Lumbar Spine

Who not 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: Spine pathways | Right Decisions (scot.nhs.uk)
Emergency conditions	Cauda equina syndrome- suspected Metastatic spinal cord compression (MSCC) – suspected Spinal infection- suspected Acute foot drop
Urgent conditions	Major spinal related neurological deficit/ worsening 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
What not to refer-other:	Presence of significant red flags as detailed above Age <16 Non MSK complaints Chronic LBP with a significant psychological/  psychiatric/ drug addiction element

Who to refer:

People with non specific low back pain, sciatica, spinal stenosis who have not responded to initial primary care management and do not have the presence of significant red flags

For further support & guidance and refer to: Spine pathways | Right Decisions (scot.nhs.uk)

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.

Signpost patient to:   https://services.nhslothian.scot/IBPS/Pages/default.aspx

Important notes:

• This single referral will gain access to the full multidisciplinary NHS Lothian integrated back pain service. Any consequent investigation/ surgical opinion/ pain service referral will be made within the service- the patient will not require to return to their GP. Please include relevant detail on your referral to allow the appropriate initial triage of the patient

• MRI scan is not required at point of referral. If a MRI is indicated as part of a patients management this will be requested within the multi-disciplinary service at the appropriate time for the patient and any intervention that

Non specific back pain (~90-95% cases in primary care)

Research has revealed that the majority of back 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. People with lumbar 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 leg pain/ radiculopathy/ spinal stenosis (~5-10% case in primary care)

Less than 5-10% of all lumbar related presentations. For those people whose pain is persistent, resistant to conservative management and wish to consider invasive options, MSK Physiotherapist’s are 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.

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

NHS Lothian Integrated Back Pain Pathway

The NHS Lothian integrated back pain service 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 offers a single point of access for patients with routine low back pain/ sciatica/ lumbar stenosis 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 the lumbar spine problem. The service is underpinned by agreed pathways, escalation criteria and multidisciplinary clinics.

The service has been designed following consultation with; General Practitioner Services, Neurosurgery Services, Orthopaedic Services, Pain Services, Pharmacy Services, Physiotherapy Services, Radiology Services, Emergency Services and Rheumatology Services.

For guidance and support refer to Spine pathways | Right Decisions (scot.nhs.uk)

Vertebral-Fragility-Fractures-Pathway-V21.pdf

Scottish Referral Guidelines for Suspected Cancer (Malignant Spinal Cord Compression): 

https://www.cancerreferral.scot.nhs.uk/malignant-spinal-cord-compression/

NHS Lothian patient website https://services.nhslothian.scot/IBPS/Pages/default.aspx

Integrated Low Back Pain Service PIL

NICE Managing LBP and sciatica visual summary

Triage decision aid (BMJ 2021)