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Lumbar Spine

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In primary care the prevalence of Low Back Pain due to

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Mechanical spine pain and radicular pain 

Compression fracture 

Unexpected cancer 

Metastasis in known cancer

Ankylosing spondylitis 

Spinal infection 

95%

4%

0.7%

9%

0.3%

0.01%

Majority of patients will have mechanical or radicular low back pain - skip to pathway here

The presence of RED FLAG signs, symptoms or risk factors should prompt urgent referral to secondary care sometimes with simultaneous referral for imaging

Spinal X-rays are low yield, high radiation dose examinations with limited indications. They are NOT indicated for mechanical back pain, radicular pain or prior to requesting an MRI.

 

Spine Xray will be declined if not justified particularly age <50yr

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History and Examination

Ankylosing Spondylitis

Risk Factors or Signs of :

  • Morning Stiffness improved with exercise

  • Alternating Buttock Pain

  • Awakening due to Back Pain during night

  • Age <40

Subcategory and Description

Imaging Recommendation

No Imaging

No Imaging

No Imaging

No Imaging

Refer for appropriate imaging or investigations based on clinical suspicion

No Imaging

Referral Recommendation

Refer to Paediatrics

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- Imaging via secondary care

Refer to Spinal Surgeons

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- Imaging via secondary care

Refer to Spinal Surgeons

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- Imaging via secondary care

Refer to Rheumatology

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- Imaging via secondary care

Age Under 16

Scoliosis?

Coccydinia?

Arthritis of Spine?

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Referred pain?

-Absent pulses

-Haematuria

-Abdominal Pain

- Pulsatile Mass

Acute Onset Pain

Pre-test Probability 0.5% of fracture

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Post test probability

1 risk factor 1%

2 risk factors 7%

>3 Risk factors 50%

Vertebral Fracture

Risk Factors:

  • Use of Steroids

  • Significant Trauma

  • Age >70

  • Female

  • Previous osteoporotic fracture

Age >50 Xray Lumbar Spine

May require MRI via secondary care

 

Refer to Spinal Surgeons if acute fracture <12 weeks or persistent pain if considering vertebroplasty

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Spinal Infection

Acute Pain with Risk Factors:

  • Steroids or other Immunosupression

  • Fever

  • Elevated WCC or CRP

  • IVDU

  • Recent sepsis or invasive procedure

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Metastatic Disease

Risk Factors:

  • Known Cancer Diagnosis

  • Unexplained weight loss

  • ESR >100mm/hr

  • Older Age

  • Unremitting or night pain

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Cauda Equina Syndrome

Risk Factors or Signs of:

  • Painless Urinary retention

  • Faecal Incontinence

  • Saddle Anaesthesia

  • Bilateral sciatica or weakness

MRI Lumbar spine

 

MRI Lumbar spine 

Consider including rest of spine

 

No Imaging

Simultaneous referral to Spinal Surgeons

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Spinal Emergency

Direct referral via A&E

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Mechanical Low Back Pain

Subcategory and Description

Imaging Recommendation

Referral Recommendation

 Low Back Pain only

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  • Constant/Intermittent

  • Aggravated flexion or extension

  • No neurology

  • SLR normal

LBP with Sciatica Pain

  • Worse with movement

  • Symptoms >6 weeks

  • Radiating into lower limb below knee

  • Positive SLR (severe aggravation of pain or symptoms)

  • Positive Femoral stretch 

No Imaging

Imaging LBP without risk factors not associated with improved outcome and associated with high prevalence of clinically irrelevant and misleading findings

MRI Lumbar spine 

Referral MUST include laterality of symptoms and suspected nerve root involved

 

Conservative management 

 

Persistent Pain >6 weeks   

 

Keele STarT Back Screening Tool  or yellow flags to risk stratify

 

Referral to spinal surgeon if positive MRI and willing to consider surgery or spinal injection

AND completed minimum 6 weeks therapy including NSAID and physio

AND fails to show substantial improvement on re-evaluation

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Score <6 Low/medium Risk; Low psychosocial element - refer to APP MSK service

Score >6 High risk;severe pain;High psychosocial element - consider Pain team referral

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LBP with Sciatica Pain & Motor deficit

  • Pain radiating into lower limb below knee

  • Develops Motor defecit such as foot drop (not isolated ankle reflex loss)

  • Positive SLR (severe aggravation of pain or symptoms)

  • Positive Femoral stretch 

MRI Lumbar spine 

Referral MUST include laterality of symptoms and suspected nerve root involved

 

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Simultaneous urgent referral to Spinal Surgeons

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LBP with Spinal stenosis or neurogenic claudication

  • Pain, weakness or numbness on one or both legs

  • Present on walking

  • Eased by sitting or bending forward

  • Normal lower limb pulses

MRI Lumbar spine 

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Referral to spinal surgeon if positive MRI and willing to consider surgery or spinal injection

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