Peninsula Single Point of Access - Flow chart

• Screen for serious pathologies and excluding red flags.

History

• Including duration, onset, aggravating and relieving factors, management, and outcome to date. Pain severity and % back and leg pain.

• Impact on family, social and work ability.

Examination

• Observation of spine, lower limbs, gait, pain behaviour & neurological examination.

• Recommend review of article by O'Sullivan and Lin. Pain Management Today 2014; 1(1): 8-13 Acute low back pain – Beyond drug therapies

Risk assessment and Risk Stratification Tool

• Consider the use of a stratification tool e.g. 9 point STarT Back risk assessment tool to help determine the complexity and intensity of support required i.e. identify those that may benefit from more intensive management to avoid developing chronic back pain.

Based on risk stratification, consider:

• Low risk - suggests patient are likely to improve quickly and have good outcome. Management should include reassurance, advice to keep active and guidance on self-management in the form of patient information leaflets and Back pain pages at MyHealth Devon website.

Patients should be advised to reconsult in primary care if they feel needed. Consider referral to community MSK physiotherapy if there is no improvement in symptoms after 4-6 weeks of Primary care management.

• Medium risk - suggests higher level of vigilance is appropriate i.e., review and re-stratify with risk tool in primary care in 1-2 weeks. Consider referral to community MSK physiotherapy if not improving.

• High risk - suggests significant risk of developing chronicity. Consider early referral to community MSK physiotherapy (may be appropriate to trial analgesia, introduce Reconnect2Life website, advise (see management section), review and re-stratify 1-2 weeks with appropriate safety netting).

At each re-attendance clinicians are advised to:

• review diagnosis and reconsider differential diagnosis.
• re-test neurology and range of movement/pain levels.
• ask regarding compliance with advice.
• ask regarding compliance/attendance with physiotherapy.

Full details of STarT Back including online training can be accessed via STarT Back – Evidence Based Implementation of Stratified Care (keele.ac.uk)

Differential Diagnosis

Differentials to consider include:

• Fracture – history of trauma or osteoporosis risk
• Atypical nerve root pain e.g., part of dermatome such as buttock, lateral hip, or lateral lower leg only. Ipsilateral low back pain with spasm could also be atypical nerve root pathology.
• Pathology in an adjacent structure
• Malignancy - e.g., prostate, ovaries, myeloma, metastases
• Infection:
  • lower urinary tract infection (UTI)
  • pyelonephritis or perinephric abscess
  • pelvic inflammatory disease (PID)
  • shingles and post-herpetic neuralgia
  • endocarditis
  • viral syndromes

• Other:
  • renal calculi
  • hydronephrosis
  • aortic aneurysm
  • pancreatitis
  • endometriosis
  • ovarian cysts
  • dysmenorrhoea
  • coccydynia
  • inflammatory disorders e.g., polymyalgia rheumatica

• Metabolic bone disease
• Inflammatory back pain – (see inflammatory back pain guidelines)

In the absence of an obvious cause (e.g., trauma), serious spinal pathology in patients with back pain in primary care is around 1%, with vertebral fracture the most common.

However, the presence of two or more red flags significantly increases the likelihood of serious spinal pathology.

Red flags remain the best tools at the clinician's disposal to raise suspicion of serious spinal pathology, when used within the context of a thorough subjective patient history and physical examination. The following international framework discusses considerations and actions.

