Back pain/ Spinal pathway

Overview

Most back pain is described as mechanical back pain, rarely needs imaging, and can be self managed, sometimes with the help of physio. 

Positive explanations to patients are important: 

• "Back pain is a symptom not a disease. Most back pain is not due to any serious disease or damage to your back. It can be likened to a sprain or strain." 
• "Your back is simply not working or moving as it should; it is unfit or out of condition"
• "Recovery and relief from your pain depend upon getting your back moving and working again, and restoring normal function." 

There is advice in Clinical Knowledge Summaries for patients with:

Low back pain without radiculopathy

Sciatica (lumbar radiculopathy)

Who to refer

Send patients to A&E with suspected cauda equina syndrome. A patient presenting with back pain and/or sciatic pain with:

• Saddle anaesthesia, perineal sensory alteration
• New difficulty or inability to initiate micturition/painless urinary retention/new onset overflow incontinence
• Change in sexual function
• Altered bowel or bladder sensation
• Inability to move bowels
• Lax anal sphincter
• Bilateral or progressive neurological deficit in the lower limbs
• Bilateral sciatica

Consider admission or discussion with on-call teams (Orthopaedics/ Neurosurgery/ Neurology):

• Severe low back pain following significant trauma
• Suspected spinal infection eg unwell with unexplained fever (Book MRI directly, perform WCC & CRP. Send to A&E if any progressive neurological dysfunction or systemically unwell)
• Multilevel weakness in the arms/legs
• Upper motor neurone signs (hyper-reflexia, clonus, positive Babinski (up-going plantar response). Consider MRI and/or discussion with on-call.
• Gait disturbance, foot drop (Grade 3/5 weakness or lower)

Muscle weakness: eg. foot drop (suggests L4-5 root impingement) or unable to stand on toes (suggests S1-2 root impingement). Severe weakness (Grade 3/5 or lower is a potential surgical emergency due to nerve root ischaemia, and needs to be referred as above. Grade 4 or 4+ weakness (eg able to move the foot against gravity, but some weakness against resistance): this can vary from mild and unimportant to severe and important, depending on individual factors including age, progression and how it affects quality of life. It is important to keep a close eye on this, and refer if progressing. Consider MRI, and you may like to discuss with on-call as above, or speak to the MSK Interface Service Advice & Guidance (note MSKI is not emergency hotlines, and are only answered during office hours).

Suspected cancer: consider appropriate imaging and 2WW referral. Refer to A&E if any progressive neurological dysfunction.

Please be aware of the following funding policies: Management of Low Back Pain and Sciatica in over 16’s Criteria Based Access and Individual Funding Request Policy and Referral for Assessment for Spinal Surgical Opinion Prior Approval Policy

BNSSG MSK SERVICES SINGLE POINT OF ACESS (SPA)

Single point referral for triage, assessment and treatment of peripheral and spinal MSK conditions & MSK Podiatry Referrals

INCLUSION CRITERIA FOR REFERRALS TO MSK SPA TRIAGE

• Patients with spinal pain (with or without leg symptoms) who have not benefited from 6 weeks appropriate primary care GP management.
• Patients referred for rehabilitation from secondary care following trauma/surgery.
• Patients requiring assessment +/- intervention from MSK physiotherapy/MSK Biomechanic podiatry/orthopaedic triage.

The single point of access is for interface and physiotherapy referrals from GPs. The option of physiotherapy is still available at the hospitals and patients should be offered choice. We will be adding regular updates of Physio wait times, at all providers, to the Physiotherapy page in Remedy which will be updated monthly to inform patient choice.

Back Pack (referral criteria on BackPack): this is a 6 week group programme, run by a physiotherapist and psychologist, particularly appropriate for chronic/recurrent back pain with high psychosocial risk factors (which can be measured by tools such as StartBack). Please give this patient info leaflet (prints correctly as a booklet) before referral to help you both decide if they would benefit from a referral. See Back Pack services section for details of how to refer.

Axial spondyloarthritis

For suspected axial spondyloarthritis: refer patients to rheumatology only if low back pain started before the age of 45 years, lasting longer than 3 months, if 4 or more of the following additional criteria are also present:

• waking during the second half of the night because of symptoms
• buttock pain
• improvement with movement
• improvement within 48 hours of taking non-steroidal anti-inflammatory drugs (NSAIDs)
• first-degree relative with spondyloarthritis
• current or past arthritis
• current or past enthesitis
• current or past psoriasis.
• If exactly 3 of the additional criteria are present, perform an HLA‑B27 test. If the test is positive, refer the person to a rheumatologist for a spondyloarthritis assessment. (Please note: approx. 10% of patients with inflammatory back pain do not carry HLA B27, and also approximately 10% of the UK population carry HLA-B27 but most do NOT have inflammatory back disease. An HLA-B27 test costs £40.00)

