Document type
Clinical pathways
Place
East and North Hertfordshire
Output type
Clinical Pathways
Pathway
Initial Back PainDrug Titration and review Neuropathic PainInitial Management of Neuropathic Pain
Information leaflet
MSK Triage Patient LetterMSK Physiotherapy Patient LetterChronic Pain Patient Letter

Back Pain

PLEASE NOTE FOR MOST MSK PATHWAYS –

  • DO NOT ORDER MSK MRIs FROM PRIMARY CARE
  • UNLESS THE PATIENT HAS A RED FLAG MOST MSK PATHWAYS REQUIRE A PERIOD OF CONSERVATIVE MANAGEMENT AND REFERRAL ONLY ON NON-RESOLUTION ONTO TO PHYSIO OR MSK TRIAGE SERVICES (SEE DETAIL FOR EACH PATHWAY ATTACHED)
  • PLEASE NOTE MSK TRIAGE SERVICES CAN ORDER MRIs AND OTHER DIAGNOSTICS

ONLY REFER DIRECT TO SECONDARY CARE IF RED FLAGS OR PRIOR APPROVAL HAS BEEN OBTAINED

For MSK concers, consider First Contact Physio. 

BACK PAIN

  • Assess patient for red flags including for:
    • Cauda equina/spinal metastasis/infection/unstable fracture/acute spinal cord compression (these should be referred as emergency referral-see pathway).
    • Suspected significant rheumatological condition/spinal deformity should be referred  as a routine expedited referral to secondary care (4-6 weeks).
    • Suspected osteoporotic fracture without cord compression-organise DEXA scan and refer as appropriate.
  • If no red flags manage as either lower back pain without radiculopathy (back pain predominates) or with radiculopathy (leg pain predominates).

Lower back pain with radiculopathy

  • If leg pain predominates assume radiculopathy.
  • Assess for myotomal weakness - if present refer to MSK triage or if concerned speak to orthopaedic registrar on call.
  • If no myotomal weakness manage as per low back pain without radiculopathy.

    Lower back pain without radiculopathy

  • Advise patient on self-management, exercise and return to normal activities.
  • Consider appropriate pharmacological treatments including NSAIDS/paracetamol - if sciatica see NICE management of neuropathic pain. https://www.nice.org.uk/guidance/cg173
  • Use Keele STarT back tool to identify high, medium or low risk back pain https://www.keele.ac.uk/media/keeleuniversity/group/startback/Keele_STarT_Back9_item-7.pdf
  • Refer high risk patients (score of 4 or more plus subscore of 4 or more) to MSK triage without delay.
  • If patient has not improved after 2-6 weeks refer to physiotherapy (NB: physiotherapy can refer to MSK triage if required)
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