The Spine Center at Beth Israel Deaconess

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1 Spinal Pain The Spine Center at Beth Israel Deaconess Medical Center developed the following detailed eplanation of our care pathways for primary care providers to help support your interactions with patients eperiencing back pain. Please keep in mind the Spinal Pain (our spine care pathways) are a guideline not a prescription. We developed these guidelines to assist in your clinical decision making by describing a range of generally acceptable interventions and outcomes, and defining best practices that meet the needs of a majority of patients, under most circumstances. However, the ultimate judgment must be based on circumstances that are relevant to that specific patient and treatment may be modified according to the individual patient s needs and your clinical judgment. At any time, you may refer a patient to the Spine Center. Our non-surgical spine specialists are available to see your patients throughout the course of their symptoms. For consultations with one of our spine surgeons, additional triage at the Spine Center is required, and we are here to assist with coordinating this option. Please contact us if you have any questions or concerns. We look forward to our ongoing partnership. Sincerely, The Spine Center Team Doctor-to-Doctor Line Call Center

2 Patient presents with spinal pain Assess your patient (diagnostic triage) Conduct a focused history and physical eamination evaluating -duration, severity and location of pain/symptoms -history of injury, previous back pain or surgery -risk factors for potentially serious conditions -presence and severity of neurologic deficits -eacerbating and relieving factors -influence of pain and treatment on ability to perform activities of daily living, mood, ability to sleep and addictive behavior -psychosocial risk factors -risk factors Presence of Red Flags Classification A Non-Specific Low Back Pain (NSLBP) B Lumbar Radiculopathy Unilateral leg pain below the knee (with/without numbness and weakness) C Spinal Stenosis/ Claudication Back pain associated with intermittent leg pain that is aggravated by standing or walking and relieved by sitting D Cervical Radiculopathy Neck and radiating arm pain/numbness, often accompanied by motor or sensory disturbances E Cervical Myelopathy Unsteadiness of gait, weakness, numb/clumsy fingers

3 Presence of Red Flags A. Progressive weakness (sudden difficulty with ambulating or inability to ambulate) Refer to Table 1 Red Flags Saddle anesthesia (numbness in the perineum) New onset urinary retention New onset bowel/ bladder incontinence Parse out to better identify reason for weakness Further evaluation by PCP Go to ED TABLE 1: Red Flags for Serious Diseases FRACTURE CANCER INFECTION Traumatic injury/onset cumulative trauma Steroid use history Women age >50 Men age >50 Male with diffuse osteoporosis or compression fracture Cancer history Diabetes mellitus Insidious onset No relief at bedtime or worsens when supine Constitutional symptoms (e.g. fever, weight loss) History UTI/other infection IV drug use HIV Immune suppression Previous surgery

4 A. Patient presents with Non Specific Low Back Pain (NSLBP) Educate Reassure patient on the favorable prognosis (see linked patient education material on bidmc.org/spinecenter) Advise patients to stay active Discourage bed rest Promote self management (carry on with normal activities as much as possible) Discourage lumbar supports Avoid the following investigations A. Diagnostic imaging Radiological imaging is not recommended for acute NSLBP for patients <50 years of age Plain radiographs are optional for patients >50 years of age EMG is not recommended for acute NSLBP B. Laboratory testing Not recommended unless specific illness is suspected ESR, CBC if cancer or infection is suspected Prescribe medication for pain relief (if needed) Non narcotic analgesics Acetaminophen NSAIDs (refer to Table 2) Muscle relaants Avoid Narcotics Prescribe Physical Therapy (reassess after 6 10 sessions) Determine level of acuity Determine appropriate classification of dysfunction with interventions of mobility, strength, coordination, stability and spinal manipulation with transition to discharge For patients whose pain is made worse by physical activity or eercise (these patients may benefit from therapeutic eercise recommendations) Active treatments have demonstrated greater efficacy than passive therapies Follow up Visit 1 (4 6 weeks after initial visit) Re assess patient status 4 6 weeks after initial visit if symptoms fail to resolve Eclude serious pathology (Red Flags) Review psychosocial risk factors Patient has shown improvement Keep going: transition to home eercise program (a few patients may still require sessions with the physical therapist) Make a decision Patient remains symptomatic Consult the Spine Center Keep the diagnosis under review, looking for pathoanatomical causes related to low back pain Consider imaging MRI degenerative disc disease; CT spondylolysis); patient may be a candidate for an intervention

