Professional Documents
Culture Documents
2013
Commissioning guide:
Low Back Pain: Broad Principles of the
patient pathway
Version 1.1: This updated version has been published in June 2014 and takes account of NICE documents
published since the original literature review was undertaken as well as further input from a pain medicine
perspective.
Sponsoring Organisation: United Kingdom Spine Societies Board (UKSSB)
British Orthopaedic Association (BOA), Royal College of Surgeons for England (RCSEng)
Date of evidence search: August 2012
Date of publication: November 2013
Date of Review: November 2016
NICE has accredited the process used by Surgical Speciality Associations and
Royal College of Surgeons to produce its Commissioning guidance.
Accreditation is valid for 5 years from September 2012. More information
on accreditation can be viewed at www.nice.org.uk/accreditation
CONTENTS
Introduction ............................................................................................................................................... 1
1
The Royal College of Surgeons of England, 35-43 Lincolns Inn Fields, London WC2A 3PE..
Introduction
This guidance is for commissioners and it gives broad principles of the patient pathway. It should be read in
conjunction with the High Value Care Pathway for Radicular Pain (under review). Details of commissioning
specific parts of the pathway will vary with local circumstances. This document is not a clinical guideline and
includes acute (lasting up to 6 weeks) and chronic (lasting more than 6 weeks) low back pain.
While reference is made to NICE guidance CG88 it is acknowledged that the current guidance is under review
by NICE with a more inclusive scope.
Low back pain without radicular pain is one of the most common musculo-skeletal conditions presenting to
GPs. Access rates have increased from 231 to 295 per 1,000 from 2005 to 2010 indicating a significant rise.
There were over 70,000 procedures for low back pain in England in 2010/11 (HES data), with around 67,000
of these being facet joint injections (OPCS code V544).1
Treatment should be aimed at allowing patients to remain independent and return to previous activities and
employment in the shortest time possible.
Patients with acute low back pain should self-manage with simple analgesia and minimal bed rest, up to a
maximum of 48 hours depending on the severity of pain followed by progressive resumption of their normal
activity. The vast majority of patients with low back pain will improve naturally assisted by good primary care
management including physiotherapy/ hands on manipulation.1
For those that do not respond, an early risk assessment should be conducted in primary care and they should
be actively managed by the appropriate therapists.
Cost effective care results in an early return to work and reduces unnecessary attendance at Emergency
Departments and General Practitioners.
Lumbar facet joint injections should not be routinely considered for patients with low back pain of up to 12
months duration.2-5 Lumbar facet joint nerve blocks may be considered for those who are being considered
for radiofrequency denervation AND are being managed by a multidisciplinary team (MDT) which includes
the chronic pain service.2
This pathway is a guide which can be modified according to the needs of the local health economy.
refer for core therapies including (NICE CG88) manual therapy involving either exercise and/or
manipulation (including physiotherapists, chiropractors, osteopaths) and/or acupuncture and/or
provision of educational material
these typically involve 5-10 sessions over 6-12 weeks.
IF high risk
should be referred to a low intensity CPPP Programme usually uni-disciplinary (physiotherapy), but
3
Those services that do not require the resources of a general hospital, but are beyond the scope of the traditional
primary care team (Ren JFM, Marcel GMOR, Stuart GP, et al. What is intermediate care? BMJ 2004;329(7462):360-61)
Injections
Facet joint injection/medial branch block/radiofrequency denervation:
injections should not be used for patients with low back pain of less than 12 months duration, or
moderate to severe depression
all injections should be carried out under radiological control
for those with low back pain of more than 12 months who have failed other treatment options (above),
injections may be considered within a multidisciplinary team (MDT) approach to pain management usually
involving a pain clinic
there is no evidence for the use of facet joint or medial branch injections in predicting the outcome of
spinal fusion surgery
however, while there is limited evidence for facet joint injections, there is fair to good evidence that
medial branch blocks (also OPCS code V544) may be effective for the treatment of chronic lumbar facet
joint pain resulting in short-term and long-term pain relief and functional improvement2.
