Spinal Pain

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1 Background Information / Scope of Pathway

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These pathways were developed to guide clinicians when managing adults with common musculoskeletal problems. The pathways are not provider specific and so the guidance and forms apply to all providers.

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2 Information Resources for Patients and Carers

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Patient information Leaflets
Spinal Treatment Service Patient Information Leaflet
neck pain
whiplash
low back pain. (includes exercises)
low back pain with leg pain
spinal stenosis

Amitriptyline Dose Increase Chart PIL
Gabapentin Dose Increase Chart PIL
Pregabalin Dose Increase Chart PIL

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3 Development & Updates to this Pathway

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Development
The pathway redesign was a clinically lead city wide process. It was conducted through the Musculoskeletal Steering Group
which had representation from the 3 CCGs, Patients, NHS Leeds, Leeds Teaching Hospitals Trust and the Leeds Musculoskeletal
Services.
The individual pathways were authored by the appropriate clinical staff involved in delivering the pathway, but chiefly comprised of
GPs, Consultants and Therapists.
The pathways went live on the 2/7/2012

Updates
Referrals Forms Updated October 2012. Major Review and Update June 2013
This involved reformatting of the pathway and referral forms.

Pathway Updated June 2015

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4 Referral Forms

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Referral Forms:
Spinal Treatment Service referral form

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5 Patient Presents with Spinal Pain

Quick info:

Spinal pain may include:

  • Axial
  • Cervical
  • Thoracic
  • Lumbar
  • Radiculopathy
  • Sciatica
  • Spinal stenosis / neurogenic claudication

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6 Inflammatory Spinal Pain

Quick info:
GP Information
Features are:

  • new onset back or buttock pain for more than 3 months with morning stiffness usually more 30-45 minutes
  • typically starts under the age of 40

Conditions:

  • ankylosing spondylitis
  • reactive arthritis
  • psoriatic and enteropathic arthritides such as Crohn's and colitis
  • rheumatoid arthritis, mainly cervical spine affected

Associations:

  • iritis
  • enthesopathies (Achilles)
  • other peripheral arthritis

Investigations:

  • lab:
    • FBC
    • ESR
    • HLA B27
    • Anti CCP
    • Rheumatoid Factor
  • imaging:
    • X-ray
    • MRI (include SI Joints if ankylosing spondylitis)

Refer to Rheumatology if clinical suspicion.

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7 Red Flag Signs

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GP Information

Serious spinal pathology is thankfully rare about 1% of all cases LBP. Investigate these patients urgently.
Patient with Moderate / Severe back pain plus:

  • previous cancer, especially breast, lung, prostate, kidney, and thyroid:
    • investigations – MRI, Bloods FBC, ESR, Bone Profile, PSA, etc
  • systemic symptoms, weight loss, underlying malignancy:
    • investigations – MRI, Bloods FBC, ESR, Bone Profile, PSA, etc
  • patients who have lost height / use of long-term steroids Osteoporotic vertebral collapse, Other Vertebral Collapse:
    • investigations – X-ray, consider MRI (+DEXA), consider Myeloma Screen
  • possible infection Discitis, Tuberculosis, IV Drug users:
    • investigations – consider MRI, Bloods FBC, ESR, CRP
  • widespread Neurological signs, Myelopathy, Cauda Equina:
    • investigations – Urgent MRI
  • trauma – low velocity - Fracture / Osteoporotic collapse / other vertebral collapse:
    • investigations – X-ray, consider MRI
  • severe back pain under the age of 20 should raise suspicions especially if non sport or injury related. Underlying malignancy, investigate early:
    • investigations – FBC, ESR, Bone Profile, MRI
  • thoracic pain if severe – Underlying malignancy, Osteoporotic vertebral collapse:
    • look for pointers from the history, eg steroid use, night pain, severe spinal tenderness take a good history of previous medical problems
    • investigations – MRI, FBC, ESR, Bone Profile, PSA…

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10 Suspected Serious Pathology Pathway

Quick info:
GP information
Refer Immediately to on call service -> CAUDA EQUINA
Refer to On call Neurosurgery @LGI - MRI on the day
Is a rare condition with a disproportionately high medico legal profile.