In your referral please either: 

1. a) send in a copy of the EMIS record via eRS in which it is made clear how your patient meets the above criteria (otherwise the referral will be rejected) or
2. b) fill in the Referral Proforma for patients with suspected axial spondyloarthritis AND attach a copy of the relevant consultation / EMIS record - See Services section

Before a rheumatology referral consider:

• FBC, U&E, LFT, bone profile
• ESR & CRP
• HLA-B27 (see note above)
• (Autoantibodies - such as RF, ANA, ANCA are not necessary for diagnosis of AxSpA and often lead to confusion)
• Imaging: is not necessary, as many rheumatologists prefer to arrange this themselves (however, you might consider X-ray of the spine for differential diagnosis). Please do NOT arrange a spinal MRI, as rheumatology do specialist scans as deemed necessary. 

If the person does not meet these criteria, but clinical suspicion of axial spondyloarthritis remains, advise the person to seek repeat assessment if new signs, symptoms or risk factors listed above develop. This may be especially appropriate if the person has current or past inflammatory bowel disease (Crohn's disease or ulcerative colitis), psoriasis or uveitis.

Please consider using the SPADE tool to help in assessing the risk of AxSpA in patients with chronic back pain: www.spadetool.co.uk.

Consider referring urgently to EIA clinic if clear joint swelling is present (and crystal-induced arthritis is not suspected or ruled out). Use the EIA referral form in such cases (see Early Inflammatory Arthritis page).  

Red Flags

When to worry, when to image:…suspicion is proportional to number of these (80% of LBP will have at least one red flag, the presence of one red flag does not necessarily trigger imaging, it just raises clinical suspicion). 

• Unremitting non-mechanical pain, night painH/o trauma  - fracture?, osteoporosis?  (Consider age versus force.)
• Structural deformity
• Persistent thoracic pain  (mets prevalence highest in thoracic spine, lowest cervical spine) 
• Past Hx: carcinoma,  (lung, prostate, thyroid, kidney, breast =  mostly metastasise to the spine); steroids, HIV, IVDU, immunosuppression
• Unwell, weight loss, constitutional symptoms
• NEW presentation under age 20 or over 55
• Neurology: especially saddle anaesthesia  and bowel and bladder disturbance  (CES);  marked muscle weakness, widespread / progressive  neurology. (Nerve root involvement / cord compression in cervical and thoracic spine) 

Before referral

Consider FBC, bone profile, CRP/ESR and myeloma screen for patients with persistent back pain, over 60 years old to rule out myeloma

At first presentation:

• screen for red flags and radicular pain
• assess impact on family, social and work ability
• physical examination - observe spine, lower limbs, gait, and pain behaviour.
• look for neurological signs
• consider back pain leaflet and video - See links in Guidelines section below.

X-rays are rarely helpful, but can be useful if osteoporotic or pathological fracture is suspected for example (see Radiology guidelines).

Only ever arrange MRI where there are a number of red flags, where you think imaging will change management (see Radiology guidelines).

At second presentation:

• rescreen for red flags and radicular pain
• consider STarT Back tool

If Low risk (<4): single biopsychosocial CBT based advice session by GP:

• Reassurance - Improvement is likely, positive language, avoid medicalising, distinction between pain and harm. 
• Advice about continuation of normal activities, including work, or return to normal activities using graded steady increases, return to work ASAP.
• Offer analgesics NSAID or topical agents, weak opioids such as Codeine. Stronger opioids only for short planned courses, and not for longer term.
• Advise recurrence is common, and can be managed by the patient
• Self-Management - Self-directed exercise programme, Self-directed relaxation techniques, and Self-directed return to normal social and occupational activities
• Indications for early clinical review and emergency attendance
• Patient information - on-line info (see Guidelines section below)
• Advice to return if not settled: safety netting.  

If medium risk, consider earlier referral to physio

If high risk, consider earlier referral to physio, or BackPack (see above)

resources

Patient information leaflets & useful links

getUBetter App

Versus Arthritis (Arthritis Research UK) - Back pain information leaflet including exercises

Exercises for back pain backcare.org.uk

Top tips for a healthy back backcare.org.uk 

Exercises for office workers backcare.org.uk

Sirona MSK Leaflet library - Back Pain Resources

Doc Mike Evans Low back pain video - You Tube link (https://www.youtube.com/watch?v=BOjTegn9RuY

Persistent pain - Strategies for keeping mobile

Useful information to help patients get active

Further information on the Pain Services page of Remedy may also be helpful.

Services

• Rheumatology - Back pain

• MSK Interface Service

• Back Pack - NBT & WGH

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.