Inflammatory Back Pain

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Inflammatory Back Pain Blood tests for rheumatology conditions Chronic Widespread Pain (CWP) aka Fibromyalgia Syndrome (FMS) Early arthritis clinic Gout Polymyalgia rheumatica Raynauds phenomenon Suspected Giant Cell Arteritis - Northern locality Suspected Inflammatory Arthritis Pathway – North and East Devon Systemic Autoimmune Disease

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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.

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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

Referral