Red flags: New to this guideline? Emergency Spinal Referral Pathway for & o Suspected spinal cord neurology Underlined text denotes hyperlinks, click on text to be (gait disturbance, multilevel taken to helpful link. Hovering over the text will show weakness in the legs and /or arms ) where the link will take you. Patient presents with o Impending Cauda Equina lower back pain / Sciatica Syndrome (Acute urinary Denotes where there is some additional information. disturbance, altered perianal Hover over the text to see a box appear. (National Pathway) sensation, (reduced anal tone and (Summary of NICE squeeze – if circumstances permit) Guidelines) o Suspected Spinal Priority Spine imaging (Protocol led MRI whole spine unless History and Examination contraindicated) o Past history of cancer *(new onset spinal pain) o Recent unexplained weight loss o Objectively unwell with spinal 1.Cauda Equina or Nerve Root Mechanical Inflammatory Suspected pain 2.Severe/rapidly Pain (Upper or Spinal Pain Component osteoporotic o Raised inflammatory markers progressing lower limb and Suspected vertebral (relative to range anticipated for motor neurology myelopathy) fractures age ) Plasma viscosity , CRP , ESR ( including according to local practice ) myelopathic o Possible immunosupression with Refer to changes new spinal pain (IVDU, HIV, Rheumatology X-ray if Chemotherapy, Steroids). suspected o Prolonged steroid use * o Known osteoporosis, with new severe spinal pain Admit to A&E o Age <15, or >60 years new onset Urgent axial back pain referral to orthopedics if *Statistically significant red flags. severe pain Although the others listed may not persisting be statistically significant these are beyond 6 the symptoms items which are weeks to commonly seen in serious discuss role of pathology. The more of these vertebroplasty present the greater the probability of serious underlying pathology

Provision of Time lines Emergency •Major neurological deficit / Major motor KEY •Sphincter failure •Spontaneous epidural haematoma Primary Care •Ankylosing with new pain •Metastatic Spinal Cord Compression with Neuro MSK CATS Symptoms /signs •Spinal infection

Secondary Care Urgent •Osteoporotic Fracture with severe or significant pain at 8 weeks Date written: February 2018 •Spinal metastases no neurological Review Date: April 2020 deficit Authors: MSK CATS Service •Patient generically unwell Contributors: Bill Wilsdon (DTHFT), Fiona Paul •Clinical signs of discitis or infection (DCHS), Rachel Hamilton (The Scott Practice) •Acute myelopathy Version: 7 •Acute presenting suspected spinal/disc infection

New to this guideline? Back to Pathway

Underlined text denotes hyperlinks, click on Pathway for Nerve Root Pain text to be taken to helpful link. Hovering over the text will show where the link will take you. Patient presents with

Denotes where there is some additional suspected nerve root pain information. Hover over the text to see a box appear. History and Examination

Reassess at 1-2 weeks using the STarT back tool

Low Risk Medium (routine) High Risk (urgent)

Promote self-care and consider the following Interventions Refer to MSK Neuro CATS service, signs/severe pain Consider Physio form available through If pain persists SystmOne & Urgent referral beyond 3 EMIS to spinal months surgeon

MSK CATS Triage Process

Refer to surgical Refer to pain clinic clinic

Date written: February 2018 Review Date: April 2019 KEY Authors: MSK CATS Service Contributors: Bill Wilsdon (DTHFT), Fiona Paul Primary Care (DCHS), Rachel Hamilton (The Scott Practice) Version: 6 MSK CATS

Secondary Care

New to this guideline? Back to Pathway Pathway for Mechanical Spinal Pain

Underlined text denotes hyperlinks, click on text to be Pain taken to helpful link. Hovering over the text will show where the link will take you. Patient presents with

mechanical spinal pain Denotes where there is some additional information. Hover over the text to see a box appear.

