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
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Scenario
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Primary Care (GP)
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MRI
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Secondary Care
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Notes
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| 1. Back Pain/Neck Pain. No red flags/radicular symptoms/neurological signs. Acute or chronic
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Yes
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No
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No
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Consider referral to physio
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| 2. BP/NP, with radicular symptoms > 6 wks (eg sciatica). No red flags or neurological signs
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Yes
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No, not routinely (see notes).
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No, not routinely
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Refer to physio If pain persists a further 6 weeks Physio ESP to request routine MRI ( within 4 weeks / reported 48 hours) if possible. Physio to refer to NS /T&O if appropriate (and MRI abnormal) to see within 4 weeks if possible.
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| 3. BP/NP with neurological signs > 2/52 (eg foot drop, arm weakness/paraesthesia)
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Yes
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Yes (GP). Urgent (to occur within 2 wks, and reported in 48 hours if possible)
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Yes. Usually needs to be seen by NS/T&O
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Refer urgently to NS/T&O (to be seen within 2 wks from MRI if possible)
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| 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
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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
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| 6. Rapidly progressive cervical myelopathy
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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
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| B. Months – Yes
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Yes (GP). Urgent (to occur within 2 wks, and reported in 48 hours if possible)
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Yes. Usually needs to be seen by NS/T&O
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Refer urgently to NS/T&O (to be seen within 2 wks from MRI if possible)
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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.
- References: https://www.nice.org.uk/guidance/ng59 and RCR i-REFER.
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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