Pathway definitions

Cauda Equina

Current or imminent compression of the sacral nerve roots resulting in neurogenic bladder and bowel dysfunction. Symptoms typically include – severe low back pain and bilateral sciatica, urinary retention, saddle anaesthesia, faecal incontinence, multilevel bilateral motor deficits (may include frequency/urgency of urine)

Red Flags

Risk factors for

  • Cancer- weight loss, new onset >55yrs, hx cancer
  • Infection- fever, IV drug use, recent infection
  • Fracture – Trauma, hx osteoporosis

Investigations

  • Cancer- X-ray/MRI (depending on availability. Note: X-ray does not rule out cancer in the spine), Bloods (FBC, LFT, ESR, CRP, BONE, PSA, Myeloma screen)
  • Infection X-ray/ MRI (as above), bloods (FBC, ESR, CRP)- consider acute referral if strong suspicion
  • Fracture – plain x-ray

Nerve root pain

  • History- Sharp shooting, neuropathic type pain below knee (L2-3 nerve root pain – remains above the knee, but is rare), often in sclerodermal pattern(follows direction down anterior, lateral or Posterior aspect of leg), or dermatomal pattern
  • Examination- Straight leg raise (SLR), crossed SLR, slump test, motor and sensory nerve testing of leg

Low back pain

All other back pain not covered in definitions

Inflammatory disease

Suspect if- younger age, awaking in second part of night, alternating buttock pain, morning stiffness (typically longer than 30 mins), improves with exercise.

GP advice

Advice sheet available on Internet for GPs to use during consultation, to assist management of back/leg pain. Encourages staying at work/ break fear -avoidance cycles/demystify

NOTE: It is anticipated that most low back pain patients will be managed in primary care, with appropriate review and adjustment of medication. Onward referral to back pain team should be reserved for those not coping or presenting management challenges beyond the scope of primary care. There is no rational for physio for all acute back pain patients.

Coping

This is a complex judgement made using the medical and social assessment skills of a GP. A patient that is responding to analgesia and advice in primary care, and following the expected natural history of the disorder. There is no evidence that specific physiotherapy input is helpful in this group.

Not Coping

This is a complex judgement made using the medical and social assessment skills of a GP. Patients whose symptoms are having an excessive, unexpected or disproportionately large, adverse impact on their life. This may affect them from a physical, emotional, social or occupational perspective. The patient will have failed reasonable management strategies in primary care. A more intensive biopsychosocial model of care is appropriate.

GP analgesia

Work up the WHO pain ladder, consider neuropathic medication if nerve root pain.

Pain Clinic

Multidisciplinary approach similar to those offered in Pain clinics with emphasis on functional rehabilitation, and self-management strategies. Will have strong links with occupational health schemes.

Yellow flags assessment

Involves consideration of factors such as work, family, social, mental health, and coping mechanisms. These are predictors of developing Chronic back pain. Can be simply assessed using StartBack questionnaire.

Back specialist team

A team lead by an experienced physiotherapist specialising in management of back. Will involve ongoing assessment and treatment. Will utilise a range of practitioners for a Bio psychosocial approach.

Nerve root block

Therapeutic injection, to relieve nerve pain in the legs. May be Epidural, Caudal or localised nerve root block, depending on local skills and provision.

Surgical Opinion

May be orthopaedic or Neurosurgical specialist, specialising in management of spinal pain. Opinion could initially be sought through a paper/MDT triage with history and MRI result, without need to see patient. Further consultation may be necessary or, in occasional cases, patient could be booked straight for pre-assessment for surgery.