radiofrequency denervation of lumbar facet joints should only be undertaken after a successful lumbar
medial branch block and as part of a MDT managed programme of care
epidural injections either sacral or interlaminar and nerve root injections are not of value for patients with
non-specific low back pain
Pain management
those who fail to respond to surgery will continue under the care of their spinal MDT and pain
management service; more complex pain management services such as spinal cord stimulation,
peripheral nerve-field stimulation or intra-thecal drug delivery systems may require onward referral to
a specialised pain management service including neurosurgery as defined by NHS England
pain management services as part of a complex care package will also be required for those who have
non-resolving LBP despite appropriate conservative treatment i.e., a high intensity CPPP and for those
patients who are not suitable for or do not wish to undergo spinal surgery
patients who have severe ongoing pain after a recent unhealed vertebral fracture despite optimal pain
management and in whom the pain has been confirmed to be at the level of the fracture by physical
examination and imaging may be considered for percutaneous vertebroplasty and/or percutaneous
balloon kyphoplasty without stenting
Surgery
Patients should be informed that the decision to have surgery can be a dynamic process and a decision to not
undergo surgery does not exclude them from having surgery at a future time point.
identify and manage Yellow Flags, if not already identified, as their presence may rule out surgery
5
surgery may be required in those patients with low back pain secondary to deformity, tumour, trauma
and infection
for those patients where no other cause can be found and where a high intensity CPPP has failed to
produce significant improvement, surgery may be considered
patients with 1 or 2 levels of degenerative change may be suitable for spinal fusion (anterior,
posterior, anterior and posterior)
primary or revision of one or two level posterior instrumented fusions are considered non-specialised
and are funded by Clinical Commissioning Groups
Users can access further procedure information based on the data available in the quality dashboard to see
how individual providers are performing against the indicators. This will enable CCGs to start a conversation
with providers who appear to be 'outliers' from the indicators of quality that have been selected.
The Procedures Explorer Tool is available via the Royal College of Surgeons website.
The Procedures Explorer for treatment of low back pain describes variation in:
Procedure
Facet joint
injection/medial branch
block
Radiofrequency
denervation lumbar facet
joint
Posterior lumbar spinal
fusion
OPCS4 codes
V544
Exclusions
Appendix 5
Appendix 5
Appendix 5
V363*
V333-6*
V343-6*, V393-7
Appendix 5
All procedures in the above table should be accompanied by a V55 code to determine number of levels: V551
= 1 level, V552 = 2 levels; V553 = >2levels
*Commissioned by NHS England. All procedures accompanied with V553 to indicate more than 2 levels are
also commissioned by the NHS England (except injections).
The quality dashboard provides an overview of activity commissioned by CCGs from the relevant pathways,
and indicators of the quality of care provided by surgical units.
The quality dashboard is available via the Royal College of Surgeons website.
For the current dashboard indicators (see Appendix 4)
Measure
Standardised activity rate
Average length of stay
Day case rate
Definition
Activity rate standardised for age
and sex
Total spell duration/total number of
patients discharged
Number of patients admitted and
discharged on the same day/total
number of patients discharged
Number of patients admitted and
discharged within 48 hours/total
number of patients discharged
Number of patients readmitted as
an emergency within 7/30 days of
discharge/total number of patients
discharged excludes cancer,
dementia, mental health
Data Source
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)
Re-operations within 30
days/1 year
HES/Quality Dashboard
(Appendix 4)
Data Source*
GP Data
HES/Quality Dashboard
(Appendix 4)
Standard
surgeon
7. Number of patients referred to pain
management
Established
secondary care
spinal MDT meeting
Spinal Task Force
standards
Access to spinal
surgeons
Training and
governance of
community
providers and other
AQP
Access to pain
services
Description
Success of spinal
assessment service
Data specification
(if required)
The service should report:
1. Number of patients seen
2. Number of patients
referred for low intensity
CPPP
3. Number patients referred
for high intensity CPPP
4. Number of MRI scans
performed
5. Number of patients
referred to spinal MDT
6. Number of patients
referred to spinal
surgeon
7. Number of patients
referred to pain
management
10
Directory
5.1
Name
Back Pain
Nonspecific low back pain
in adults
Back Pain
5.2
Publisher
NHS Choices
EMIS
Link
www.nhschoices.nhs.uk
www.patient.co.uk
Arthritis
Research UK
www.arthritisresearchuk.org
Name
Sheffield Back Pain
Service
The Back Book
Low back pain and
sciatica
Back Care
Red Flags (Appendix 2)
Publisher
Link
www.sheffieldbackpain.com
ISBN 0-11-702949-1
http://www.cks.nhs.uk/back_pain_low_and_sciatica
www.backcare.org.uk
www.sheffieldbackpain.com/professionalresources/learning/in-detail/red-flags-in-back-pain
British Pain Society Spinal Pain Working Group
consensus opinion (2012)
12
Yellow Flags
(Appendix 2)
Royal College of
Anaesthetists
NICE
www.britishpainsociety.org
www.sheffieldbackpain.com/professionalresources/learning/in-detail/yellow-flags-in-backpain
www.nice.org.uk/cg88
NICE
http://www.nice.org.uk/guidance/QS56
NICE
http://publications.nice.org.uk/peripheral-nervefield-stimulation-for-chronic-low-back-pain-ipg451
Keele University
www.keele.ac.uk/sbst/
Hill et al 2011
MAPI Trust
http://www.mapi-trust.org/
Patient safety
Patient
experience
Equity of access
Benefit
Getting patients back to work
Improved outcome
Prevention of chronicity
Avoiding use of addictive and morphine
based analgesia11-13
Risk
Long term unemployment
Resource impact
Patient choice of
provider and
location of
intermediate
care
Further information
7.1
Research recommendations
7.2
7.3
dependency
Cost of CPP programmes
Cost of supporting MDT
Other recommendations
Improved patient information
Patient Decision Aid for Low Back Pain
Evidence base
1. Carvell J. Commissioning Spinal Services Getting the Service Back on Track: A Guide for Commissioners
of Spinal Services. London: Spinal Task Force, 2013.
