Adult Low Back Pain Guidelines

Please note this guideline is for lumbosacral spine conditions only.

Cervical and thoracic cases are excluded and should be referred to Pain Clinic or spinal surgery depending on clinical requirement.

Please note an MRI is not required for Spinal Interface.

Red Flags/High Complexity Causes

The Cauda Equina Pathway Remains Unchanged

For Impending/Established Cauda Equina

Refer to Emergency Department

Provide the patient with a Cauda Equina Cue Card to aid with safety netting - Cauda Equina Information Cards | MACP (macpweb.org)

“A patient presenting with back pain and/or sciatic pain with any disturbance of their bladder or bowel function and/or saddle or genital sensory disturbance or bilateral leg pain should be suspected of having a threatened or actual Cauda Equina Syndrome”

British Association of Spine Surgeons (2018)

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:

Back Pain and / or Sciatic Pain with:

New (within 2 weeks) difficulty initiating micturition or impaired sensation of urinary flow
New (within 2 weeks) Altered Perianal, perineal or genital sensation S2-S5 dermatomes – area may be small or as big as a horse’s saddle (subjectively reported or objectively tested)
Severe or progressive neurological deficit of both legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
New (within 2 weeks) Loss of sensation of rectal fullness
New (within 2 weeks) Sexual dysfunction (achievement of erection or ability to ejaculate, loss of vaginal sensation)
Sudden Onset Bilateral Radicular Leg Pain (sciatica) or unilateral radicular leg pain that has progressed to bilateral

Conus Medullaris Syndrome

Sudden and bilateral neurological deficit of the legs such as major motor weakness
Symmetrical and bilateral perianal numbness
Early onset urinary retention, overflow urinary incontinence and faecal incontinence
Unexpected laxity of the anal sphincter
Recent-onset erectile dysfunction frequently associated

Please note patients can present with a combination of these syndromes

The following presentations also require emergency referral to ED:

Spinal pathology with significant/rapidly worsening motor/sensory/sphincter disturbance
Severe acute low back pain straight after significant trauma – consider unstable vertebral fracture as cause
Visceral causes: Ruptured AAA, Aortic dissection

Suspected metastatic spinal cord compression higher than cauda equina needs to be admitted under medicine via AcuteGP

Urgent Referral/Discuss With On Call Neurosurgery either by phone or via www.referapatient.org depending upon clinical urgency

Primary spinal tumours found on MRI imaging
Low back pain with sustained slowly progressive motor or sensory loss with cauda equina/conus medullaris and red flags excluded
Late complication directly related to recent Spinal Surgery even if discharged from follow up
Please note an MRI is required for all Neurosurgical referral letters

Discuss with On Call Neurosurgery On Call by phone or via www.referapatient.org depending upon clinical urgency

Suspected Discitis
Suspected Osteomyelitis
Suspected Spinal Abscess

If Vertebral Metastases/Pathological Vertebral Fracture

Suspected Primary Cancer Fast track suspected cancer referral

Known Primary Cancer and Active Treatment MDT Cancer Co-ordinator

Unknown Primary Site Urgent Oncology

Common metastases to bone: Breast, Lung, Thyroid, Renal, Prostate, Melanoma

Myeloma Fast track/Urgent referral depends upon clinical severity

https://rms.cornwall.nhs.uk/primary_care_clinical_referral_criteria/rms/primary_care_clinical_referral_criteria/haematology/mgusmyeloma

In The Absence Of Red Flags/High Complexity Diagnoses To Consider:

Mechanical back pathology: Sciatica, Spinal stenosis, Disc prolapse/annular tears
Non-pathological vertebral fractures
Spondylolithesis
Spondylosis
Severe scoliosis and spinal deformity - Complex Spinal Surgery Team, Royal Devon & Exeter
Inflammatory causes
https://rms.cornwall.nhs.uk/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/rheumatology/inflammatory_back_pain_in_adults
Visceral causes/Endocarditis/PE/Shingles/Post herpetic neuralgia/Aortic aneurysm/Metabolic bone disorders

Primary Care Management

The STarT back tool can help identify those at risk of chronic pain STarTBacK Online – STarT Back (keele.ac.uk)

