MSK ICATS Spine Management, Referral Threshlds and Management Pathways v10 FINAL Referral reasn / Patient presentatin Management Taken frm the Map f Medicine: Threshlds fr t initiate a referral t BICS / ICATS Management Pathway fr the nwards referral) Symptms suggestive f cauda equina syndrme (cmpressin f the cauda equina). Back pain plus ne r mre f: CAUDA EQUINA SYNDROME lss f bwel cntrl (faecal r flatus incntinence) and unexpected laxity f anal sphincter lss f bladder cntrl (urinary retentin r incntinence) severe r prgressive neurlgical deficit in the lwer extremities r gait disturbance saddle anaesthesia r paraesthesia (lss r change f perianal and perineal sensatin) N/A N/A Immediate referral t A&E r Orthpaedics Page 1 f 17
Referral reasn / Patient presentatin SUSPECTED SERIOUS PATHOLOGY Acute mtr deficit i.e. ft drp Management Investigatin: - Histry - Examinatin and Assessment - Prvisinal / wrking diagnsis(es) Diagnstics: - Nne - Explanatin f cause - Pain relief: paracetaml may prvide pain relief while ften recmmended fr nn-specific back pain, there is n evidence that NSAIDs are mre effective in imprving radicular symptms than paracetaml r placeb mderate analgesia (paracetaml and cdeine) can als be tried if paracetaml fails t cntrl pain, thugh there are few direct trials supprting its use fr this indicatin there is n evidence t supprt the use f muscle relaxants, diazepam, baclfen, antidepressants r cytkine inhibitrs fr relieving sciatica there may be a significant risk f dependence when sme f these medicatins are used fr lng perids. Threshlds fr t initiate a referral t BICS / ICATS REFER ALL Management Pathway fr the nwards referral) 1. Assessment and examinatin 2. If mytmal weakness Request urgent MRI scan 3. Review MRI scan reprt Needs surgery refer n Watchful waiting Needs general physi refer n Needs ICATS review bk appintment Page 2 f 17
Referral reasn / Patient presentatin Drsal / thracic back pain With systemic symptms (including IVDUs, renal and immuncmprmised patients) Drsal / thracic back pain Withut systemic symptms Management Investigatin: - Histry - Examinatin and Assessment Diagnstics: - Bld screen full bld screen - Refer t ICATS Investigatin: - Histry - Examinatin and Assessment Diagnstics: - If female > 60 years r Male > 70 years, d bld screen full bld screen - If significant change in symptms Request plain film x-ray Request bne density scan if indicated Threshlds fr t initiate a referral t BICS / ICATS REFER ALL Refer t ICATS if: pain is nt adequately cntrlled / reslved Management Pathway fr the nwards referral) 1. Assessment and examinatin 2. Request MRI 3. Review MRI scan reprt Needs surgery refer n Watchful waiting Needs general physi / manual therapy refer n Request haematlgy refer n Medical referral refer n 1. Assessment and examinatin 2. Analgesia mdificatin Nerve blcks Facet injectin Osteprsis refer t Kathy Fraser at PRH Interventinal radilgy (kyphplasty) - First six weeks manage in primary care - Refer t General Physitherapy / manual therapy - Medical management f steprsis - Analgesia Page 3 f 17
Referral reasn / Patient presentatin Myelpathy (crd cmpressin) i.e. lss f gait, lss f hand cntrl r prgressive neurlgical weakness Management Investigatin: - Histry - Examinatin and Assessment - Prvisinal diagnsis Diagnstics: - Nne - Refer t ICATS / secndary care fr MRI scan - Explanatin f cause - Pain relief: paracetaml may prvide pain relief while ften recmmended fr nn-specific back pain, there is n evidence that NSAIDs are mre effective in imprving radicular symptms than paracetaml r placeb mderate analgesia (paracetaml and cdeine) can als be tried if paracetaml fails t cntrl pain, thugh there are few direct trials supprting its use fr this indicatin there is n evidence t supprt the use f muscle relaxants, diazepam, baclfen, antidepressants r cytkine inhibitrs fr relieving sciatica there may be a significant risk f dependence when sme f these medicatins are used fr lng perids Prgressin f symptms is key t the urgency f the referral. Threshlds fr t initiate a referral t BICS / ICATS REFER ALL Exclusins: Rheumatid Arthritis with neck pain Additinal neur signs Dwn s Syndrme The abve exclusins list require emergency referral / shuld be treated with special care Management Pathway fr the nwards referral) 1. Assessment and examinatin 2. If mytmal weakness Request urgent MRI scan 3. Review MRI scan reprt Needs surgery refer n Watchful waiting Needs general physi refer n 4. Needs ICATS review bk appintment Page 4 f 17