2. Falco FJ, Manchikanti L, Datta S, Sehgal N, Geffert S, Onyewu O, Zhu J, Coubarous S, Hameed M, Ward
14
SP, Sharma M, Hameed H, Singh V, Boswell MV. An update of the effectiveness of therapeutic lumbar
facet joint interventions. Pain Physician 2012;15-6:E909-53.
3. Carette S, Marcoux S, Truchon R, Grondin C, Gagnon J, Allard Y, Latulippe M. A controlled trial of
corticosteroid injections into facet joints for chronic low back pain. New England Journal of Medicine
1991;325-14:1002-7.
4. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin
RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL,
Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti
L. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal
pain. Pain Physician 2007;10-1:7-111.
5. NICE. Low back pain: (CG88) Early management of persistent non-specific low back pain. London:
National Institute of Clinical Excellence, 2009.
6. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E,
Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low
back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;3789802:1560-71.
7. http://www.keele.ac.uk/sbst/ (accessed 29/09/13/2013).
8. Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, Potter R, Underwood MR. Group
cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and
cost-effectiveness analysis. Lancet 2010;375-9718:916-23.
9. Lamb SE, Lall R, Hansen Z, Castelnuovo E, Withers EJ, Nichols V, Griffiths F, Potter R, Szczepura A,
Underwood M. A multicentred randomised controlled trial of a primary care-based cognitive behavioural
programme for low back pain. The Back Skills Training (BeST) trial. Health Technology Assessment
2010;14-41:1-253, iii-iv.
10. Wennberg JE, Fisher ES, Goodman DC, Skinner JS. Tracking the Care of Patients with Severe Chronic
Illness: The Dartmouth Atlas of Health Care 2008. Lebanon, New Hampshire: The Dartmouth Institute for
Health Policy and Clinical Practice 2008:1-123.
11. Okie S. A flood of opioids, a rising tide of deaths. New England Journal of Medicine 2010;363-21:1981-5.
12. Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, Fiellin DA. Systematic review:
opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Annals of
Internal Medicine 2007;146-2:116-27.
13. Jamison RN, Clark JD. Opioid medication management: clinician beware! Anesthesiology 2010;1124:777-8.
7.4
A commissioning guide development group was established to review and advise on the content of the
commissioning guide. This group met four times, with additional interaction taking place via email.
15
Name
John Carvell
Job Title/Role
Chair
Emeritus Consultant Spinal
and Orthopaedic Surgeon
Ashley Cole
Joe Dias
Chair, Musculoskeletal
Commissioning Guidance
Development Project;
Consultant Orthopaedic
Surgeon
Consultant Orthopaedic and
Spinal Surgeon
Nigel Henderson
Rick Nelson
Consultant Neurosurgeon
Richard Smith
Consultant Rheumatologist
Awadh Jha
Martin Hey
Christopher Mercer
Debbie Cook
Physiotherapist
Patient
Judith Fitch
Patient
Paul May
Affiliation
Chair Spinal Taskforce DH and
Chair CRG Complex Spinal
Surgery
Member Spinal Taskforce DH
and CRG Complex Spinal
Surgery Orthopaedic Expert
Working Group
British Orthopaedic
Association and
Musculoskeletal CCG
Development Chair
Member Spinal Taskforce DH
and CRG Complex Spinal
Surgery
President of Society of British
Neurological Surgeons
British Society for
Rheumatology
Royal College of General
Practitioners
The Walton Centre
The consultative process has also taken into account the views of the Chartered Society of Physiotherapy, the
Faculty of Pain Medicine, the British Pain Society, and specialised Pain Services Clinical Reference Group.
