Treatment for lower back pain begins with classifying the pain: mechanical pain arising from muscles, ligaments, facet joints or the disc; radicular pain that travels down the leg with numbness or weakness because a nerve root is compressed; pain from spinal canal narrowing that appears on walking and eases on sitting; or, in a small minority, pain caused by something serious such as infection, an osteoporotic fracture or a tumour. This classification governs everything that follows, because what helps one pattern can be worthless in another. The reassuring reality is that most lower back pain is mechanical, not dangerous, and improves gradually over weeks. That is why imaging is not ordered for every patient at the outset: an MRI in the first weeks, with no warning features, **usually does not change treatment**, and it frequently shows disc bulges and degenerative changes that are also present in people with no pain at all, frightening patients unnecessarily and driving them towards procedures they do not need. Imaging is requested when there are red flags, when radicular pain fails to settle, or when a specific intervention is being planned. Treatment rests on a principle that contradicts common belief: **bed rest delays recovery and increases pain**. The correct approach is to keep moving within tolerable limits and then build activity up gradually, alongside physiotherapy that strengthens the deep trunk muscles and corrects movement patterns, pain relief sufficient to allow that movement, adjustments to work and seating, and attention to weight, sleep and stress, all of which genuinely influence whether pain persists. In selected cases image-guided injections are used for temporary relief that opens a window for rehabilitation. The limits matter too. Back braces are a short-term aid rather than a lasting solution, and relying on them weakens the trunk muscles. Cracking or traction of the back does not put a vertebra back in place as is often claimed; vertebrae do not slip out and get pushed back by hand, and any immediate improvement comes from temporary muscle relaxation. Surgery benefits a defined group - clear nerve root compression that is not settling, disabling canal narrowing, or a neurological red flag - and is not a treatment for simple mechanical back pain. Seek urgent care for loss of bladder or bowel control, numbness between the thighs, or progressive leg weakness. Suitability for any procedure is decided by clinical examination, not by reading.
Procedure steps
- 1
History taking and the search for red flags
The doctor asks how the pain began, what worsens and eases it, whether it travels down the leg and how far, and about numbness, weakness or changes in passing urine. Red flags are specifically sought: fever, unexplained weight loss, a history of cancer, long-term steroid use, osteoporosis or a fall, relentless night pain, and onset at a very young or an older age.
- 2
Physical and neurological examination
Range of movement is measured, the back, pelvis and surrounding muscles are palpated, and leg strength, sensation, reflexes and nerve tension tests are examined while gait and standing posture are observed. This examination separates mechanical from radicular pain and from canal narrowing, and decides whether imaging is needed now or can wait while initial treatment starts.
- 3
Imaging when indicated, not routinely
With no red flags, an MRI is not requested in the first weeks because it rarely changes management and shows changes that are common in people without pain. Imaging is ordered when a red flag is present, when radicular pain persists or worsens after an adequate treatment period, when there is neurological weakness, or before planning an injection or surgery, and it is always read together with the examination.
- 4
Physiotherapy and graded return to activity
An exercise programme starts to strengthen trunk and pelvic muscles, improve hip flexibility and correct bending and lifting patterns, with explicit encouragement to keep moving and working within tolerance because prolonged rest increases pain. Sitting posture, screen height, mattress and pillow are reviewed, and short daily home exercises are prescribed, since consistency matters more than intensity.
- 5
Medication, interventions and follow-up
Analgesics or neuropathic pain medicines are used according to pain type and your other conditions, for a defined trial period rather than open-ended. In selected cases image-guided injections are offered as temporary relief that permits rehabilitation. Reviews measure function rather than pain alone, and cases with neurological weakness or failure to progress are referred for surgical assessment.
Before the procedure
Before the appointment, write down when and how the pain started, whether there was an accident, a heavy lift or a fall, and how far or how long you can now walk or sit compared with before. Note whether pain travels down the leg and how far, and whether there is numbness, weakness or catching of the foot. Bring a complete list of your medicines, including painkillers, anti-inflammatories, blood thinners, steroids and supplements, with what helped and what did not. Bring previous imaging and reports on a disc or app rather than phone photographs alone, plus physiotherapy reports if you have them. Wear comfortable clothing that allows examination of the back and legs, and tell the doctor straight away about fever, weight loss, a cancer history or any urinary problem.
After the procedure
Keep moving and do not take to your bed: prolonged rest increases stiffness, weakens muscles and lengthens the episode. Do your prescribed exercises daily in short sessions and expect mild discomfort at first without it meaning harm. Change how you lift by bending at the hips and knees, keeping the load close to your body and never twisting as you lift, and change position every half hour during desk work. Do not rely on a back brace permanently, do not increase painkiller doses yourself, and avoid repeated forceful traction or cracking sessions. Manage your weight and sleep, and stop smoking, which accelerates disc degeneration. Go to the emergency department immediately with **loss of bladder or bowel control or urinary retention**, **numbness between the thighs and around the anus**, **progressive leg weakness or a dropping foot**, fever with back pain, severe pain after a fall especially if you have osteoporosis, or unexplained weight loss or night pain that wakes you every night.
Expected duration
The assessment visit usually takes 20 to 40 minutes and a physiotherapy session 30 to 45 minutes, while most mechanical cases typically improve over two to six weeks.
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