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GP triage – Spinal Menu

Common Spinal Problems

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Mechanical Spinal Pain

+/- Mild-moderate Radicular pain without neurological deficit

Treatment Plan
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.
Severe Lumbar Nerve Root Pain

with/ without neurological deficit

Treatment Plan
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
Plan 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.
Red Flags

Cancer/ Infection/ Fracture/ Inflammatory disease

Treatment Plan
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 Cechanical 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
Treatment Plan
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