Lower Back Pain Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Patients who present with low back pain (i.e. pain below the costal margin and above the inferior gluteal folds) with or without leg pain that has lasted more than 6 weeks but less than 12 months

This guidance does not cover:

  • Under 18s (Wakefield) Under 16s (North Kirklees)
  • Patients with long term chronic back pain of 6mths+ (Wakefield)

Commissioning Statements:

  • Spinal Injections are not routinely commissioned - Please see Commissioning Statement for further information
  • Referrals for Spinal Stimulation are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Upright/Open MRI referrals are subject to an eligibility criteria that must be met before a referral is made - Please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval or IFR Processes in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Assessment

Signs and Symptoms

Sciatica

  • Can occur at any age; often insidious.
  • Usually starts as axial low back pain.
  • Progresses to pain being referred down the posterior aspect or the posterolateral aspect of the leg (below the knee).
  • Commonly unilateral leg pain, occasionally bilateral.
  • Neurological examination normal.

Radiculopathy

  • As per Sciatica however, there will be the presence of at least one of the following:
  • oMyotomal weakness
  • oSensation Loss
  • oHyporeflexia

Stenosis

  • >48 years of age.
  • Often increased BMI.
  • Gradual onset of unilateral or bilateral leg pain.
  • Worse with standing/walking.
  • Eased with sitting/leaning forward.
  • Consider vascular cause: check peripheral pulses, will only get symptoms when walking not when standing.
  • Neurogenic Claudication: Better up hill.
  • Vascular claudication: Worse up hill.

Non-Specific (Mechanical) Low Back Pain

  • Gradual, often insidious onset.
  • May report repetitive or unaccustomed activity prior to symptom onset.
  • Pain located within the lumbar spine, may refer to the buttocks, upper posterior thigh but there are no symptoms below the knee (sciatic pain) or neurological features.

Persistent Low Back Pain

  • Pain located within the lumbar spine, may refer to the buttocks, upper posterior thigh but there are rarely symptoms below the knee (sciatic pain) or neurological features.
  • Symptoms present for >3/12 and have often been seen in Physiotherapy/CATS before.
  • Consider the presence of Psychosocial features e.g. low mood, catastrophising, fear avoidance, guarding, anxiety, deconditioning

History and Examination

For additional information on signs and symptoms please click here - Signs and Symptoms

Clinical history should include:

  • Occupation & Hobbies
  • Duration and back pain history
  • Worries about the pain
  • Is pain back- or leg-dominant?
  • Distribution of leg pain – side of pain, below knee pain, which toes are affected?
  • Triggers
  • What helps
  • Past medical history - history of addiction
  • X-ray and MRI are not indicated as this stage

Use history to identify Cauda Equina

  • Current or imminent compression of the lumbosacral nerve roots resulting in neurogenic bladder and bowel dysfunction
  • Symptoms typically include:
    • severe low back pain and bilateral nerve root pain
    • new onset urinary dysfunction
    • saddle anaesthesia
    • loss of anal tone
    • faecal incontinence
    • multilevel bilateral motor deficits
  • The presentation is a combination of symptoms
  • The majority of people do not have bilateral leg pain – most do, however, have leg pain
  • A range of urinary symptoms may be present, ranging from increased frequency through to incontinence

Yellow Flags

Psycho-social factors influencing back pain which predict tendency towards chronic/persistent pain:

  • Attitudes - towards the current problem. Does the patient feel enabled and informed to be able to self-manage?
  • Beliefs - The most common misguided belief is that the patient feels they have something serious causing their problem-usually cancer. 'Faulty' beliefs can lead to catastrophisation.
  • Compensation - Is the patient awaiting payment for an accident/ injury at work/ RTA?
  • Diagnosis - or more importantly Iatrogenesis. Inappropriate communication can lead to patients misunderstanding what is meant, the most common examples being 'your disc has popped out' or 'your spine is crumbling'. Also poor communication of scan findings that are known to be common in asymptomatic individuals e.g. degenerative or bulging discs, facet wear or annular tears (see evidence)
  • Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxious states are at a high risk of developing chronic pain
  • STarT back screeningtool. can be used to assess pychosocial issues, offering a guide for the most appropriate primary care management strategies