International Framework for Red Flags for Potential Serious Spinal Pathologies

• Rapidly changing spinal cord neurology (gait disturbance, multi-level weakness in the legs and/or arms, brisk reflexes, major motor/radiculopathy)
• Possible spinal infection (systemically unwell, fever, history of immunosuppression, IVDU, recent bacterial infection)
• Suspected Cauda Equina Syndrome (urinary retention / incontinence, faecal incontinence, altered perianal and / or genital sensation)
  • (National Suspected Cauda Equina Syndrome (CES) Pathway)
  • GIRFT CES Interactive pathway

Cauda Equina Syndrome (CES) is a collection of patient symptoms and clinical signs. No single symptom or sign is pathognomonic. Some of the features may include:

• Sudden onset (new within 2 weeks) of bilateral radicular pain or sudden progression of unilateral radicular pain to bilateral distribution
• Sudden onset (new within 2 weeks) of unilateral or bilateral neurological deficit of the legs, such as major motor weakness (knee extension, ankle eversion, or foot dorsiflexion)
• Recent-onset (new within 2 weeks) urinary retention and/or urinary incontinence
• Recent-onset (new within 2 weeks) faecal incontinence or loss of sensation of rectal fullness
• Recent-onset (new within 2 weeks) perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
• Recent-onset (new within 2 weeks) unexpected laxity of the anal sphincter
• Recent-onset (new within 2 weeks) sexual dysfunction (reduced ability to achieve erection or ejaculate, loss of vaginal sensation)

Conus Medullaris Syndrome

• Sudden and bilateral neurological deficit of the legs such as major motor weakness
• Symmetrical and bilateral perianal numbness
• Early onset urinary retention, overflow urinary incontinence and faecal incontinence
• Unexpected laxity of the anal sphincter
• Recent-onset erectile dysfunction (frequently associated)

Relevant symptoms that can be precursors to CES

• Uni-lateral or bilateral radicular leg pain
• Reduced dermatomal sensation
• Myotome weakness

Safety netting
Where there is a suspicion of a developing cauda equina syndrome, provide the patient with ‘safety net’ advice highlighting the symptoms to look out for and action to take.

Provide the patient with a CES symptom information card, direct to this video and impress timescales of action.

Clinical cue cards in multiple languages can be found here: Cauda Equina Information card

English version: Cauda Equina Information card

Information within the cue cards can aid communication of sensitive, sometimes subtle changes.

Progression of precursor symptoms above with any suggestion of change in:

• Bladder or bowel function
• Saddle sensory change

Suspect CES and perform a full neurological examination to establish:

• Dermatome sensory loss
• Myotome weakness
• Reflex changes
• Sensation to light touch pinprick throughout the saddle region including the buttocks, inner thighs and perianal region

N.B. Digital rectal examination is no longer considered essential in primary care within the UK.

Risk factors that increase the likelihood of serious pathology include:

• people at extremes of age (e.g., over 60 years)
• immunocompromised people (IVDU, HIV, Chemotherapy, Steroid use)
• history of cancer
• current and sustained weight loss

Patients with:

• suspected cancer (2ww: specialty dependent on symptoms)
• suspected Inflammatory back pain (urgent rheumatology referral)
• major motor loss (power below 4/5 MRC grade), that isn’t appropriate for ED (urgent spinal interface referral via e-RS)
• Stable / not new CES Symptoms over 14 days duration (urgent spinal interface referral via e-RS)
• suspected spinal Fracture e.g., sudden onset back pain, point bony tenderness etc. (urgent referral to spinal interface service for new onset of concerning features (mechanism, point bony tenderness, significant pain) or failure to progress with treatment at 8 weeks)
  • Risk factors that increase the likelihood of spinal fracture include:-
    • Female over 50 years
    • Excessive alcohol consumption (risk increases when drinking greater than 3 units per day)
    • Vitamin D deficiency
    • Long-term corticosteroid use (greater than 5 or 7.5mg per day over a 3-month period)
    • Rheumatoid Arthritis
    • Diabetes
    • Smoking (greater than 20 cigarettes per day)
    • Dietary restriction, eating disorders, absorption disorders (eg, Crohn’s disease)

MRI should NOT be requested for spinal pain with or without sciatica in a primary care setting.

• Current NICE /UKSSB guidelines state ‘MRI only for use in a specialist clinic if it will change outcome’.

