MSK Physiotherapy for people with cervical and thoracic spine problems is provided at a local level. Integrated pathways for people with cervical and thoracic spine problems is currently under development to be provided as part of the NHS Lothian Integrated Spinal Pathway (June 2021). Until the launch of the NHS Lothian Integrated Spinal Service it may be required to refer the patient back to the GP/ other primary care clinician for consideration of onward referral to a secondary care service if it is felt that this is the best course of management.
The NHS Lothian integrated spinal pathway is a multidisciplinary collaboration. The service is based on the principles of the right care, from the right person, at the right time in the right place. The service will offer a single point of access for patients with routine cervical and thoracic spine problems who require referral for their problem following failure to improve with initial primary care management.
Once within the service patients will be able to access all the multidisciplinary services that are required for their problem including physiotherapy, investigation, surgical opinion and pain clinic opinion. There will be no need for patients to return to their GP to seek additional referrals or investigations for their cervical and/or thoracic spine problem. The service will be underpinned by agreed pathways, escalation criteria and multidisciplinary clinics.
- For clinical support and referral guidance see NHS Lothian Primary Care Cervical/ Thoracic Decision Tool
- Further information and support
M.A & P.A. 15-09-23
| Who to refer/red flag presentations: | Serious pathology as a cause of MSK conditions is considered rare, but needs to be managed either as emergency or urgent referral to relevant secondary care service. Consider below & also see relevant body area tab for further specific information and advice. Please make sure all red flag concerns have been managed prior to any MSK Physiotherapy referral For further support & guidance and refer to: NHS Lothian Primary Care Cervical/ Thoracic Decision Tool |
| Emergency conditions | Metastatic spinal cord compression (MSCC) – suspected Spinal infection, fracture- suspected Cervical artery/ vertebral artery dissection- suspected |
| Urgent conditions | Major spinal related neurological deficit/ worseing neurological deficit- suspected Insufficiency fracture Primary and secondary cancers- suspected New inflammatory arthritis/ myositis- suspected Inflammatory spinal pain – suspected |
| Consider serious pathology as a differential diagnosis if person presents with: | escalating pain and progressively worsening symptoms that do not respond to conservative management or medication as expected systemically unwell (fever, weight loss) night pain that prevents sleep due to escalating pain and/or difficulty lying flat |
| Who not to refer – other: | Presence of significant red flags as detailed above Age <16 – consider referral AHP Physio RHCYP Non MSK complaints Chronic spinal pain with a significant psychological/ psychiatric/ drug addiction element |
Who to refer:
People with cervical and thoracic problems who have not responded to initial primary care management, do not have the presence of significant red flags or other exclusion criteria. Examples include non-specific neck pain, thoracic pain, radicular arm pain/ cervical radiculopathy, whiplash associated disorders, degenerative cervical spine disease, torticollis,
For further support & guidance and refer to:
Decision Tool
NHS Lothian Primary Care Cervical/ Thoracic Decision Tool
Neurology- Neck and Arm pain advice and pathway – Ref help
How to refer:
Refer via SCI Gateway Referral “AHP-Physiotherapy” then choose local site.
Please provide as much detail as possible to help the triage process.
Important notes:
- June 2021- ongoing pilot of development of NHS Lothian Integrated Back Pain Service towards Lothian integrated Spinal Service (to be launched in due course)
Non specific neck pain/ degenerative cervical spine pain (~90-95% cases in primary care)
Research has revealed that the majority of neck pain (90-95%) has no underlying specific pathology or identifiable cause and as such the vast majority of cases at this lower end of the complexity spectrum are managed within primary care +/- MSK Physiotherapy. As detailed within the NHS Lothian Neurology ref help advice section “EVERYONE gets cervical spondylosis as they get older – like grey hair. There is poor correlation between radiological ‘age-related’ changes and neck pain. Doing a plain cervical x-ray on someone with neck pain and telling them they have cervical spondylosis/arthritis/”wear and tear” may be harmful /reduce the effectiveness of physiotherapy”.
People with cervical spine problems who are referred to MSK Physiotherapy are managed within agreed pathways of care. Prognosis is good. For these cases imaging will not guide management and can cause more harm than benefit. Research has shown that imaging does not improve clinical outcomes with liberal use being linked with greater work absence, unnecessary use of health services through action on incidental findings and provoke unnecessary worry or concerns in patients from a labelling effect.
Radicular arm pain/ radiculopathy/ (~5-10% case in primary care)
Less than 5-10% of all cervical related presentations. For those people whose pain is persistent, resistant to conservative management and wish to consider invasive options, MSK Physiotherapist’s will be able to arrange an opinion with spinal advanced practice physiotherapists within the integrated MSK service (iMSK). These spinal APP’s work closely with Consultant Neurosurgeons, radiologists, MSK Physiotherapists and the Pain Management Service. They are able to arrange investigations, undertake regular virtual clinics with Consultant Neurosurgeon’s and onward referral to Neurosurgery as appropriate.
As detailed within the NHS Lothian Neurology ref help advice: “We often are asked for MR Cervical Spine to ‘show the cause’ of someone’s pain……………….MR C-spine is rarely helpful:
a) because usually it is muscular pain with radiation not radiculopathy;
b) cervical radiculopathy usually improves with conservative treatment;
c) neurosurgery is rarely offered/has little evidence base in this area. MR C-Spine is not available open access in NHS Lothian . We request it mainly to look for spinal cord pathology.”
Please consider further information and support ;
Neck and Arm Pain- Neurology Ref Help Advice
Neurology- Neck and Arm pain advice and pathway – Ref help
Specific spinal pathology (~1% of cases in primary care)
These conditions include cancer, infection, inflammatory disease, cauda equina syndrome, acute foot drop and fracture. If there is suspicion of a specific underlying spinal pathology, please follow the ‘red flag’ pathways
Support and guidance
For guidance and support refer to NHS Lothian Primary Care Cervical/ Thoracic Decision Tool
- Link to NHS Inform page neck problems https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/neck-problems
- Link to NHS Inform page- cervical spondylosis https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/cervical-spondylosis
