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GP triage – Spinal Menu

Back
Common Spine Problems
Mechanical Spinal Pain
+/- Mild-moderate Radicular pain without neurological deficit
Affected Area
  • Pain between the bottom of the rib cage and the buttock, plus or minus leg
  • Aggravated by specific positions/activities
  • May have somatic leg pain (no loss of nerve function and no positive nerve tension signs eg SLR)
  • Pain varies
  • Sleep may be disturbed
  • Education & advice
  • Encourage normal activity
  • Avoid bed rest
  • Gentle exercise
  • Advice and reassurance
  • Refer to physiotherapy
  • Analgesia: NSAIDS (+PPI for>45 years) Paracetamol (do not offer paracetamol alone)
  • Weak opioids if the above not helpful Muscle relaxants, eg diazepam
  • Review 2 weeks after onset
  • Consider use of STaRT Back tool to guide onward referral www.keele.ac.uk/sbst
  • Routine imaging not required
  • Consider onward referral if conservative treatment unsuccessful
  • Patient is functionally limited in ADLs and wants to consider surgery/injection.
Treatment Planning
Severe Lumbar Nerve Root Pain
with/ without neurological deficit
Affected Area
  • Pain
  • Radicular pain or nerve root pain tends to be in the distribution of a nerve root
  • Pain can vary in nature radiating to below the knee often in the foot and/or toes
  • May be associated with muscle weakness, numbness, or tingling and change in reflexes
  • Pain on movement
  • May have night pain
  • +VE with SLR/Femoral Nerve tension test
  • Analgesia
  • NSAIDs
  • Paracetamol
  • Neuropathic pain medication
  • Refer physiotherapy
  • Advice and information
  • Stay active where possible-modify activity if pain too severe
  • Consider MRI if:
    radicular pain is present and not controlled by medication at 4-6 weeks
    neurology is progressive and pain uncontrolled
  • Refer to MSK service – No response to conservative treatment.
  • Refer to physiotherapy – Struggling with ADLs/ work/ conservative treatments.
Treatment Planning
Red Flags
Cancer/ Infection/ Fracture/ Inflammatory disease
Affected Area
  • Individually, red flag symptoms have weak predictive value due to a high false positive rate. Red flags in combination may increase their predictive value.
  • Cancer:
  • History of previous cancer (lung, breast, prostate most common)
  • Consider new onset if the patient:
  • is older than age 55 years (with increasing suspicion with increasing age)
  • Unexplained weight loss
  • Constant progressive non mechanical pain
  • Thoracic pain (two out of three spinal metastases are in the thoracic region)
  • Infection:
  • History of fever/ systematically unwell
  • Intravenous drug misuse
  • Recent infection
  • Fracture:
  • Suspect if: history of trauma or Osteoporosis
  • Structural deformity on examination
  • Inflammatory disease:
  • Younger age
  • Awakening in the second part of night
  • Alternating buttock pain
  • Morning stiffness (typically longer than 30 minutes)
  • Pain improves with exercise
  • Consider serious pathology in patients at particular risk:
  • People younger than age 20 years
  • Immunocompromised people, including patients on immunosuppressive medications, eg corticosteroids
  • Back pain is common in people older than age 55 and therefore is a weak red flag in isolation
  • An acute episode of spinal pain in a person older than age 70 years is predictive of osteoporotic collapse
  • Low back pain affecting activity in a person younger than age 16 years is a strong red flag for cancer, as back pain is less common in this age group
  • Erythrocyte Sedimentation Rate (ESR) more than 50mm/h with packed cell volume (PCV) less than 30% is useful for predicting cancer.
  • Continue treatment for low back pain if the tests prove negative
  • Cancer:
  • Blood tests:
  • FBC
  • ESR
  • CRP
  • Bone profile
  • PSA
  • Prot EP
  • Bence Jones s protein
  • Serum light chain protein
  • MRI
  • Infection:
  • blood tests:
  • FBC
  • ESR
  • CRP
  • MRI
  • Spinal fracture:
  • X-ray
  • MRI
  • Inflammatory disease:
  • FBC and ESR
  • CRP and HLA-B27
  • MRI
  • X-ray
  • Immediate referral to A&E or orthopaedics for suspected cauda equina syndrome, fracture, or infection.
  • Urgent or 2 week referral to oncology for suspected cancer.
  • Consider urgent referral to Rheumatology for stable osteoporosis vertebral collapse.
Cauda Equina Syndrome
Affected Area
  • Back pain-(usually but not always)
  • plus one or more of:
  • Erectile dysfunction
  • Problems with ejaculation
  • Loss of vaginal sensation
  • Loss of bowel control
  • Laxity of anal sphincter tone
  • Urinary retention, frequency or incontinence
  • Saddle anaesthesia or paraesthesia
  • Severe or progressive neurological deficit in the lower extremities or gait disturbance
  • Immediate referral by telephone to Orthopaedics / Neurosurgery on call Registrar
  • Urgent MRI
  • Immediate referral by telephone to Orthopaedics / Neurosurgery on call Registrar