GP Advice/Analgesia

Reassess at 1-2 weeks using the STarT back tool

Low Risk Medium – High Risk Promote self-care and consider the following Interventions Refer to MSK CATS service, Consider Physio form available through If pain persists SystmOne & beyond 3 EMIS months

MSK CATS Triage Process

Refer to Secondary Refer back to GP Discharge from the Refer on to other Care service services

KEY Date written: February 2018 Review Date: April 2019 Primary Care Authors: MSK CATS Service Contributors: Bill Wilsdon (DTHFT), Fiona Paul (DCHS), Rachel Hamilton (The Scott Practice) MSK CATS Version: 6

Secondary Care Back to Pathway and sciatica in over 16s: assessment and management NICE guideline. Published: 30 November 2016 nice.org.uk/guidance/ng59

© NICE

NICE Back Pain Flow Chart – taken from the NICE guidance (https://www.nice.org.uk/guidance/ng59)

 Point 4 – pharmacological Rx – NSAIDS or weak opioids with or without paracetamol, not strong opioids and not paracetamol alone. Do not offer SSRI/SNRI/TCAs/anticonvulsants for LBP without sciatica. See NICE guidance on management of neuropathic pain for pharmacological treatment of sciatica.  Point 5 – Manual therapy - Only in combination with exercise +/- psychological treatment package  Point 6 – Combined physical and psychological programmes - Including CBT approach, preferably in a group context in patients with either o Significant psychological obstacles (STarT back score) o Or previous treatments not effective  Point 7 –Psychological therapies - only in combination with exercise +/- manual therapy

Date written: February 2018 Review Date: April 2019 Authors: MSK CATS Service Contributors: Bill Wilsdon (DTHFT), Fiona Paul (DCHS), Rachel Hamilton (The Scott Practice) Version: 6

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 Point 8 – Radiofrequency denervation - Consider for facet joint pain when non-surgical treatment not worked and main source of pain or thought to come from structures supplied by the medial branch nerve and pain is >/= 5/10 on VAS o After positive response to diagnostic medial branch block. Do not offer imaging in specific fact joint pain as a pre-requisite for radiofrequency denervation o Medial branch of dorsal ramus supplies tissues from the midline to zygapophysial (facet joint) line and innervates 2-3 adjacent facet joints and related soft tissues. Therefore the injection should decrease pain and muscle spasm.  Point 9 – Additional specific treatments for sciatica – e.g. neuropathic pain meds inline with current guidance o Consider epidurals (LA and steroid) in patients with acute severe sciatica o Consider spinal decompression surgery (where non surgical interventions not helped and MRI consistent with examination findings)  Point 10 – Additional surgical procedures – spinal cord stimulation for chronic pain of neuropathic or ischaemic origin, only as part of a clinical trial  Point 12 – eg TENS or PENS (percutaneous electrical nerve stimulation), USS, interferential therapy

Date written: February 2018 Review Date: April 2019 Authors: MSK CATS Service Contributors: Bill Wilsdon (DTHFT), Fiona Paul (DCHS), Rachel Hamilton (The Scott Practice) Version: 6

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Keele STarT Back Tool

https://www.keele.ac.uk/sbst/startbacktool/sbtoolonline/

LOW RISK

“Based on risk stratification, consider: simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)”

Entry criteria  No adverse social and psychological factors  Low risk on STarT Back tool  IF presentation is mechanical (non-specific) low back pain

Interventions  Advice and information  Improvement is likely  explanation of signs and symptoms  distinction between hurt and harm  appropriate reassurance about good prognosis  advice about regular adequate analgesia  advice about continuation of normal activities, including work, or return to normal activities using graded steady increases  Simple patient information is provided by the AR UK leaflet or the Back Book.  Fit note  no onward referral necessary AND patient in agreement  advice to re-consult if symptoms fail to improve or worsen  Indications for early clinical review and emergency attendance  discharge

Date written: February 2018 Review Date: April 2019 Authors: MSK CATS Service Contributors: Bill Wilsdon (DTHFT), Fiona Paul (DCHS), Rachel Hamilton (The Scott Practice) Version: 6