• To manage patient expectations, patients should be informed they may not require imaging if being referred to specialist clinic. This should be reinforced that this is a good sign and there is nothing concerning in their presentation.

• Only consider referral for spinal x-ray in cases of suspected fracture

• Blood Tests are appropriate in some patients to exclude differential diagnoses (see above) e.g., suspicion of inflammatory back pain, infection, or cancer.

N.B. This guideline is aimed to support all clinicians in the community (e.g., AHP, physiotherapists, GPs) who are involved in managing patients with low back pain with or without sciatica/radiculopathy. As such, some aspects may appear unusually detailed to the experienced clinician.

i. Provide each patient with a package of care tailored to the individual for up to 12 weeks from initial presentation.

At each re-attendance:

• review diagnosis and reconsider differential diagnosis.
• re-test neurology and range of movement/pain levels.
• check compliance with advice.
• check compliance/attendance with physiotherapy.

ii. Promote and advise self-care and self-management through all activities within this guidance:

iii. As part of shared decision-making conversation:

• Holistic assessment, understanding what matters to the person, discuss appropriate treatment options, associated risks, benefits, consequences, values and preferences
• Discuss options for onward referral
• Consider use of decision support tools (STarT Back)
• Discuss referral / self-referral for conservative treatment / community MSK physiotherapy if symptoms are not improving
• Consider onward referral if symptoms worsen despite treatment

iv. Risk assessment and Risk Stratification Tool

Consider the use of a stratification tool e.g. 9 point STarT Back risk assessment tool to help determine the complexity and intensity of support required i.e. identify those that may benefit from more intensive management to avoid developing chronic back pain.

Based on risk stratification, consider:

• Low risk - suggests patient are likely to improve quickly and have good outcome. Management should include reassurance, advice to keep active and guidance on self-management in the form of patient information leaflets and Back pain pages at MyHealth Devon website.
• Patients should be advised to reconsult in primary care if they feel needed. Consider referral to community MSK physiotherapy if there is no improvement in symptoms after 4-6 weeks of Primary care management.
  

• Medium risk - suggests higher level of vigilance is appropriate ie review and re-stratify with risk tool in primary care in 1-2 weeks. Consider referral to community MSK physiotherapy if not improving.
• High risk - suggests significant risk of developing chronicity. Consider early referral to community MSK physiotherapy (may be appropriate to trial analgesia, introduce Reconnect2Life website, advise as detailed below, review and re-stratify 1-2 weeks with appropriate safety netting).

1) Advice and Information

• Reassurance - most back pain usually improves enough within a few days to a few weeks, to be able to return to normal activities.

• Positive attitude to outcome – try to keep patients at work and maintain activity levels. Biopsychosocial factors can impact outcomes. There are helpful messages to ‘use’ and ‘avoid’ with patients, reference: Acute low back pain – Beyond drug therapies (O’Sullivan & Lin).
• Self-management - signpost to self-management education MyHealth Devon

• Encourage early activity – activity is not harmful and may help to reduce pain in many patients. In the first few days of a new episode of low back pain, avoiding aggravating activities may help to relive pain. Staying as active as possible and returning to all usual activities gradually is important in aiding recovery – this includes staying in work where possible. Use of fit note if work is not possible/modifications required.
• Bed Rest - avoid bedrest in non-specific low pain and radiculopathy: scientific studies now indicate prolonged rest and avoidance of activity for people with low back pain actually leads to higher levels of pain, greater disability, poorer recovery, and longer absence from work.
  
• Exercise is shown to be very helpful for tackling back pain and is also the most effective strategy to prevent future episodes. Start slowly and build up both the amount and intensity of what you do and don’t worry if it’s sore to begin with – you won’t be harming your back.
  
• Prevent future episodes - through life-style choices (healthy diet, weight management, smoking cessation, exercise, and good manual handling).
  

• Wider primary care team - engage with wider primary care team such as social prescriber, clinical pharmacist, health, and wellbeing coach as available and required.
• Other services - consider directing to voluntary/third sector self-management resources, emotional/mental health wellbeing services.
  

