Non-specific radiating leg pain

Who can refer:

• All primary care clinicians i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners
• Patient self referral (resident of East Lothian HSCP, Edinburgh HSCP and West Lothian HSCP Where To Find Us – Musculoskeletal Physiotherapy opens a new window)
• Secondary care consultants and associated teams
• MSK physiotherapists are able to escalate/refer to spinal advanced practice physiotherapists underpinned by agreed pathways and processes NHS Lothian Integrated Spinal Service

Who to refer:

• All routine cases of low back pain and spine related leg symptoms who have not responded to initial primary care management within a 4-6 week period and do not have the presence of significant red flags nor have suspected inflammatory spinal pain – see sections serious lumbar spine conditions and other considerations and inflammatory spinal pain
• Spine related leg symptoms-  Consider earlier referral in cases intractable symptoms and/ or developing motor deficit but without significant red flags and suspected neurogenic claudication in which symptoms are beginning to affect quality of life and the ability of the patient to look after themselves.
• Non-specific low back pain in the absence of a dominant psychological component who have not received recent physiotherapy for their condition or who have received physiotherapy previously for their condition but;
  • have experienced a substantial change in their presentation
  • require assistance with achieving a functional goal
  • wish further assessment and considerations of management options
  • have clinical features suggestive of an underlying specific cause for their lower back pain i.e. spondylolisthesis, spondylolysis, in which further investigation would guide management (other than serious spinal pathology).For further support & guidance and refer to: Spine pathways | Right Decisions (scot.nhs.uk) opens a new window

• 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 may be required. A patient leaflet to support this decision has been created in conjunction with Neurosurgery, Neurology, Radiology, GPs and Physiotherapy within NHS Lothian available below.
• Lumbar x ray is not indicated in patients with spinal related leg symptoms with no adverse features
• Additional information regarding imaging available for xray and MRI found at radiology ref help spine Plain X-Rays – RefHelp opens a new window and neuroradiology ref help Neuroradiology – RefHelp opens a new window

Who not to refer:

• Patients who have the presence of significant red flags/ suspicion of serious lumbar spine condition or have suspected inflammatory spinal pain – see Serious lumbar spine conditions (Red Flags) – RefHelp
• Age <16
• Chronic back pain with a significant psychological / psychiatric / drug addiction element/ pain causing significant distress & disability, no planned referral to another speciality for diagnosis or treatment of pain – see Chronic pain Chronic Pain – RefHelp opens a new window.

How to refer:

• For all cases of routine low back pain / spine related leg pain – refer via SCI Gateway Referral “AHP-Physiotherapy” then choose local site.
• This single referral will gain access to the full multidisciplinary NHS Lothian integrated back pain pathway. Any subsequent investigation/ surgical opinion/ pain service referral will be made within the service
• Please include all relevant details on your referral to allow the appropriate initial triage of the patient. Initial triage will occur within MSK Physiotherapy and if appropriate will be passed to spinal advanced practice physiotherapy service.
• Please signpost patients to Integrated Spinal Service Webpage opens a new window for patient information.

Other information

For all routine cases of low back pain and spine related leg pain who meet the criteria under “who to refer”, referral to other specialities including Orthopaedics, Neurosurgery, Neurology & Rheumatology is not indicated.  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.

Chronic Pain Service

Consider direct referral to Chronic Pain services under the following circumstances:

• Patients with chronic low back pain whom;
  
  
  • do not meet criteria for SCI Gateway Physiotherapy referral as above
  • pain causing significant distress and disability
  • duration > 6 months
  • Age 16 years or over
  • No planned referral to another speciality for diagnosis or treatment of pain.

See Chronic Pain RefHelp Page opens a new window for further information and details