Effective Management of Low Back Pain in Primary Care: Key Practices and Red Flags

Dr Adeline Leong, Director, Clinical Services, SingHealth Duke-NUS Pain Centre; Head & Senior Consultant, Department of Pain Management, Singapore General Hospital

Lower back pain is a common presentation in primary care and most acute episodes can be effectively managed by general practitioners with reassurance, activity guidance and short-term analgesia. This article outlines practical strategies for assessment and early management, and highlights when referral to multidisciplinary spine and pain services is indicated for complex, persistent or red-flag cases.

CASE VIGNATE:

Mr Tan, a 42-year-old office worker, presents with three days of midline low back pain and right L5 radicular leg pain after lifting luggage. He has no previous history or similar issues. He has no red flags.

INTRODUCTION

Lower back pain (LBP) is one of the most common reasons for primary care consultation and work absence. While most acute episodes resolve within weeks, LBP is clinically heterogeneous, often multifactorial and occasionally signals serious pathology. Effective care begins with timely exclusion of red flags, followed by patient-centred, multimodal management grounded in a biopsychosocial framework.

This article synthesises current best practices for Singapore-based general practitioners (GPs), outlines when to refer to specialist care and describes available interventional and surgical options alongside the role of SingHealth institutions.

PREVALENCE OF LOWER BACK PAIN IN SINGAPORE

Consistent with global estimates, low back pain is the leading cause of years lived with disability (YLDs) in Singapore, affecting working-age and older adults alike. Singapore-specific point prevalence estimates vary by survey and population but are broadly similar to international data:

• Point prevalence: around 10-30%
• 1-year prevalence: 15-45%
• Lifetime prevalence: up to 60-80%.

80-90% of acute non specific LBP improves substantially within six weeks. Recurrences are common; a subset transitions to chronic LBP (> 3 months), which accounts for a disproportionate share of disability, healthcare utilisation and productivity loss.

PATIENT PROFILE AND SYMPTOMS

Patient presentation is varied and can be broadly classified into:

• Acute: (< 3 months) vs chronic (> 3 months)
• Lower: back pain and/or radicular leg pain.

A common presentation is the development of non specific LBP after straining, lifting or prolonged sitting. LBP anatomical generators include paraspinal muscles, ligaments, facet joints, sacroiliac joints and intervertebral discs.

Radicular pain (or colloquially known as sciatica) describes back pain with leg pain usually extending below the knee in a dermatomal fashion. When this is associated with persistent numbness and/or weakness, it is termed radiculopathy and usually indicates underlying nerve root compression.

DIAGNOSIS

A combination of history taking, examination and provocative tests may allude to the main generator of pain. Investigations such as X-rays and MRI may assist with diagnosis but often do not correlate well with patients’ complaints.

Occasionally, diagnostic blocks may be required for accurate diagnosis. Often, there may be multiple pain generators which increases the diagnostic complexity. Table 1 summarises the various LBP generators and likely presentations.

COMMON BENIGN CAUSES OF LOWER BACK

When LBP becomes chronic, psychosocial complications are common. These include features such as sleep disturbances, low mood, fear avoidance and employment issues.

LIKELY TREATMENT OPTIONS FOR MR TAN BY HIS GP

After screening and ruling out red flags, Mr Tan should be reassured that most acute LBP improves within weeks. He should avoid bed rest beyond three days and keep active within his tolerance. Fluctuations in pain levels are common; Mr Tan should focus on function and graded activity, not zero pain.

For analgesics, Mr Tan can be started on PO paracetamol. A short course of NSAIDs/COX-2 inhibitors can be very effective if there are no contraindications (assess GI, renal, CV risk; consider PPI gastroprotection in higher-risk patients). If needed for severe pain, limited ad hoc use of weak opioids (e.g., panadeine, codeine, tramadol) can be used with adequate counselling of side effects and oversight of temporary use.

Topical NSAID gels or analgesic patches can be safe and temporarily helpful particularly for myofascial and joint-related pain.

As Mr Tan has evidence of neuropathic radicular leg pain, consider starting nortriptyline/amitriptyline at low dose in the evening (e.g., 10mg ON), or gabapentin (100-300mg ON)/pregabalin (25-75mg ON); start low, and up-titrate as tolerated, with clear instructions of regular use resulting in analgesic effect in two to four weeks’ time (as opposed to 30-60 mins onset for PRN use of analgesics). Common side effects include sedation and drowsiness; avoid nortriptyline/amitriptyline for patients on concurrent serotoninergic drugs and prolonged QTc.

Non-pharmacological management is equally important and includes early referral to physiotherapy for trunk mobility/stretching, core endurance and pacing. Heat or cold packs could be used effectively. When tolerated, Mr Tan should be encouraged to walk, swim or cycle in graduated increments.

