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Referral
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Inflammatory Back Pain
Scope
Patients with suspected inflammatory back pain should be referred to a Rheumatologist : consider Spinal pathway for other cases. Validated screening questions can help distinguish inflammatory spinal pain from mechanical causes of pain: In Patients with back pain for longer than 3 months
- Age of onset below 40 years
- Pain with an insidious onset
- Pain improved by exercise
- Pain not improved by rest
- Pain at night (with improvement on getting up & moving around)
If answered positively to 4 or 5 of above – these patients should be considered to have inflammatory pain & be referred to rheumatology.
The incidence of serious pathology in patients with back pain in primary care is around 1%, with vertebral fracture the most common: consider the following possibilities:
- Cancer (primary or secondary) - Refer to appropriate specialist or via 2 week wait
- Suspicion of infection
- Fracture (traumatic or pathological)
- Inflammatory back pain - suggested by morning stiffness lasting more than 30 minutes, pain improved by exercise and NSAIDs, episodes of buttock pain, waking early due to pain, systemic peripheral features of inflammatory arthropathy.
- Consider serious pathology in patients at particular risk:
- People at extremes of age
- Immunocompromised people
- Past history of Cancer
- Current and sustained weight loss
Investigations required
- FBC U&E
- CRP & Plasma viscosity
Referral Criteria
If there is no evidence of inflammation in the history (as described above) then consider referral to Spinal physiotherapy services for further assessment.
There is no role for plain X-ray in the primary care investigation of chronic back pain unless suspicion of vertebral fracture.
Evidence
Sieper J et al. Ann Rheum Dis. 2009; 68: 784-788
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: July 2016
Reviewed: February 2019