2) Pharmacological interventions (as per NICE guidance)

Pain relief for low back pain +/- radiculopathy should be used at the lowest effective dose for the shortest possible period of time (max 2 weeks initially).

Repeat prescriptions are not advised unless there is clear documented evidence of benefit.

Pain relief for low back pain

• Consider oral non-steroidal anti-inflammatory drugs (see section 10.1.1 Non-Steroidal anti-inflammatory drugs (NSAIDs))
  • Prescribed at the lowest dose and shortest possible period of time
  • Consider weak opioids (+/- paracetamol) only if NSAID is contraindicated, not tolerated or has been ineffective (see section 4.7.2 Opioid analgesics and section 4.7.1 compound analgesic preparations)
  • Consider addition of gastroprotective treatment
• For low back pain DO NOT OFFER
  • Paracetamol alone
  • Opioids for managing chronic low back pain
  • Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants, anticonvulsants including gabapentinoids

Pain relief for sciatica / radiculopathy

• Consider oral non-steroidal anti-inflammatory drugs (see section 10.1.1 Non-Steroidal anti-inflammatory drugs (NSAIDs))
  • Prescribed at the lowest dose and shortest possible period of time
• Consider the use of neuropathic analgesia (please note that NICE NG59 specifically states gabapentinoids should be avoided – see below).
  • Prescribed at the lowest dose and shortest possible period of time

• For sciatica / radiculopathy DO NOT OFFER
  • Gabapentinoids, oral steroids, benzodiazepines, or opioids for acute or chronic sciatica / radiculopathy
  • Do not use opioids for chronic sciatica / radiculopathy (over 12 weeks)
  • Explain the risk of ongoing use of these medications if people are already taking them

Guidance for healthcare professionals on drug driving

3) Referral to MSK physiotherapy

• MSK physiotherapy will assess and on top of exercises, may arrange referral to Back Fit Spinal Rehabilitation group exercise Back Pain Programme / Combined Physical and Psychological Programme (CPPP) (low intensity) if appropriate and available.

Referral Criteria

Refer To MSK Physiotherapy

Consider referral to MSK physiotherapy if the:

• patient is stratified as medium or high risk on STarT back tool
• patient is stratified as low risk on STarT back tool, but has shown minimal improvement after 4-6 weeks of Primary care management
• patient has relapsed following previous successful treatment

It is expected that ALL patients with low back pain with or without sciatica (not attributed to serious pathology) will have completed 12 weeks of conservative management in the community (including assessment by community MSK physiotherapy), before considering onward referral to ANY specialist service.

To avoid referrals being returned, please ensure that this is clearly stated in any referral to the Spinal Interface service.

Refer to the Spinal Interface service (via e-Referral Service - e-RS):

The ESP Spinal Interface service will complete a comprehensive assessment, refer for diagnostic tests or refer onto pain management and spinal surgeons via the Spinal MDT where appropriate.

Urgent

Patients with:

• major motor loss (power lower than 4/5 MRC grade), that isn’t appropriate for ED (urgent spinal interface referral via e-RS)
• Stable / not new CES Symptoms over 14 days duration (urgent spinal interface referral via e-RS)
  
• suspected spinal Fracture e.g., sudden onset back pain, point bony tenderness etc. (urgent referral to spinal interface service for new onset of concerning features (mechanism, point bony tenderness, significant pain) or failure to progress with treatment at 8 weeks)
  
• Acute progressive deterioration of symptoms (e.g., foot drop)
  

Urgent/Routine

The ESP Spinal Interface service will triage these referrals to decide on urgency.