Further investigations such as X-rays are not routinely indicated without red flags.

Mr Tan comes in for a review and reassessment four to six weeks later and his pain is still persistent. What do you do now?

Reassess Mr Tan for any red flags and consider escalation accordingly.

Table 2

Investigations that can be considered:

• Lumbar X-ray: Consider in trauma, suspected compression fracture, deformity or persistent pain > 6 weeks in older adults.
• MRI of lumbar spine: Reserve for red flags, progressive neurological deficits, severe radicular pain not improving after four to six weeks of conservative care or pre-interventional/surgical planning.

Interim management prior to referral to pain medicine or spine surgeon:

• Consider careful up-titration of weak opioids andneuropathic agents.
• Address sleep hygiene; encourage activity scheduling and graded exposure; consider brief cognitive-based therapy pain coping resources.

LIKELY TREATMENT OPTIONS BY SPECIALISTS

Spine surgery (orthopedics or neurosurgery) would review patient for underlying biomedical causes and exclude any conditions that require surgical interventions. For refractory radiculopathy with structural compression, progressive neurological deficits, significant instability (e.g., spondylolisthesis) or deformity, decompression and/or stabilisation surgery canrelieve leg-dominant pain, prevent neurological deterioration and improve function after careful risk benefit discussion.

Pain medicine

Pain medicine is well-poised to coordinate the comprehensive multidisciplinary biopsychosocial approach to the patient’s overall pain management (Refer Figure 2).

In addition to pain education and optimising analgesia and neuropathic agents, the pain medicine specialist can perform specific pain interventions for diagnostic clarity and medium-term pain relief when conservative therapy is insufficient, enabling more effective rehabilitation. (Refer Table 3: LBP interventions)

SingHealth institutions deliver high volumes of spine and interventional pain care, using evidence-based pathways that emphasise early function, judicious imaging and multidisciplinary rehabilitation, aligned with international guidelines.

At the SGH Pain Management Centre (PMC), our pain medicine specialists are well poised to provide pain education, biomedical management and perform the various pain interventions. We also work closely with our allied health colleagues, acupuncturists and other specialists such as spine surgeons to provide the best holistic multidisciplinary care for our patients, with a goal of improving not just pain but importantly function, employment and quality of life.

Besides the provision of advanced pain interventions within a sustainable biopsychosocial management framework, we also run group pain management programmes twice a year which meet the gold standard for pain management internationally.

THE GP’S ROLE IN TREATMENTON GOING, POST & SHARED CARE

The Pain Management Centre at SGH cherishes our partnership with patients’ GPs and seek to actively discharge or co-manage our patients with their GPs. We have embarked on developing our Community Pain Management Programme to keep patients well and out of hospital.

In the chronic phase, we aim to de-prescribe and optimise sustainable non-pharmacological management for LBP. GPs are our valued partners in maintaining patients’ treatment, whom we support with easy referrals back to SGH PMC when required.

CONCLUSION

Most acute low back pain episodes in Singapore resolve with straightforward, primary care-led management that emphasises activity, education and time-limited analgesia. The clinical priority is to exclude red flags early, avoid unnecessary imaging and maintain function.

For persistent, radicular or diagnostically complex presentations, early collaboration with SingHealth’s/SGH PMC’s multidisciplinary spine and pain services allows access to targeted interventions and surgical expertise where appropriate.

In chronic LBP, a biopsychosocial, self-management–centred approach, supported by physiotherapy and behavioural strategies, offers the best chance of sustained functional improvement with minimal medication burden.

GPs are pivotal across the continuum—triaging, initiating evidence-based care, coordinating referrals and anchoring long-term support—so that patients can live well despite back pain.

Dr Adeline Leong was awarded the Ministry Of Health Human Manpower Development Plan Scholarship in 2020 and completed her Pain Medicine HMDP in Australia. She was admitted to the Fellowship of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists in October 2022, for which she was awarded the Merit Award in the FPM 2020 Examinations.

Dr Leong has been the Head of the Department of Pain Medicine at Singapore GeneralHospital since Jan 2025. She was the director of Sengkang General Hospital’s Pain Medicine Department from December 2020 to August 2025. She practises anaesthesia and pain medicine at both Sengkang and Singapore General Hospitals. 

GPs can call our Pain Management Clinics for appointments at the following hotlines for more information:

Singapore General Hospital
Pain Management Centre: 63214377

Changi General Hospital
Chronic Pain Clinic: 6788 3003

Sengkang General Hospital
Pain Management Clinic: 6930 6000

KK Women’s and Children’s Hospital
Women's Pain Centre: 6394 8073
Children's Pain Management Clinic: 6394 8459
Referrals: cpmc@kkh.com.sg