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Back and Neck Pain

  

These are guidelines for most patients most of the time. Like all guidelines, there are exceptions. Acute back pain is for < 6 weeks, chronic > 6 weeks


Spinal Pathways Summary for Back and Neck Pain

Acute back pain is defined as < 6 weeks & chronic back pain > 6 weeks

MRI for low back pain (without serious neurological deficit or red flags eg indicators of infection or neoplasia) does NOT affect clinical outcome. In most cases with back pain (especially low back pain), the MRI should be considered a prelude to surgery, ie to guide the surgeon to a surgical target.

Spinal XR is usually not helpful, unless looking for osteoporotic collapse in the elderly

If you need to discuss a patient, ring Neurosurgery registrar on bleep 2300.

On a Wednesday ring T&O registrar on bleep 2699. If in doubt, ask

CLICK HERE FOR RED FLAG INFORMATION

Click on each of the scenarios below for further information

Scenario

 

Primary Care (GP)

 

MRI 

 

Secondary Care 

 

Notes

 

                                                1. Back Pain/Neck Pain. No red flags/radicular symptoms/neurological signs. Acute or chronic

 

Yes

 

 

No

 

 

No

 

 

                      Consider referral to physio

 

 

2. BP/NP, with radicular symptoms > 6 wks (eg sciatica). No red flags or neurological signs

 

 

 

 

 

 

 

                                        Yes

 

 

 

 

 

 

 

 

 

                                                                                                                                                                                        No, not routinely (see notes).

 

 

 

 

 

 

 

 

 

 

                                                                                        No, not routinely

 

 

 

 

 

 

 

 

 

 

                      Refer to physio (to be seen within 2 weeks)

If pain persists a further 6 weeks Physio ESP to request routine MRI ( within 4 weeks / reported  48 hours) if indicated.

Physio to refer to NS /T&O if appropriate (and MRI abnormal) to see within 4 weeks.

                                                3. BP/NP with neurological signs > 2/52 (eg foot drop, arm weakness/paraesthesia)

 

 

Yes

 

 

 

Yes (GP). Urgent (to occur within 2 wks, and reported in 48 hours)

 

Yes. Usually needs to be seen by NS/T&O

 

                                                                                    Refer urgently to NS/T&O (to be seen within 2 wks from MRI)

 

 

                                                4. BP/NP with red flags (eg Spinal Cord Compression, infection/neoplasia) Yes. Send patient to ED with letter for ED Consider (ED). Immediate (< 4 hours, if requested)                             ED, and refer to NS/T&O if appropriate                                                             See NS/T&O if appropriate (or gen med, oncology etc)
                                                                                               5. Cauda Equina Syndrome

 

Yes. Send patient to ED with letter for ED Yes (ED). Immediate (<4 hours)                             ED, and refer to NS/T&O if appropriate                                                             See NS/T&O

 

                                                                                                 6. Rapidly progressive cervical myelopathy

 

 

 

 

 

 

A. Days/weeks – Yes. Send patient to ED with letter for ED

Yes (ED).               Immediate (<4 hours)  

ED, and refer to NS/T&O if appropriate

                                                            See NS/T&O

 

B. Months – Yes

 

 

Yes (GP). Urgent (to occur within 2 wks, and reported in 48 hours)

 

Yes. Usually needs to be seen by NS/T&O

 

                      Refer urgently to NS/T&O (to be seen within 2 wks from MRI)

 

 Notes

At present all MRIs (via PACS) have been connected across the West Midlands. So, if necessary, a Neuro/Spinal T&O surgeon can view the scan carried out in a referring hospital.

These include UHCW, GEH (Nuneaton), SWFT (Warwick), Worcester Royal Hospital and Alexandra Hospital (Redditch).

GPs: it is important to be aware of addictive nature of opiates and pain modulating drugs (gabapentin and pregabalin). These should only be prescribed for short periods.

 

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Coventry Guidance
Referral to Adult Musculoskeletal Service – Coventry

If initial conservative GP management has failed refer to Adult Physiotherapy Musculoskeletal Service via NHS E-referral for initial physio triage and to be assessed for a treatment programme including:

  • Exercise therapy
  • Manual Therapy
  • Acupuncture
  • Self-management advice and education

If neurological symptoms refer urgently to Adult Physiotherapy Musculoskeletal Service

If diagnostic imaging is required the patient will be referred and the findings discussed with the patient.

If appropriate the patient can be referred to Neurosurgery, Pain Clinic or Spinal Orthopaedics. Alternatively patients can be discussed in the Virtual Clinic. Here more complex cases are reviewed with an orthopaedic spinal surgeon and surgery or spinal injections can be considered.

Rugby Guidance

If initial conservative GP management has failed refer to Rugby Adult Physiotherapy Musculoskeletal Service for assessment and management.

The Rugby Physiotherapy Service is administered by South Warwickshire NHS Foundation Trust.

The referral form for Rugby physio can be found on the right hand panel.

Physiotherapy contact number for all clinics:
Tel: 01926 608068

Patients can refer themselves for musculoskeletal (only) physiotherapy using this self-referral form.

The Physiotherapy Service provides in-patient and outpatient services at Warwick, Stratford, Leamington & Ellen Badger Hospitals, as well as outpatient services in a variety of clinics across South Warwickshire, listed below:

  • Alcester Primary Care Centre, Fields Park Drive, Alcester, B49 6QR
  • Bidford Health Centre, High Street, Bidford on Avon, B50 4BQ
  • Ellen Badger Hospital, Stratford Road, Shipston Upon Stour, CV36 4AX
  • Henley in Arden Surgery, Prince Harry Road, Henley, B95 5JD
  • Kenilworth Clinic, Smalley Place, Kenilworth, CV8 1QG
  • Kineton Surgery, The Old School, Market Square, Kineton, CV35 0LP
  • Leamington Spa Rehabilitation Hospital, Heathcote Lane, Warwick CV34 6SR
  • MEON Medical centre, Goose Lane, Lower Quinton, CV37 8TA
  • Southam Clinic, Pendyke Street, Southam, CV47 1PF
  • Studley Poole Medical centre, Studley B80 7QU
  • Stratford Upon Avon Hospital, Arden Street, Stratford Upon Avon, CV37 6NX
  • The Hospital of St Cross, Barby Road, Rugby, CV22 5X

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