Patients with:

• Signs or symptoms of lumbar origin who have completed 12 weeks of conservative management in the community (including assessment by community MSK physiotherapy)
• Insufficient improvement with core therapies
  

• Radicular pain: -
  • Severe radicular pain at 2-6/52 depending on initial recovery
  • Non tolerable radicular pain at 6/52

Refer To Pain Management Service (via e-Referral Service - e-RS):

• Patients with chronic low back pain without sciatica whose symptoms have not responded to MSK Physiotherapy assessment and management presenting with significant complexity that cannot be managed in primary care requiring pain management MDT assessment.

(Referrals should explicitly state past medical history including drug, alcohol, and mental health to enable appropriate triage. Wider mental health must be addressed separately and supported appropriately in primary care).

• Introduce patients to Reconnect2Life, LiveWell with pain and Flippin pain websites.
  

Referral Instructions

Refer to the Spinal Interface Service via e-RS

• Specialty: Orthopaedics
• Clinic Type: Spine – Back Pain (not scoliosis/deform)
• Service: DRSS-Eastern-Orthopaedics-Spine- Devon ICB- 15N

Refer to the Pain Management Service via e-RS

• Specialty: Pain Management
• Clinic Type: Pain Management
• Service: DRSS-Eastern-Pain Management- Devon ICB -15N

Referral Form

DRSS Referral Form

This referral guidance is based on:-

NICE NG59 – Low back pain and sciatica in over 16s: assessment and management (November 2016)

NHS England 2017 low back and radicular pain pathway National Back and Radicular Pain Pathway.

BestMSK health collaboration The aim of the BestMSK Health Collaborative is to recover and rebuild high quality high value personalised MSK provision, integrated across primary, community and secondary care and with mental health, social services and the third sector organisations.

Spinal Surgery: National Suspected Cauda Equina Syndrome (CES) Pathway (February 2023) GIRFT

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral

GP Information

MyHealth Devon

Start Back tool online Keele University website and GP advice on use of tool

Nice guidelines NG 59 - Low back pain and sciatica in over 16s: assessment and management

International Framework for Red Flags for Potential Serious Spinal Pathologies (jospt.org)

UKSSB (UK Spine Societies Board)

National-Suspected-Cauda-Equina-Pathway-February-2023-FINAL-V2.pdf (gettingitrightfirsttime.co.uk)

Opioids and driving - Guidance for healthcare professionals

Sheffield aches and pains - guidance for primary care.

Acute low back pain – Beyond drug therapies

Royal College of Radiologists

NICE guideline Osteoporosis - assessing the risk of fragility fracture

4.7.1 compound analgesic preparations

4.7.2 Opioid analgesics

Patient Information

Recommended resources for patients and carers. NHS Devon does not take responsibility for the content of third party information resources.

MyHealth Devon

British Association Spinal Surgeons: patients area/ patient information

Low back pain, back pain management and understanding pain - Good videos to show to patients (see links below)

• "low back pain" by Dr Mike Evans
• Understanding pain and what to do in less than five minutes

When you should seek urgent help for your backpain - YouTube

Keele - Back Pain leaflet

Versus Arthritis - exercises and useful advice

Drugs and the driving law

NICE - patient information

Sheffield back pain - patient information

The Pain toolkit – self-management website for people in chronic pain, wide ranging resource with details of the pain cycle, patient videos as well as guidance for health care professionals.

My pain management (myhealth-devon.nhs.uk)

ReConnect2Life - Torbay and South Devon NHS Foundation Trust

Evidence

Finucane, L., Downie, A., Mercer, C., Greenhalgh, S., Boissonnault, W., Pool-Goudzwaard, A., Beneciuk, J., Leech, R. and Selfe, J., 2020. International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy, 50(7), pp.350-372.

Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-1571.

McCullough BJ, Johnson GR, Brook MI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012; 262: 941-946.

O’Sullivan, P, & Lin, I. 2014. Acute low back pain. Beyond drug therapies. Pain Management Today Vol 1(1); pp8-13.

Pathway Group

Pain management and Back pain Clinical Pathway Group on behalf of NHS Devon.

Publication date: March 24