  • Incidence ~ 1:50,000
  • Severe back pain ( but not always)
  • Pain in one leg (unilateral) or both legs (bilateral) that starts in the buttocks and travels down the back of the thighs and legs
    (sciatica)
  • Numbness in the groin or area of contact if sitting on a saddle (perineal or saddle paraesthesia)
  • Lower extremity muscle weakness and loss of sensations
  • Reduced or absent lower extremity reflexes
  • Inability to urinate (urinary retention)
  • Difficulty initiating urination (urinary hesitancy)
  • Decreased sensation when urinating (decreased urethral sensation)
  • Inability to stop or control urination (urinary incontinence)
  • Inability to stop or feel a bowel movement (faecal incontinence)
  • Constipation – note on its own this is not a red flag (remember analgesia codeine opiates)
  • Loss of anal tone and sensation always do a PR

History + Examination Hints and Tips Low back pain +/- sciatica
Age:

  • < 20 severe malignancy / rheumatological
  • < 20 Extension related + Sport Spondylolysis
  • 20-55 More mechanical disc / soft tissue
  • > 55 Spinal Stenosis, Facet Joint, Hip Joint Arthritis, disc

Causes:

  • Any number lifting pulling bending -> More mechanical disc / soft tissue
  • Sometimes no cause
  • Postural / ergonomic / obesity / lack of activity
  • If associated with > 45 min am stiff > 3 months < 40 yrs at first onset possibly rheumatologic

Duration:

  • How long have you had the problem? Days, Months, Years
  • Is this first time?
  • Several episodes of pain before -> Disc / Mechanical

Pain location:

  • Below gluteal fold Nerve root compression / lower limb problem
  • Buttock + Groin referred to the knee = possible hip joint
  • Above the L5 spinous process Not SIJ

Pain:

  • Improving / staying same? -> Wait before investigate
  • Worsening? Investigate early

What makes pain better or worse?

  • Worse sitting -> Disc
  • Worse Standing -> Disc / Spinal Stenosis
  • Worse Walking -> Disc prolapse / spinal stenosis / Hip joint
  • Easier sitting -> Spinal Stenosis
  • Easier walking -> Mechanical >>> Rheumatological

How far can you walk?

  • Has walking distance deteriorated quickly -> Severe Stenosis / Large Disc -> Investigate early

Neurological symptoms:

  • Mild Sciatica to knee: Wait before Investigating
  • Moderate Pain Dermatomal
  • Severe Severe dermatomal pain: Investigate early
  • Very Severe Severe Sciatica and bowel / urinary sx: Investigate / Refer Immediately

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15 Self Management in Primary Care

Quick info:
Patient information
Please see attached patient information leaflets on neck pain, whiplash, low back pain. and low back pain with leg pain

GP information
The assessment and management of Mechanical Low Back pain is discussed in the information leaflet attached to the previous node.
Management of Neck pain without radicular symptoms follows similar principles:

  • pain relief
  • encourage return to work / normal activity
  • discussion of fear avoidance and reassurance
  • provide patient information leaflets

If symptoms persist then consider referral to spinal treatment service.

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17 Refer to Spinal Treatment Service

Quick info:
Spinal Treatment Service referral form

A new spinal treatment service has been established. Those patients with spinal pain +/- sciatica / radiculopathy of new onset whose symptoms have persisted after a period of self management / conservative treatment or are particularly severe, that further imaging and/or treatment is required can be referred to the spinal treatment service.
This service will review the referral information, speak to the patient, and following discussion will formulate a management plan which may include physiotherapy (Tier 1) or MSK-MDT (Tier 2) assessment, with imaging where appropriate. Onward neurosurgical referral will be made where necessary.

Patient information:
Spinal Treatment Service Patient Information Leaflet

Key Dates

Published: 14-Jan-2016, by Leeds
Valid until: 19-Jun-2017