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A Single Point of Access to the spinal pathway is being introduced across the Peninsula.
Back pain is extremely common and often resolves with early supported self-management– See MyHealth Devon information.
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.
MRI should NOT be requested for spinal pain with or without sciatica in a primary care setting.
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.
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.
Adults with low back pain with or without sciatica not attributed to serious pathology within primary care, including patients:
Children under the age of 18 years
Patients with:
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.
At each re-attendance clinicians are advised to:
Full details of STarT Back including online training can be accessed via STarT Back – Evidence Based Implementation of Stratified Care (keele.ac.uk)
Differentials to consider include:
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
EMERGENCY As a guide: to be seen the same day by the Emergency Department (ED) (who will involve the Orthopaedic spinal / Neurosurgery teams as required): Notify referral to Royal Devon University Healthcare North Devon Hospital ED EPIC (Emergency Physician in Charge) on (01271) 322577 |
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:
Conus Medullaris Syndrome
Relevant symptoms that can be precursors to CES
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:
Suspect CES and perform a full neurological examination to establish:
N.B. Digital rectal examination is no longer considered essential in primary care within the UK.
URGENT – as a guide, to be referred urgently to appropriate specialist or via 2-week wait: |
Risk factors that increase the likelihood of serious pathology include:
Patients with:
MRI should NOT be requested for spinal pain with or without sciatica in a primary care setting.
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:
ii. Promote and advise self-care and self-management through all activities within this guidance:
iii. As part of shared decision-making conversation:
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:
1) Advice and Information
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
Pain relief for sciatica / radiculopathy
Guidance for healthcare professionals on drug driving
3) Referral to MSK physiotherapy
Consider referral to MSK physiotherapy if the:
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.
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:
Urgent/Routine
The ESP Spinal Interface service will triage these referrals to decide on urgency.
Patients with:
(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).
Refer to the Spinal Interface Service via e-RS
Refer to the Pain Management Service via e-RS
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
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
NICE guideline Osteoporosis - assessing the risk of fragility fracture
4.7.1 compound analgesic preparations
Recommended resources for patients and carers. NHS Devon does not take responsibility for the content of third party information resources.
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)
When you should seek urgent help for your backpain - YouTube
Keele - Back Pain leaflet
Versus Arthritis - exercises and useful advice
Sheffield back pain - patient information
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.
Pain management and Back pain Clinical Pathway Group on behalf of NHS Devon.
Publication date: March 24