged sitting, standing or an unaccustomed effort
• Gradual improvement over days to weeks, sometimes with flares along the way

Certain patterns suggest the pain may not be simply mechanical:

• Pain that began gradually before the age of 45, improves with movement, worsens with rest, wakes you in the second half of the night, or comes with morning stiffness lasting more than half an hour, which points towards inflammation
• Sudden severe pain in an older person, or in someone on long-term steroid tablets, which raises the possibility of a fracture
• Pain that is mainly in the leg rather than the back, often with tingling or numbness, which suggests an irritated nerve root
• Back pain that is one part of widespread body pain with fatigue and unrefreshing sleep

Assessment starts with an unhurried history and a physical examination, because the pattern of the pain usually tells the story. How the pain began, what makes it better or worse, how it behaves at night and in the morning, and whether anything else is going on in the body all help separate mechanical pain from the less common causes. Most people with recent mechanical back pain need no tests at all.

Where the picture suggests inflammation, blood tests can look for markers of inflammation and related clues, though normal results do not exclude an inflammatory cause on their own. MRI is the most useful scan for the spine, as it can show inflammation in the spine and pelvis, a compressed nerve root, or a vertebral fracture, and Dr Borukhson can arrange an MRI promptly where it is indicated. If a fracture due to thinned bone is suspected or confirmed, a DEXA bone density scan measures bone strength and guides treatment to protect against further fractures.

For mechanical back pain, the evidence and UK guidance point the same way: keep moving. Staying as active as the pain allows, continuing normal activities where possible, and returning to work early all speed recovery. Bed rest is not advised, as it tends to prolong the problem. Heat, such as a hot water bottle or warm bath, can ease muscle spasm, and simple pain relief, including anti-inflammatory tablets where they are suitable for you, can take the edge off while nature does the healing. For pain that persists, a structured exercise programme, often guided by a physiotherapist, is the core of treatment, and approaches such as manual therapy can be added alongside exercise rather than instead of it.

Where assessment points to a specific cause, treatment follows that cause on its own merits. Inflammatory back pain is treated as described in the axial spondyloarthritis guide, with anti-inflammatory medication, exercise and, where needed, targeted therapies. A vertebral fracture is managed with pain relief and treatment to strengthen the bone. Sciatica is usually managed in the same way as mechanical back pain, with time and staying active, and only a minority of cases need injections or surgery. Widespread pain is approached as set out in the fibromyalgia guide.

Simple habits make a real difference, both to recovery and to keeping future episodes at bay.

• Keep moving. Gentle activity such as walking is safe and helpful, even when the back is sore. Movement is treatment, not a risk.
• Return to normal life steadily. Build activity back up over days rather than waiting to be pain-free, and pace rather than push.
• Build strength and fitness. Regular exercise that works the back, core and legs is the best-established way to reduce the chance of recurrence.
• Mind the basics. A healthy weight, not smoking, good sleep and attention to stress all support a healthy back.

Episodes of back pain often recur, and a flare is not a sign that damage has been done. Most people find that each episode settles, and that confidence in the back returns with steady activity.

Call 999 or go to A&E immediately if back pain comes with any of the following, as they can signal pressure on the nerves at the base of the spine (cauda equina syndrome), which needs emergency treatment:

• Numbness or tingling around the back passage, genitals or inner thighs (the saddle area)
• New difficulty passing urine, or loss of control of the bladder or bowels
• Weakness in one or both legs that is new or getting worse

Severe back pain after significant trauma, such as a fall from a height or a road accident, also needs emergency assessment.

Arrange an urgent medical review if back pain comes with fever, unexplained weight loss or night sweats, if you have a history of cancer, or if you feel generally unwell with the pain. Sudden severe back pain in an older person, or in anyone taking long-term steroid tablets, should also be reviewed promptly in case a vertebra has fractured.

See a doctor on a routine basis if the pain is not improving after a few weeks of sensible self-care, if it keeps returning, or if the pattern sounds inflammatory, with morning stiffness and pain that eases with movement.

Most back pain never needs a rheumatologist, and it would be wrong to suggest otherwise. The value of a specialist assessment lies in the smaller group of cases where the pattern does not fit. Inflammatory back pain is regularly mistaken for ordinary back trouble for years, vertebral fractures in older people often go unrecognised, and persistent pain sometimes turns out to be part of a wider condition that responds to a different approach. A considered assessment separates mechanical pain from these other causes, provides firm reassurance where reassurance is the right answer, and starts the correct treatment early where it is not. If your back pain is persistent, recurrent or simply does not behave the way ordinary back pain should, a careful review is worthwhile.

When should back pain be treated as an emergency?

Go to A&E or call 999 if back pain comes with numbness or tingling around the back passage or genitals, new difficulty passing urine or controlling the bladder or bowels, or weakness in the legs. These can point to pressure on the nerves at the base of the spine, called cauda equina syndrome, which needs emergency treatment to prevent permanent damage. Severe back pain after significant trauma, such as a fall from a height or a road accident, also needs emergency assessment.

How can I tell if my back pain is inflammatory rather than mechanical?

The pattern is the main clue. Inflammatory back pain tends to begin gradually before the age of 45, feels worse with rest and better with movement, can wake you in the second half of the night, and comes with morning stiffness lasting more than half an hour. Mechanical pain usually behaves the other way around, easing with rest and aching more with activity. If the inflammatory pattern sounds familiar, a specialist assessment is worthwhile, because conditions such as axial spondyloarthritis are often mistaken for ordinary back trouble for years.

Should I rest in bed until my back pain settles?

No. UK guidance is clear that bed rest is not advised for back pain, because it tends to slow recovery rather than help it. Staying as active as the pain allows, continuing normal activities where possible, and using heat and simple pain relief are the approaches that work best for ordinary mechanical back pain. Movement may be uncomfortable at first, but it is safe and it helps.

Will I need an MRI or other tests for my back pain?

Most people with recent mechanical back pain need no tests at all, because the history and examination tell the story and scans rarely change the advice. Imaging becomes important when the pattern suggests something more, such as inflammation, nerve compression or a possible fracture. MRI is the most informative scan for the spine in those situations, and Dr Borukhson can arrange one promptly where it is genuinely indicated. Blood tests and a bone density scan are added where the picture calls for them.

What is sciatica, and does it need urgent treatment?

Sciatica is pain that travels from the back or buttock down the leg, often with tingling or numbness, and it happens when one of the nerve roots leaving the spine is irritated, most often by a bulging disc. It is usually more unpleasant than dangerous, and most episodes settle over weeks with the same self-care as ordinary back pain. It needs urgent attention only if red flag symptoms appear, such as numbness in the saddle area, new bladder or bowel problems, or progressive weakness in the leg.