5 B. Patient presents with Lumbar Radiculopathy Unilateral leg pain below the knee (with/without numbness and weakness) Initial Assessment Conduct detailed neurological eam including motor, sensory testing, refle If there are any symptoms of urinary or bowel and bladder symptomatology (including urinary retention or incontinence) then a rectal eam needs to be done to eclude cauda equina syndrome Conduct a supine Straight Leg Raise (SLR) +/ forward fleion, hyperetension and slump tests to assess L4, L5, S1 Conduct a Femoral Stretch Test (FST) to assess L1, L2, L3 nerve root irritability Identify the type of pain and eacerbating factors Do a complete lower etremity physical eamination to rule out a musculoskeletal cause of the pain Consider serious medical causes of radiculopathy (e.g. demyelinating disease, vitamin B12 deficiency, syphilis, herpes, diabetes and others) Depending on Pain Severity and time course, consider referral to the Spine Center Physical therapy evaluation/treatment for 4-6 weeks Consider imaging study and lumbar epidural steroid injection Advise patient in the acute phase to avoid heavy lifting or aggravating movements, though staying active is very important Neuropathic pain medication trial: Gabapentin, Pregabalin, Tramadol, etc. (short course) Avoid narcotics

6 C. Patient presents with Spinal Stenosis/Claudication Back pain associated with intermittent leg pain that is aggravated by standing or walking and relieved by sitting Clinical Diagnosis Diagnostic tests not routinely indicated No imaging studies if no Red Flags Medical Treatment Education Eercise to tolerance; avoid harm (pain/numbness following eercise that persists for hours) Medication (Avoid Narcotics) Physical Therapy 4 weeks Needs improvement First Follow Up Visit (4 6 weeks after initial visit) Improvement in pain and function MRI Does Not Show Compression Imaging (MRI) Refer to Spine Center MRI Shows Compression Physical therapy with transition to home program Continue what has helped Regular follow up (every 6 months) Not a neurocompressive disorder Further work up for neuropathy/other pathology Fluoroscopically Guided Epidural Steroid Injections (ESI) Follow up in 2-4 weeks No Improvement in pain and function? Yes Surgical options PCP discussion Risk evaluation Continue what has helped Regular follow up (every 6 months)

7 D. Patient presents with Cervical Radiculopathy Neck and radiating arm pain/numbness, often accompanied by motor or sensory disturbances Yes No Anteroposterior, lateral and fleion etension cervical spine radiography; MRI Non progressive neurologic deficit or no neurologic deficit Refer to Spine Center Degree of urgency depends upon progression of symptoms Depending on Pain Severity and time course, consider referral to Spine Center Physical therapy evaluation 4-6 weeks Imaging study with MRI and consider ESI Neuropathic pain medication trial: Gabapentin, Pregabalin, etc Tramadol (short course) Avoid narcotics

8 E. Patient presents with Cervical Myelopathy Unsteadiness of gait, weakness, numb/clumsy fingers Simultaneous Educate Advise against activities predisposing to falls Warn re: symptoms to watch for Order investigation Urgency depends upon severity and progression of symptoms. If concerned, consult with Spine Center. Cervical spine rays MRI CT myelogram if contraindication to MRI Prescribe medication for pain relief Acetominophen Anti inflammatories Prescribe therapy Physical therapy for: Gait training/balance training Strength training Occupational therapy for: Activities of daily living MRI shows significant spinal cord compression, that is, cord effacement, or intramedullary signal change, spinal cord deformity, severe stenosis Follow up visit after MRI Assess pain management and review symptom progression: Eclude serious pathology (Red Flags) and manage accordingly MRI does not show spinal cord pathology Cervical myelopathy is not present Consult with Spine Center Consider other pathology (e.g. multiple sclerosis, brain pathology, amyotrophic lateral sclerosis, folate or B12 deficiency, peripheral neuropathy) and manage accordingly

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