Referral reasn / Patient presentatin NERVE ROOT PAIN (RADICULOPATHY) Sciatica Brachialgia Acute (<6 weeks since nset) Management Investigatin: - Histry - Examinatin and Assessment - Nerve rt tensin / signs - Reassure patient - Advise patient t keep mbile - Pain relief: Paracetaml may prvide pain relief while ften recmmended fr nn-specific back pain, there is n evidence that NSAIDs are mre effective in imprving radicular symptms than paracetaml r placeb Tramadl (as likely t be least cnstipatry piate) Lcal Neurpathic Pain Guidelines there may be a significant risk f dependence when sme f these medicatins are used fr lng perids - DO NOT give cdeine (especially if suspected disc prlapse. Secndary cnstipatin and straining may exacerbate disc herniatin.) Threshlds fr t initiate a referral t BICS / ICATS Refer nly t ICATS if: Prgressive neurlgical weakness Mre than 6 weeks Otherwise manage in primary care! Management Pathway fr the nwards referral) 1. Assessment and examinatin 2. Analgesia mdificatin Nerve blck Epidural If severe request fr MRI scan 3. Review MRI scan reprt: Nerve blck Epidural Page 5 f 17
Referral reasn / Patient presentatin Sciatica Brachialgia Chrnic (>6 weeks since nset) Management Investigatin: - Histry - Examinatin and Assessment - Nerve rt tensin / signs - Ability t wrk / ADLs affected? - If pain is nt severe, cntinue t manage in Primary Care: Reassure patient Advise patient t keep mbile Exercise plan Self management plan Educatin Back Bk Pain relief: Paracetaml may prvide pain relief while ften recmmended fr nn-specific back pain, there is n evidence that NSAIDs are mre effective in imprving radicular symptms than paracetaml r placeb Tramadl Lcal Neurpathic Pain Guidelines there may be a significant risk f dependence when sme f these medicatins are used fr lng perids Threshlds fr t initiate a referral t BICS / ICATS Refer t physitherapy in the first instance Refer t ICATS if: very severe pain and / r cntinue t require high levels f analgesics and n imprveme nt with physithera py Management Pathway fr the nwards referral) 1. Assessment and examinatin 2. Refer fr manual therapy / general physi Pain relief and educatin If facet jint injectin If severe request MRI scan / x-ray 3. Review MRI scan reprt Epidural Nerve blck DO NOT give cdeine (especially if suspected disc prlapse. Secndary cnstipatin and straining may exacerbate disc herniatin.) Page 6 f 17
Referral reasn / Patient presentatin Management Threshlds fr t initiate a referral t BICS / ICATS Management Pathway fr the nwards referral) MECHANICAL BACK PAIN Symptms: Mechanical back pain - Flare ups Acute (<6 weeks) Investigatin: - Histry - Examinatin and Assessment - If signs start t demnstrate neurpathic pain r nerve rt pain fllw nerve rt pain pathway - NONE manage in primary care - Reassure patient - Exercise plan - Self management plan - Use patient utcme tl - Pain relief: Paracetaml is the first-line medicatin, althugh there is limited evidence regarding its efficacy: if paracetaml alne des nt prvide sufficient pain cntrl, ffer: NSAIDs and/r: weak piids cnsider ptential benefits and risks f these medicatins and patient preference when prescribing medicatins: if NSAIDs r COX-2 inhibitrs are prescribed cnsider the cncmitant use f PPI s in patients with additinal risk factrs. (See N/A Page 7 f 17