Information specialist support provided by Bazian, 10 Fitzroy Square, London, W1T 5HP.
16
17
18
History and Examination in a patient with back pain which indicates possible serious
spinal pathology
History:
-
Examination:
-
limb weakness
generalised neurological deficit
hyper-reflexia, clonus, extensor plantar responses
saddle anaesthesia (loss of pinprick sensation unilaterally or bilaterally)
reduced anal tone/squeeze
new/progressive spinal deformity
urinary retention
Yellow Flags
The most important and widely used model for the examination of the spine is the Bio-PsychoSocial model. This aims to encompass all elements of a patient's problem. The aim of the
psychosocial assessment is to find those patients who are likely to develop chronicity. The
factors which highlight the patient's risk of chronicity can be identified using the 'yellow flags'
system:
19
Attitudes - towards the current problem. Does the patient feel that with appropriate help
and self-management they will return to normal activities?
Beliefs - The most common misguided belief is that the patient feels they have something
serious causing their problem - usually cancer. 'Faulty' beliefs can lead to catastrophisation.
Compensation - Is the patient awaiting payment for an accident/injury at work/RTA?
Diagnosis - or more importantly iatrogenesis. Inappropriate communication can lead to
patients misunderstanding what is meant, the most common examples being 'your disc has
popped out' or 'your spine is crumbling'.
Emotions - Patients with other emotional difficulties such as on-going depression and/or
anxiety states are at a high risk of developing chronic pain.
Family - There tends to be two problems with families, either over bearing or under
supportive.
Work - The worse the relationship, the more likely they are to develop chronic LBP.
1.
Low risk. Patients at low risk of poor outcome each receives a 30 minute face to
face appointment that consists of a comprehensive assessment including a physical
examination, individualised education and reassurance about diagnosis, prognosis and
treatments and advice about medication, activity and work. This is supplemented with
written materials (the Back Book and a leaflet about local exercise and activity facilities)
and a 15-minute educational DVD.
2.
Medium risk. For these patients a referral to physiotherapy is beneficial both in
terms of their clinical outcomes and cost savings. Physiotherapists negotiate an
individualised treatment plan with the patient aiming to reduce symptoms, disability and
promote self-management. They use a range of evidence based interventions including
advice, explanation, reassurance, education, manual therapy and exercises. Acupuncture
treatment is provided at the discretion of the physiotherapist and patient. Consistent with
evidence based guidelines bed rest, traction, massage and electrotherapy were not
recommended.
3.
High risk. For these patients a referral to an appropriately skilled physiotherapist is
beneficial both in terms of their clinical outcomes and cost savings. In the STarT Back trial it
was cost-effective to allow longer appointments for high-risk patients. The high risk
treatment (outlined below) is in addition to the treatments provided for medium risk
patients.
a.
Build rapport, validate and normalise the patients experiences.
b.
Conduct a comprehensive biopsychosocial assessment (physical examination,
exploration of the impact that pain is having on the patients physical and psychosocial
functioning, identification of the patients beliefs and expectations regarding LBP and its
20
To support the commissioning guides the Quality Dashboards show information derived
from Hospital Episode Statistics (HES) data. These dashboards show indicators for
activity commissioned by CCGs across the relevant surgical pathways and provide an
indication of the quality of care provided to patients.
The dashboards are supported by a metadata document to show how each indicator
was derived.
http://rcs.methods.co.uk/dashboards.html
21
22
Example CCG
23
24
25
M462
M463
M464
M465
M490
M491
M492
M493
Osteomyelitis of vertebra
Infection of intervertebral disc (pyogenic)
Discitis, unspecified
Other infective spondylopathies
Tuberculosis of spine
Brucella spondylitis
Enterobacterial spondylitis, and
Spondylopathy in other infectious and parasitic
diseases NEC
26
DURAL TEAR
ICD-10
ICD-9
C960, T812
NERVE INJURY
ICD-10
ICD-9
VASCULAR INJURY
ICD-10
ICD-9
T817
27
T845
9966
T814 G061
9985
DVT
ICD-10
ICD-9
I801, I802
4511
PE
ICD-10
ICD-9
I260, I269
4150, 4151
AMI
OPCS
ICD-10
K40-, K41-, K42-, K43-, K44-, K45-, K46-, K49-, K50-, K63I200, I21-, I22-, I248, I460
GI BLEED
ICD-10
STROKE
ICD-10
I60-, I61-, I62-, I63-, I64-, I65-, I66-, I670, I671, I672, I677, I678, I679, G451, G452,
G453, G454, G458, G459
28
RENAL FAILURE
ICD-10
N17-, N19-
29