Low back pain — structured viva

Structured oral on low back pain: defending no-imaging with trial data, dismantling paracetamol and steroid habits with PACE and Goldberg, the opioid nulls, stratifying chronicity risk with STarT Back, selling cognitive functional therapy, and proving you know what cauda equina timing evidence actually shows.

Prompt

The examiner opens: 'Your patient wants a back MRI and a box of oxycodone — talk me through why you'll refuse both.' The viva branches through imaging evidence, drug-trial honesty, risk stratification, chronic-pain management and the emergency that must never be missed.

Stem

You are the GP. A 46-year-old with two weeks of nonspecific low back pain demands an MRI and strong painkillers, saying his cousin "had his spine fixed by surgery". ^[1]

References10Show

[1]Chou R et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet (London, England), 2009.PMID 19200918
[2]Williams CM et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet (London, England), 2014.PMID 25064594
[3]Goldberg H et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA, 2015.PMID 25988461
[4]Jones CMP et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet (London, England), 2023.PMID 37392748
[5]Krebs EE et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA, 2018.PMID 29509867
[6]Hill JC et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis & rheumatology (Hoboken, N.J.), 2008.PMID 18438893
[7]Hill JC et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet (London, England), 2011.PMID 21963002
[8]Kent P et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. The Lancet. Rheumatology, 2023.PMID 37146623
[9]Peul WC et al. Surgery versus prolonged conservative treatment for sciatica. The New England journal of medicine, 2007.PMID 17538084
[10]Najjar E et al. Reassessing the clock in cauda equina syndrome: a systematic review and meta-analysis of surgical timing and outcomes. Neurosurgical review, 2026.PMID 41991105

Low back pain — structured viva

Stem

You are the GP. A 46-year-old with two weeks of nonspecific low back pain demands an MRI and strong painkillers, saying his cousin "had his spine fixed by surgery". ^[1]

References10Show

[1]Chou R et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet (London, England), 2009.PMID 19200918
[2]Williams CM et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet (London, England), 2014.PMID 25064594
[3]Goldberg H et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA, 2015.PMID 25988461
[4]Jones CMP et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet (London, England), 2023.PMID 37392748
[5]Krebs EE et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA, 2018.PMID 29509867
[6]Hill JC et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis & rheumatology (Hoboken, N.J.), 2008.PMID 18438893
[7]Hill JC et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet (London, England), 2011.PMID 21963002
[8]Kent P et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. The Lancet. Rheumatology, 2023.PMID 37146623
[9]Peul WC et al. Surgery versus prolonged conservative treatment for sciatica. The New England journal of medicine, 2007.PMID 17538084
[10]Najjar E et al. Reassessing the clock in cauda equina syndrome: a systematic review and meta-analysis of surgical timing and outcomes. Neurosurgical review, 2026.PMID 41991105