Guidelines fr Prescribing PPI s in adults, BSUH, Octber 2009) cnsider c-prescribing a laxative with piids t cunteract the cnstipating effects f piids, as straining t defecate may aggravate back pain aim fr the lwest dse required fr relief f symptms when prescribing piids, shrt-acting agents given at regular intervals, rather than n a pain-cntingent basis is recmmended evidence suggests that NSAIDs have sme effect fr shrt-term pain relief cmpared t placeb, but there are n benefits cmpared t paracetaml, narctic analgesics r muscle relaxants Mechanical back pain Persistent (> 6 weeks t < 12 mnths since nset) Investigatin: - Histry - Examinatin and Assessment (Taken frm Map f Medicine) - Develp a management plan t aid the patient in understanding what t expect and their rle and respnsibilities in managing the pain. - Cntinue t ffer reassurance and psitive messages that encurage the patient t return t nrmal activities. - If signs f serius disease are still absent, cnsider initially ffering ne f the fllwing: Physical activity and exercise prgrammes Referral fr manual therapy Refer t physitherapy in first instance Refer t ICATS if: Nn respnsive t manual therapy Nn respnse t analgesia Wrsening pain Unable t cpe at hme / wrk Diagnstic cnfirmatin Cmplex 1. Assessment and examinatin 2. Investigatins t include (if diagnstic uncertainty): Blds X-ray MRI NCS CT Bne Scan Lk fr inflammatry disrders, sacrilitis, spndyllisthesis, TB, ther medical presentatins 3. Cnsider referring n t Page 8 f 17
Acupuncture Further drug therapy - Cnsider a different ptin frm the list abve if the respnse t the first-line therapy is nt satisfactry. - Brief educatinal interventins aimed at reducing sick leave and disability may be useful althugh NICE d nt recmmend educatin as a sle interventin. - Clinicians need t be aware f the imprtance f the patient s emplyment ptins fr a phased return shuld be explred in each case. bipsychscia l cmrbidities rheumatlgy, rthpaedics, Medics, further physitherapy / Functinal Recvery Prgramme (FRP) 4. Cnsider referring fr Pain Management Prgramme (PMP) 5. Multi disciplinary and bipsychscial grups / functinal prgrammes - Patients dealing with disability and lss f emplyment shuld be directed specific areas f supprt e.g. thrugh an ccupatinal health department and specially trained staff. Mechanical back pain Acute n chrnic (chrnic patients with flare up) Investigatin: - Histry - Examinatin and Assessment (Taken frm Map f Medicine) - Develp a management plan t aid the patient in understanding what t expect and their rle and respnsibilities in managing the pain. - Cntinue t ffer reassurance and psitive messages that encurage the patient t return t nrmal activities. Refer t physitherapy in if nt imprved after 6 weeks Refer t ICATS if: Previus pr respnse t manual therapy If seen previusly in PMP / FRP If refusal t g 1. Assessment and examinatin 2. Investigatins t include (if nt dne befre / if diagnstic uncertainty): Blds X-ray MRI NCS CT Bne Scan Lk fr inflammatry disrders, sacrilitis, Page 9 f 17
- If signs f serius disease are still absent, cnsider initially ffering ne f the fllwing: Physical activity and exercise prgrammes Referral fr manual therapy Acupuncture Further drug therapy - Cnsider a different ptin frm the list abve if the respnse t the first-line therapy is nt satisfactry. - Brief educatinal interventins aimed at reducing sick leave and disability may be useful althugh NICE d nt recmmend educatin as a sle interventin. - Clinicians need t be aware f the imprtance f the patient s emplyment ptins fr a phased return shuld be explred in each case. t physitherapy If nn respnsive t physitherapy Nn respnse t analgesia Wrsening pain Unable t cpe at hme / wrk Diagnstic cnfirmatin Cmplex bipsychscial cmrbidities spndyllisthesis, TB, ther medical presentatins 3. Cnsider referring n t rheumatlgy, rth., Medics, further physitherapy / Functinal Recvery Prgramme (FRP) 4. Cnsider refresher / tp up sessin(s) fr Pain Management Prgramme (PMP) 5. See persistent categry abve - Patients dealing with disability and lss f emplyment shuld be directed specific areas f supprt e.g. thrugh an ccupatinal health department and specially trained staff. - Explre psychscial factrs Mechanical back pain Chrnic (> 12 mnths) Investigatin: - Histry - Examinatin and Assessment (Taken frm Map f Medicine) - Develp a management plan t aid the patient in understanding what t expect and their rle and Refer t ICATS if: presentatin wrsening and unable t manage in primary care Fr diagnstic 1. Assessment and examinatin 2. Explre: Psychscial factrs CBT Mindfulness Cunselling Page 10 f 17
