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The National Low Back Pain and Radicular Pain Pathway

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The National Low Back Pain and Radicular Pain Pathway NHS England Trauma Programme of Care National Low Back and Radicular Pain Pathway 2017 Together with Implementation Guide Including Implementation of NICE Guidance NG59 “Low back pain and sciatica in over 16s: assessment and management 2016” Second Edition Approved by the CRG for Spinal Services 20 February 2017 National Back Pain and Radicular Pain Pathway 1 Second Edition 2.0 20th Feb 2017 Contents Contents .................................................................................................................................................................... 2 The Pathway ............................................................................................................................................................. 3 Implementation......................................................................................................................................................... 5 Results of Pathway .................................................................................................................................................. 6 Clinical Results ......................................................................................................................................................... 7 IT and Data Collection .......................................................................................................................................... 11 Implementation in the Future ............................................................................................................................... 12 Back Pain Pathway Flowchart ............................................................................................................................. 14 Radicular Pain Pathway Flowchart ..................................................................................................................... 14 Box 1 - Public Education and Self Care ............................................................................................................. 16 Box 2 - First Presentation and Initial Management .......................................................................................... 18 Box 3 - Early Clinical Review ............................................................................................................................... 22 Box 4 - Low Risk .................................................................................................................................................... 25 Box 5 - Discharge / self-management. ............................................................................................................... 27 Box 6 - Red Flags .................................................................................................................................................. 28 Box 7 - Inflammatory spinal disease ................................................................................................................... 32 Box 8 - Radiculopathy Assessment and Initial Management ......................................................................... 35 Box 9 - Specialist Triage Assessment: ............................................................................................................... 38 Box 10 - Core Therapy.......................................................................................................................................... 41 Box 11 - Specialist Triage review following Core Therapies .......................................................................... 45 Box 12 - Comprehensive Multi-Disciplinary Combined Physical and Psychological Programme ............ 47 Box 13 - Specialist Triage review following Comprehensive Multi-Disciplinary CPPP ............................... 51 Box 14 - Surgical Opinion for Axial Back Pain .................................................................................................. 53 Box 15 - Surgery for Axial Pain ........................................................................................................................... 56 Box 16 - Pain Management Services ................................................................................................................. 59 Box 17 – Medial Branch Block +/- Radiofrequency Denervation ................................................................... 71 Box 18 - Conservative Therapy for Lumbar Radicular Pain ........................................................................... 74 Box 19 - Imaging in Patients with Radicular Pain ............................................................................................. 78 Box 20 - Non-concordant Imaging ...................................................................................................................... 80 Box 21 - Concordant imaging .............................................................................................................................. 81 Box 22 - Nerve Root Block/Epidural ................................................................................................................... 83 Box 23 - Spinal Surgical Opinion / Surgery ....................................................................................................... 85 Box 24 - Occupational Health and return to Work ............................................................................................ 88 Appendix 1. Stakeholders and their nominated Representatives .................................................................. 91 Appendix 2. Specialist Triage Practitioner ......................................................................................................... 93 Appendix 3 Outcome measures .......................................................................................................................... 94 Red Flag Appendices ............................................................................................................................................ 95 2017 Update at a Glance: Summary and Incorporation of NICE 2016 ....................................................... 101 National Back Pain and Radicular Pain Pathway 2 Second Edition 2.0 20th Feb 2017 Summary The NHS England Pathfinder Projects were established in 2013 to address high value care pathways which crossed commissioning and health care boundaries e.g. from general practice through primary care and community services and into secondary care. The Pathfinder Projects were designed for all stakeholders to work collaboratively to develop commissioning structures across the whole pathway. The Pathfinder Project for the Trauma Programme of Care Board was low back pain (LBP) and radicular pain. This is a high value care pathway in view of the very large number of patients involved. LBP is extremely common and is the largest single cause of loss of disability adjusted life years, and the largest single cause of years lived with disability in England (Global Burden of Disease, 2013). In terms of disability adjusted life years lost per 100,000, LBP is responsible for 2,313. By contrast the remainder of musculoskeletal complaints counts for 911, depression 704 and diabetes 337. It should be borne in mind that this is principally occurring in people of working age, or with families. UK specific data shows that LBP was the top cause of years lived with disability in both 1990 and 2010 – with a 12% increase over this time. DALY loss between 1990 and 2010 has increased by 3.8% to 3,002/100,000 (95% CI 3,188 to 5,338). In other words, 3% of the population’s life is being lost to LBP. Total DALY loss from illness in 2010 was 27,163/100,000 (down from 31,842 in 1990). Thus, LBP accounts for 11% of the entire disability burden from all diseases in the UK; furthermore the burden is increasing both absolutely (3.7% increase) and proportionally (7% to 8.5%). In CG88 NICE estimated that the cost of LBP to the NHS in 2008 was £2.1 billion. The same analysis estimated that the societal cost of informal care and production loss was £10.7 billion in 1998. Overall, LBP is one of the most costly conditions for which an economic analysis has been carried out in the UK and this is in line with findings in other countries. The pathfinder project had three goals. 1. To produce a generic pathway for the management of LBP and radicular pain in adults, from the general practitioner’s surgery to specialised care, agreed by all Stakeholders. 2. To use this pathway of care as the basis for collaborative commissioning between CCGs, Area Teams and NHS England Specialised Services. 3. To construct a commissioning vehicle with specifications, uniformly trained personnel and access policies which will permit introduction of new evidence in a straightforward way. A Clinical Group was formed with accredited representatives from each of the stakeholders in the diagnosis and management of LBP and radicular pain. The Clinical Group worked with existing evidence and guidelines and did not itself undertake any evidence reviews. One objective of the project was to provide a commissioning vehicle by which future advice could be implemented in a simple and straight forward fashion. The pathway, agreed by all 30 stakeholders, was completed and first published in June of 2014. The pathway has been implemented in many CCGs, and evidence of the effectiveness of the pathway is now available. In December 2016 stakeholder representatives met again to update the Pathway to incorporate the NICE guidance “Low back pain and sciatica in over 16s:
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