Back pain/ Spinal pathway - Draft

Overview

Self -Limiting Back Pain

Back pain, particularly lower back pain, is very common and usually mechanical in nature. It usually improves within a few weeks but can sometimes last longer or keep coming back. Imaging is rarely needed and patients can usually self manage with the help of reassurance and self care. A self help app such as getubetter or referral to a physio may also be helpful.

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." 

Safety- Netting

Give the patient advice on when to re-present including red flags. A patient information leaflet or link can be helpful.

If the patient represents then:

• Rescreen for red flags and radicular pain - See Red Flag section below
• If no red flags then consider using the STarT Back tool

STarT Back Tool

This tool can help assess risk of chronicity and guide next steps in managment. It takes less than a minute to complete.

Low risk

Consider single biopsychosocial CBT based advice session by FCP or GP:

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

Medium risk, In addition to above consider earlier referral to physio

High risk, In addition to above consider earlier referral to physio and/or BackPack.

There is further advice in Clinical Knowledge Summaries for patients with:

• (1) Back pain - low (without radiculopathy) | Health topics A to Z | CKS | NICE
• (2) Sciatica (lumbar radiculopathy) | Health topics A to Z | CKS | NICE

Assessment in primary care

Initial assessment in primary care should exclude Red Flags that may indicate if an emergency hospital admission is required. See the Red Flag section below for details.

If these conditions are not suspected then most patients can be initally managed in primary care.

History and Examination

Assessment of the patient should include a detailed history and examination:Assessment | Back pain - low (without radiculopathy).

Please also see notes on  assessment of any muscle weakness as below:

Level of impingement - muscle weakness can present in various ways depending on level of impingement.

• Foot drop suggests L4-5 root impingement
• Unable to stand on toes suggests S1-2 root impingement

Grade of weakness - Use the Oxford Scale

Grade 4 or 4+  i.e. 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 consider imaging or referral if progressing. Consider MRI or speak to the MSK Interface Service Advice & Guidance (note MSKI A and G is not for emergencies, and calls are only answered during office hours).

Grade 3 or lower is a potential surgical emergency due to nerve root ischaemia, and needs to be referred as an emergency (see Red Flag section below).

Investigations

Investigations should be directed towards suspected cause. Imaging should not be undertaken if the patient is likely to have a self limiting condtion.

Bloods - consider appropriate bloods if an underlying cause is suspected such as:

• Age - if >60 and persistent back pain consider bloods to rule out myeloma.
• Inflammatory symptoms -consider axial spondyloarthritis or EIA
• Constitutional symptoms such as fatigue or weight loss - consider malignancy.

Imaging - do not request plain x-ray or MRI unless it is likely to change management.

• X-ray can be useful if osteoporotic or pathological fracture is suspected. 
• MRI should only be considered where there are a number of red flags, and imaging will change management.  

See the Spinal Imaging in Primary Care  page for further advice on appropriate use of imaging.

Red Flags

Cauda Equina Syndrome (suspected)

If cauda equina syndrome is suspected then consider same day admission to Emergency Department. A local CES pathway is in development. CES should be considered if a patient presents with back pain and/or sciatic pain and one of more of the following (1):

• Sudden-onset bilateral radicular leg pain or unilateral radicular pain progressing to bilateral pain; severe or progressive neurological deficit such as major motor weakness of knee extension, ankle eversion, or foot dorsiflexion.
• Recent-onset difficulty initiating micturition or impaired sensation of urinary flow; urinary retention and/or overflow urinary incontinence (late signs).
• Recent-onset loss of sensation of rectal fullness; faecal incontinence (late sign).
• Recent-onset erectile dysfunction or sexual dysfunction.
• Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia).
• Unexpected laxity of the anal sphincter.
• Gait disturbance or difficulty walking. 

Spinal fracture (suspected)

• Sudden onset of severe central spinal pain which is relieved by lying down.
• A history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis.
• Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra).
• Point tenderness over a vertebral body. 

