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Spinal Glos Care Pathway Overview

MSK Specialist Triage commenced in July 2018. All spinal triage referrals for Orthopaedic review across Gloucestershire are divided between Gloucester Care Services (GCS) and Gloucestershire NHS Foundation Trust (GHNHSFT). GHNHSFT triage patients within the Gloucester and Cheltenham localities, and GCS triage the five other localities. The two organisations work closely together to ensure consistency and standardisation of approach.

Please strongly consider Supported Self-Management

Please click the relevant flowchart box to be taken directly to textual information

Red Flags

Serious pathology in the absence of an obvious cause (eg trauma) is very rare, but be aware of signs suggestive of more serious pathology.

  • loss of bowel control (faecal or flatus incontinence) and unexpected laxity of anal sphincter
  • loss of bladder control (urinary retention or incontinence)
  • severe or progressive neurological deficit in the lower extremities or gait disturbance
  • saddle anaesthesia or paraesthesia (loss or change of perianal and perineal sensation)

  • new onset pain in patient over age 50 years (defined as over age 55 years in some guidelines), or younger than age 20 years
  • incidence of pain in adolescents is becoming increasingly common; epidemiological surveys show point prevalence rates of around 30%
  • history of cancer
  • failure to improve after one month

  • persistent night pain (unrelieved by change in position)
  • structural deformity of the spine
  • pain at multiple sites
  • unexplained weight loss

  • fevers, chills, rigors
  • immunosuppression
  • intravenous (IV) drug misuse
  • recent bacterial infection
  • penetrating wound

  • sudden onset of back pain associated with major trauma or minor trauma in people with osteoporosis or in those taking corticosteroids
  • structural deformity of the spine
  • severe central pain, relieved by lying down

  • sensory or motor loss
  • history of serious injury
  • in people with or at high risk of osteoporosis
  • other disorders which increase the chance of serious aetiology, eg:

If suspected tumour - refer via 2ww

If the patient is still under consultant care post-operatively any issues relating to post-operative recovery should be referred back to the consultant

Refer to the Trauma Triage Service or A&E for suspected fracture

NB: Be aware that some red flags have very high false-positive rates and as such have little diagnostic value in primary caresettings. Careful clinical judgment to decide whether to investigate further or refer is needed.

Differential Diagnosis

Please do not refer to the MSK Specialist Triage (APS and Orthopaedics) Service for the following:

Exclude

Action to take

Suspected fracture or acute traumatic injury

Refer to A&E or the Trauma Triage Service

Suspected new diagnosis of inflammatory arthritis

Refer to Rheumatology

Supported Self-Management

Many patients with spinal problems can, with advice and guidance, manage their problems without additional support. Please see the individual conditions for specific guidance.

Advice on how to do this can be found in the Patient and Carer Information section and Community Resources section.

See the Core Physiotherapy Services section below for patient self-referral information, printable posters and business cards.

Primary Care Assessment - Risk Stratification Tool

Consider using risk stratification (for example, the STarT Back risk assessment tool) for each new episode of low back pain with or without sciatica to inform shared decision-making about stratified management. 

STarT Back Risk Stratification is a prognostic 9-point screening tool to be completed with the patient by GPs and First Contact Practitioners; it is a key feature of the National Low Back Pain & Radicular Pain Pathway and NICE NG59 (Risk Assessment and Risk Stratification Tools 1.1.2 and 1.1.3).  STarT Back generates an overall score and psychosocial subscore that divides patients into low, medium and high risk of developing persistent back pain-related disability thus indicating one of the three appropriate targeted treatment pathways.

Full details of STarT Back including online training can be accessed via http://www.keele.ac.uk/sbst/. A brief video has been produced looking at the use of STarT Back in practice and is available to watch here; https://youtu.be/r9wEgy4La4o 

Please also see the Clinician Education Section here for the STaRT Back E-Learning package.


Based on risk stratification, consider:

  • Simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and have a good outcome (low risk), e.g. reassurance, advice to keep active and guidance on self-management  in the form of patient-facing information leaflets.
  • More complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor outcome (medium and high risk) by means of self-referral or referral into Core Physiotherapy.
Core Physiotherapy Services

Please click the image below for further information

                                                                       

Referral Criteria - MSK Specialist Triage (APS and Orthopaedics)

Direct refer to the MSK Specialist Triage (APS and Orthopaedics) using the MSK Referral form where:

  • there is diagnostic uncertainty or
  • there is uncertainty around management choices or where surgery is indicated or
  • comprehensive conservative measures have been unsuccessful or
  • patient is medically unfit or has declined surgery

MSK Specialist Triage will decide on the appropriate management pathway for your patient based on the information in your referral. Further details about Specialist Triage are below.

Core and MSKAPS services operate an eight week waiting time target for routine appointments, and two week waiting time targets for urgent appointments.

MSK Specialist Triage (APS and Orthopaedics) - Adults only

Access to an Orthopaedic opinion for any adult Spinal problems is through the MSK Specialised Triage (APS and Orthopaedics) - Adults only. GHNHSFT triage patients within the Gloucester and Cheltenham localities, and GCS triage the five other localities. The two organisations are working closely together to ensure consistency and standardisation of approach.

Direct referral to Orthopaedics for children remains as it currently is.

Triage of adult elective care referrals is an NHS England mandated change that is fully supported by Gloucestershire’s lead orthopaedic consultants.

All MSKAPS and Orthopaedic referrals should be made to 'MSK Specialist Triage' on eRS. This is the only way of accessing Orthopaedics for patients registered with a Gloucestershire GP.

As part of the agreed, countywide strategy, all referrals must be made via e-RS (electronic Referral system).  More information on paper referral switch off can be found, here.

The effectiveness and accuracy of triage depends on the quality of information given by the referrer. The MSK referral form outlines the information required by Specialist Triage and by Secondary Care to decide how to manage a patient appropriately. The MSK referral form has been formatted to auto-populate patient’s data (name, date of birth, etc.)  in all clinical systems, saving administrative time.

Direct refer to the MSK Specialist Triage (APS and Orthopaedics) using the MSK Referral form where:

  • there is diagnostic uncertainty or
  • there is uncertainty around management choices or where surgery is indicated or
  • comprehensive conservative measures have been unsuccessful or
  • patient is medically unfit or has declined surgery

MSK Specialist Triage will decide on the appropriate management pathway for your patient based on the information in your referral. Further details about Specialist Triage are below.

Core and MSKAPS services operate an eight week waiting time target for routine appointments, and two week waiting time targets for urgent appointments.

Please follow these links for further information;

Contact details for the MSK Specialist Triage Services can be found here.

When to do Investigations

  • FBC
  • U&Es
  • LFTs
  • Bone profile
  • Fasting glucose
  • Thyroid Function Tests
  • Inflammatory markers
  • Plasma Viscocity
  • CRP
  • Urine dipstick tests for blood, protein or glucose.
  • Consider Vitamin D with risk factors.

  • Routine x-rays not indicated (as initially managed as acute back pain).
  • Consider standing lumbar X-ray views if suspicious of bony pathology e.g. fracture, tumour or infection or if considering referral for intervention.

  • Consider MRI when a diagnosis of serious spinal pathology is suspected e.g. malignancy, infection, fracture, cauda equina syndrome or if any worrying features exist e.g. severe or progressive neurological deficits exist).
  • MRI is indicated prior to considering referral for intervention such as injections or surgery.
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