respnsibilities in managing the pain. - Cntinue t ffer reassurance and psitive messages that encurage the patient t return t nrmal activities. - If signs f serius disease are still absent, cnsider initially ffering ne f the fllwing: Physical activity and exercise prgrammes Referral fr manual therapy Acupuncture Further drug therapy - Cnsider a different ptin frm the list abve if the respnse t the first-line therapy is nt satisfactry. - Brief educatinal interventins aimed at reducing sick leave and disability may be useful althugh NICE d nt recmmend educatin as a sle interventin. - Clinicians need t be aware f the imprtance f the patient s emplyment ptins fr a phased return shuld be explred in each case. - Patients dealing with disability and lss f emplyment shuld be directed specific areas f supprt e.g. thrugh an ccupatinal health department and specially trained staff. cnfirmatin n respnse t previus manual therapy / PMP / FRP Cmplex bipsychscial cmrbidities 3. Investigatins t include (if nt dne befre / if diagnstic uncertainty): Blds X-ray MRI NCS CT Bne Scan Lk fr inflammatry disrders, sacrilitis, spndyllisthesis, TB, ther medical presentatins 4. Cnsider referring n t rheumatlgy, rth., Medics, further physitherapy / Functinal Recvery Prgramme (FRP) 5. Cnsider refresher / tp up sessin(s) fr Pain Management Prgramme (PMP) Page 11 f 17
Referral reasn / Patient presentatin Neck pain Acute trticllis Management Symptms: Acute trticllis usually reslves within 24 48hurs. Occasinally, symptms may take up t a week t reslve. Recurrence is cmmn. Investigatin: - Histry - Examinatin and Assessment: Unable t rtate head Offer analgesia t relieve symptms. Advise gentle exercise within the cmfrt zne. Intermittent heat r a cld pack t help reduce pain and spasm. Maintain a gd psture. Advise against: Rutine use f a sft cervical cllar. If pain n mving the neck is severe, then wearing a sft cllar fr a few days may help. It is preferable t keep the neck mbile with gentle exercise. Threshlds fr t initiate a referral t BICS / ICATS T be managed in primary care NONE Management Pathway fr the nwards referral) NONE Neck pain with radiculpathy see brachialgia pathway Neck pain nn specific: acute phase (first 6 weeks) Investigatin: - Histry - Examinatin and Assessment NONE Page 12 f 17
Reassure that neck pain is a very cmmn prblem and that the symptms likely t reslve. Encurage the persn t remain active Discurage wearing a cervical cllar. Strngly discurage prlnged absence frm wrk. Crrect pr psture A firm pillw may prvide cmfrt at night: Offer analgesia Subacute phase 6 weeks t 12 weeks Investigatin: - Histry - Examinatin and Assessment Management Refer t physitherapy Address any psychscial factrs, (Fear r avidance beliefs, Assciated anxiety and depressin, Mediclegal issues, Family dynamics) Refer t ICATS If cmplex psychscial cmrbidities 1. Assessment and examinatin 2. Explre: Psychscial factrs CBT Mindfulness Chrnic phase mre than 12 weeks Investigatin: - Histry - Examinatin and Assessment Management Analgesia including trial f a lw-dse tricyclic antidepressant. Re-examine psychscial factrs peridically Refer t physitherapy Cnsider referral t ICATS clinic. Refer t ICATS if: N better with physitherapy and analgesia If seen previusly in FRP / PMP Refer t urgent ICATS if Suspecting serius spinal abnrmality Cunselling 3. Investigatins t include (if nt dne befre / if diagnstic uncertainty): Blds X-ray MRI NCS CT Bne Scan Lk fr TB, ther medical presentatins Page 13 f 17