Self Help Back pain | The Chartered Society of Physiotherapy (csp.org.uk)
Live well with pain is a step by step online guide to living well with persistent pain Home - Live Well with Pain
Pain cafes run across Cornwall to support patients to live well with pain. Information on the Pain Café locations and times can be found here
Analgesia

NICE Low Back Pain And Sciatica In Over 16s Recommendations Updated 2020

Do not offer strong opioids, gabapentinoids, antiepileptics, SSRIs, SRNIs or TCAs for managing back pain
Do not offer opioids for chronic sciatica or chronic low back pain
For sciatica do not offer gabapentinoids, other antiepileptics, benzodiazepines or oral corticosteroids as there is no evidence of benefit and there is evidence of risk of harm
If a person is already on opioids, gabapentinoids or benzodiazepines for sciatica, explain the risks of continuing them and participate in shared decision making about safe withdrawal of them using resources such as Opioids Aware | Faculty of Pain Medicine (fpm.ac.uk)

Occupational

Self refer to Occupational Health if restricting/unable to work. Promote and facilitate return to work and activities of daily living.

NB. Belts, corsets, foot orthotics, rocker sole shoes, peripheral electrical nerve stimulation and TENS machines are not recommended by NICE

For patients with:

mild to moderate spinal and/or radicular pain with or without non-progressive mild sensory loss
yellow flags
diagnosis uncertain but serious pathology not suspected

In addition to the Primary Care management above, provide progressive strengthening exercise guidance and appropriate manual therapy for at least 12 weeks, choice as below:

AQP Manual Therapy

Physiotherapy, chiropractor and osteopathy options for lumbar back pain under 1 year duration. See here

Cognitive Functional Physiotherapy

Physiotherapy with a cognitive functional approach to help patients cope with stable, chronic lumbar back pain with or without out radiation without neurological deficit, any duration. See here

MSK Physiotherapy

Physiotherapy option for lumbar back pain over 1 year duration

Imaging and MRI Guidelines

In the absence of red flags/suspicion of vertebral fracture, plain X rays are not routinely indicated.²

MRI Guidelines

Routine lumbar spine MRIs are not available for Primary Care and can only be accessed by Spinal Interface.

Emergency MRIs for suspected cauda equina or conus medullaris are arranged via ED

Urgent MRI can still be accessed provided the criteria are met See Here

Spinal Interface Service

This is NOT an Urgent Service, Routine referrals only.

Spinal Interface is a single point of access assessment service for all referrals.

Following assessment patients can be:

Provided advice, education and guidance
Directly listed for spinal injection if meets specific criteria
Discussed in MDT for:
- Direct listing for spinal injection
- Consultant Pain Clinic Appointment
- Nurse Pain Clinic Appointment
- Referral for neurosurgery

Please note all low back pain referrals for further intervention require assessment at Spinal Interface first. Direct low back pain referrals for Spinal MDT, Spinal Injection/Intervention, Pain Clinic or Spinal Surgery will NOT be accepted.

Spinal Interface Referral Criteria

Moderate to severe spinal and radicular pain
WITH/WITHOUT non-progressive mild to moderate power loss
WITH/WITHOUT moderate sensory loss

Previous spinal surgery input and has been discharged from surgical follow up

Patients with the following are required to have tried progressive strengthening exercise guidance and appropriate manual therapy for at least 12 weeks prior to referral, within the last 6 months and related to current episode of symptoms being referred for.

Please note referrals will be returned if details of the manual therapy are not included in the referral.

Mild to moderate spinal and/or radicular pain
WITH/WITHOUT non-progressive mild sensory loss not responding to appropriate tailored medication
Diagnosis uncertain, but serious pathology not suspected
Severe/worsening yellow flags or persistent yellow flags not responding to initial primary care management/manual therapy

Spinal Interface Exclusions

Cauda equina/conus medullaris syndrome
Red flag pathology
Rapidly deteriorating neurology
Proven neoplasm
Under 18 years
Recent Spinal Surgery or Spinal Cord Stimulator under Pain Services in the same region and has not been discharged from Surgical or Pain Services follow up
Cervical pathology or thoracic pathology – refer these to Pain Clinic or Spinal Surgery depending upon clinical need
Widespread inflammatory disease
Coccydynia
Lumps/bumps

Direct access routine MRIs are no longer available in primary care and are therefore not required prior to referral.