Examination

Initial assessment

  • Entering the room e.g. expression, demeanour, body language, gait

Focused examination

  • Standing - Look - Level pelvis/Obvious spinal deformity/Scars
  • Move
    • Range of movement
    • Any signs of fear avoidance on moving
    • Does flexion cause leg pain?
    • Is it worse on extension?
    • Which side hurts?
  • Sitting
  • Lying - Supine
    • Muscle wasting
    • Straight leg raise – degrees of raise, is there crossover pain?
    • Hip screen
    • Power and reflexes
  • Lying - Prone
    • Palpation mid line tenderness
    • Evidence of Hypersensitivity (Hyperalgesia) or neuropathic sensitisation
    • Femoral stretch

Differential Diagnoses

  • Pathology in an adjacent structure
    • Malignancy: - In the kidney or pelvis, 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
    • Inflammatory disorders: Ankylosing spondylitis, Polymyalgia rheumatic, Coccydynia
    • Metabolic bone disease

NB: Common findings such as osteoarthritis or lumbar spondylosis also occur in asymptomatic people and may not be the source of the pain.

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Suspected cauda equina syndrome suspected, rapidly changing neurology or systemically unwell
  • The incidence of serious pathology in patients with back pain in primary care is around 1%, with vertebral fracture the most common:
    • 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

Undertake the following to aid diagnosis, inform management or prior to referral

  • If non-specific back pain is diagnosed no investigations including MRI are required at this stage.
  • MRI is only indicated in specific acute cases as defined in the below guidance unless there are red flags X-ray is not appropriate at this stage according to the guidelines of the royal college of Radiologists

Management

NICE CG 88 summary on pharmacological management

  • Regular paracetamol is the first medication option
  • If this provides insufficient pain relief offer an NSAID and/or weak opioids
  • Give due consideration to the risk of side effects from NSAIDs especially in older people and other people at increased risk of experiencing side effects
  • Co-prescribe NSAIDs with a PPI for people over 45
  • Consider offering a TCA if other medicines provide insufficient pain relief
  • Only consider strong opioids for short-term use to people in severe pain but try to avoid in the non-specialist setting.
  • Give due consideration to the risk of opioid dependence and side-effects for both strong and weak opioids
  • Do not use SSRIs for treating pain

After 4 – 6 weeks of initial management:

  • If improvement continue supportive management in primary care.
  • If the patient is not improving and/or has not returned to work then:
    • Review your initial diagnosis: including psychosocial factors, attitudes and beliefs about the pain
    • Continuing with current treatment and check compliance


Referral

Referral Criteria

  • Red Flags
  • North Kirklees - If no improvement following conservative management or diagnosis is unclear refer to CONNECT COMMUNITY MSK SERVICE who will offer:
    • Physiotherapy
    • Patient education and wellbeing groups
    • Access to imaging
    • And referral to secondary care if required
    • Please click here to open the Clinical Decision Making Aid for further guidance on which part of Connect's pathway to refer into i.e. Physioline, Physio or CATs
  • Wakefield - If no improvement following conservative management or diagnosis is unlear refer to physiotherapy who will refer to the most appropriate services, including secondary care. Referrals to Community Direct Access Physiotherapy can be made to one on the following providers in accordance with patient choice

Referral Requirements

  • For Spinal Injections, Spinal Stimulation and Upright/open MRI referrals documented evidence is required to demonstrate that the patient meets the commissioning statement criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statements:

  • Spinal Injections are not routinely commissioned - Please see Commissioning Statement for further information
  • Referrals for Spinal Stimulation are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Upright/Open MRI referrals are subject to an eligibility criteria that must be met before a referral is made - Please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval or IFR Processes in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referral Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about their options.have. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Prior to referral for surgery the patient should understand their options and the benefits and risks and the likelihood of these occurring. If relevant patients should be signposted to decision aids for Sciatica from Slipped disc treatment options

Patient Information/Public Health/Self Care

Evidence/Supporting Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 04. 2017
  • Publication Date: 05.2017
  • Last Updated: 06.2018
  • Review Date: 03.2019
  • Ref No: MSK1 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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