4. Cnsider referring n t rheumatlgy, rth., Medics, further physitherapy / Functinal Recvery Prgramme (FRP) 5. Cnsider refresher / tp up sessin(s) fr Pain Management Prgramme (PMP) Neck pain whiplash acute Symptms: Histry f sudden r excessive neck extensin, flexin, r rtatin. Symptms may be delayed fr hurs r days after the injury. The tw mst cmmn symptms are: Disabling neck pain, with r withut referral t the shulder r arm and headache. The persn may als have: Fatigue, dizziness, paraesthesiae. Nausea. Jaw pain and Psterir cervical sympathetic syndrme, including headaches r facial frmicatin (sensatin f ants crawling ver the face). Investigatin: - Histry - Examinatin and Assessment Examine fr signs f muscular spasm, pint tenderness, and neurlgical prblems in the upper r lwer limbs. It is safe t assess fr range f neck Manage in primary care first 6 weeks Refer t physitherapy after 6 weeks Refer t ICATS if prgressive intractable pain If nerve pain see brachialgia pathway 1. Assessment and examinatin 2. Explre: Psychscial factrs CBT Mindfulness Cunselling 3. Investigatins t include (if nt dne befre / if diagnstic uncertainty): Blds X-ray MRI NCS CT Bne Scan Page 14 f 17
mvements. Beware f have midline cervical tenderness (as this suggests a fracture r dislcatin) r ther serius injuries. Exclude spinal crd cmpressin (myelpathyif suspected refer t A&E. Assess the presence f assciated stress, anxiety, r depressin and pr cncentratin. Lk fr 'yellw flags' that indicate psychscial barriers t recvery and that suggest that the acute injury culd prgress t becme a chrnic prblem. Lk fr TB, ther medical presentatins 4. Cnsider referring n t rheumatlgy, rth., Medics, further physitherapy / Functinal Recvery Prgramme (FRP) 5. Cnsider refresher / tp up sessin(s) fr Pain Management Prgramme (PMP) Prvide reassurance that whiplash-assciated disrder is usually benign and self limiting. Encurage early return t usual activities and early mbilisatin. Explain that usual activities may initially be painful, but this is nt harmful r indicative f nging damage. Discurage rest, immbilisatin, and the use f sft cllars, crrect errneus beliefs. Offer analgesia Late whiplash Investigatin: - Histry - Examinatin and Assessment Management Refer t physitherapy in first instance and 1. Assessment and examinatin Page 15 f 17
Advice: Resist pressure t ver-treat and ver-investigate. Encurage and facilitate a return t nrmal activities. Diagnse and treat anxiety and depressin where they cexist. D nt sanctin behaviurs that prmte disability. D nt enhance the persn's expectatins f a pr utcme and chrnic disability. Reduce, where pssible, the influence f cmpensatin claims and discurage the use f symptm diaries, as these encurage the persn t fcus n their pain and disability rather than their functin and abilities. Cntinue educatin regarding behaviur and beliefs. Offer analgesia including lw-dse tricyclic antidepressant n treatment previus Refer t ICATS if patient at risk f develping chrnicity 2. Explre: Psychscial factrs CBT Mindfulness Cunselling 3. Investigatins t include (if nt dne befre / if diagnstic uncertainty): Blds X-ray MRI NCS CT Bne Scan Lk fr TB, ther medical presentatins 4. Cnsider referring n t rheumatlgy, rth., Medics, further physitherapy / Functinal Recvery Prgramme (FRP) 5. Cnsider refresher / tp up sessin(s) fr Pain Management Prgramme (PMP) Page 16 f 17
Referral reasn / Patient presentatin Management Threshlds fr t initiate a referral t BICS / ICATS Management Pathway fr the nwards referral) Spinal pain related t pregnancy Advice? If unable t manage in primary care please refer all referral t gyneaclgy physitherapy in the first instance (Central Registratin BGH). The patients will be screened by physitherapy within 48 hurs and if deemed inapprpriate will be referred n the ICATS spine service N/A N/A Page 17 f 17