Referrals For Consideration Of Spinal Injections

Please follow the Adult Low Back Pain pathway for all referrals. The Spinal Interface Service and MDT follow a unified policy on Spinal Injections and Radiofrequency Denervation developed and agreed by both Devon and Kernow CCGs. These can be accessed here

In summary spinal Injection therapy can be commissioned if:

Patients with severe sciatica with or without low back pain with corresponding level of spinal pathology on clinical assessment and imaging, not improved with non-pharmacological and pharmacological treatments as per the Adult Low Back Pain pathway and part of a MDT plan

Spinal injections for sciatica should not be repeated if performed less than 6 months earlier
Epidural injections for neurogenic claudication for patients with central canal stenosis
Patients with non-specific low back pain that is not associated with a corresponding level of spinal pathology or serious identifiable causes on clinical assessment and concordant imaging
Radiofrequency denervation is a specialist decision following assessment in Spinal Interface and MDT, please follow the Adult Low Back Pain guidelines. Repeated radiofrequency denervation will only be commissioned when the previous procedure was more than 16 months earlier and the origin of the pain is in the same location.

Expediting Spinal Neurosurgery Referrals

Please specify the reasons why the patient needs to be expedited in detail for example:

Details of progression of motor and/or sensory deficits
Details of change in distribution of pain
Extent of worsening pain including level of distress caused and details of analgesia tried including neuropathic agent use
Extent of functional impairment

If the patient is already under Spinal Interface Service, please copy the corresponding team into the expedite letter.

Spinal Interface are happy to be contacted about any expedite queries for their patients not requiring immediate Spinal Surgical attention by email to:

spinal.interface@nhs.net (Three Spires)

cft.mskspinalinterface@nhs.net (CPFT)

Please note expedite requests that do not contain detailed reasons will be returned for further clarification.

Patient Information

British Association of Spinal Surgeons (BASS) patient information leaflets on invasive interventions from facet joint injections to surgical procedures

British Association of Spine Surgeons - Booklets

NHS Choices Lumbar Decompression Surgery patient information leaflet

http://www.nhs.uk/Conditions/Lumbardecompressivesurgery/Pages/Whatisitpage.aspx

Date Review : 26/04/2024

Next Review: 26/04/2027

GP Sifter: Dr Rebecca Hopkins

Version 1.6

Contributors

Dr. Natalie Dawes, GP and CCG Lead Orthopaedics

Janine Kennedy, Extended Scope Spinal Physiotherapist, Spinal Interface

Steve Iliffe, Extended Scope Spinal Physiotherapist, Spinal Interface

Dr. Robert Searle, Consultant Anaesthetist, Pain Clinic, Royal Cornwall Hospitals NHS Trust

Dr. Tom Sulkin, Consultant Radiologist, Royal Cornwall Hospitals NHS Trust

Mr. Andrew Clarke, Consultant Orthopaedic Spinal Surgeon, Royal Devon and Exeter

Dr. Rebecca Hopkins, GP and RMS Guidelines Lead Orthopaedics

Morissa Livett, MSK Clinical Lead Physiotherapist, Cornwall Partnership Foundation NHS Trust

References

Integrated Spinal Pain and Non Spinal Triage Service, Neurosurgery, Derriford
Low Back Pain and Sciatica In Over 16s Guideline. National Institute of Clinical Excellence. November 2016
National Low Back and Radicular Pain Pathway 2017. NHS England 20 February 2017
Opioids Aware, Faculty of Pain Management
Drug Driving And Medicine: Advice For Healthcare Professionals. Department of Transport 2014
SB Tool Online. STaRT Back Tool, Keele University, 2007
MRI Guidelines
Spinal Injections In Pain Clinic. Royal Cornwall Hospital Truro, December 2015
What The Pain Clinic Offers. Kernow Referral Management Service Pain Clinic Guidance
Patient Information Booklets. British Association Of Spinal Surgeons 2017
Lumbar Decompression Surgery. NHS Choices, 2015
NBP-CN: National Backpain Pathway – Clinical Network (2020) Early Recognition of Cauda Equina Syndrome: A Framework for Assessment and Referral for Primary care / MSK interface services