Cancer (suspected)

• Age 50 years or over.
• Gradual onset of symptoms or progressive pain. 
• Severe unremitting lumbar pain; thoracic back pain; night spinal pain preventing sleep; spinal pain aggravated by straining (for example coughing, sneezing, or defaecation).
• Localised spinal tenderness.
• Mechanical pain (aggravated by standing, sitting or moving). 
• No symptomatic improvement after 4–6 weeks of conservative treatment.
• Unexplained weight loss.
• Claudication (muscle pain or cramping in legs when walking or exercising). 
• Past history of cancer (breast, lung, prostate, renal, and gastric cancer are more likely to metastasize to the spine).

Infection - such as discitis, vertebral osteomyelitis, spinal or epidural abscess (suspected)

• Fever; systemically unwell.
• Recent infection.
• Diabetes mellitus.
• History of intravenous drug use.
• HIV infection, use of immunosuppressant drugs, or other cause of immunocompromise.

Other indications for urgent assessment

Consider admission or discussion with on-call teams (Orthopaedics/ Neurosurgery/ Neurology) if one or more of the following:

• 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)

When to worry, when to consider imaging

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) 

Referral

Patients with symptoms that are not improving with primary care management or where there are more concerning symptoms or signs may need imaging and/or referral. Please consider the options below.

Physiotherapy

Most PCNs have access to a FCP (First Contact Practitioner) who can assess and give advice on management of back pain.

GPs and FCPs can then refer on to physiotherapy in the community or secondary care physios according to patient choice. See the MSK Physio services page for details.

Back Pack - Back Pack (Remedy BNSSG ICB)

Back Pack 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).

Spinal MSK single point of access (Sirona) - Musculoskeletal Interface (MSKI) Service (Remedy BNSSG ICB)

Referral criteria:

• 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 (i.e MSK physiotherapy/MSK Biomechanic podiatry/orthopaedic triage).

Suspected Inflammatory Conditions

Consider rheumatology referral if Axial Spondyloarthritis (axSpA) or Early Inflammatory Arthritis (EIA) are suspected and referral criteria are met. See pages below:

• Axial Spondyloarthritis (including ank spond) - think axSpA if onset at age under 45 years and back pain for more than 3 months and other criteria apply.
• Early Inflammatory Arthritis - think EIA if persistent joint inflammation/ swelling for more than 4 weeks and other referral criteria apply.

Osteoporotic Vertebral Fracture

Patients with confirmed osteoporotic vertebral fracture and pain that is not settling after 6 weeks may benefit from vertebroplasy. See the referral criteria and pathway below:

• Osteoporotic Vertebral Fracture (Remedy BNSSG ICB)

Orthopaedics or Neurosurgery Referral

Direct referral to orthopaedics or neurosurgery for spinal pain or radiculopathy are not available in BNSSG. These services can only be accessed via the MSK single point of access as detailed above.

Funding policies are also in place to restrict surgical procedures (but do not restrict primary care referrals for assessment).

• Management of Low Back Pain and Sciatica in over 16’s Criteria Based Access and Individual Funding Request Policy 
• Referral for Assessment for Spinal Surgical Opinion Prior Approval Policy

Resources

Clinical Knowledge Summaries (NICE)

(1) Back pain - low (without radiculopathy) | Health topics A to Z | CKS | NICE

(2) Sciatica (lumbar radiculopathy) | Health topics A to Z | CKS | NICE

Assessment Tools

STarT Back tool.

Patient Information

Back pain - NHS (www.nhs.uk) - includes advice for patients on red flags.

Should You Have an MRI For Low Back Pain? - YouTube - video that explains why MRI is often not required and how results can raise unnecessary concerns.

MRI spinal leaflet from NHS England. Gives advice about limitations on MRI use and interpretation of results for patients.

Self Care Apps

Getubetter - a free app endorsed by BNNSG ICB that can help guide a patients recovery from back pain (and other MSK conditions).

Services

• MSK Interface Service

• Back Pack - NBT & WGH

• Rheumatology - Back pain

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.