low back pain: broad principles of the patient pathway
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Commissioning guide 2013 Low Back Pain
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
Commissioning guide 2013 Low Back Pain
CONTENTS
Introduction ............................................................................................................................................... 1
1 High Value Care Pathway for Low Back Pain ........................................................................................ 2
1.1 Primary Care……………………………………………………………………………………………………………………………………………2
1.2 Intermediate Care……………………………………………………………………………………………………………………………………4
1.3 Secondary Care……………………………………………………………………………………………………………………………………….4
2 Procedures explorer for Low Back Pain ................................................................................................ 6
3 Quality dashboard for low back pain ................................................................................................... 7
4 Levers for implementation .................................................................................................................. 8
4.1 Audit and peer review measures ……………………………………………………………………………………………………………8
4.2 Quality Specification/CQUIN (Commissioning for Quality and Innovation)……………………………………………10
5 Directory .......................................................................................................................................... 12
5.1 Patient Information for low back pain……………………………………………………………………………………………………12
5.2 Clinician information for low back pain………………………………………………………………………………………………… 12
6 Benefits and risks .............................................................................................................................. 13
7 Further information .......................................................................................................................... 14
7.1 Research recommendations………………………………………………………………………………………………………………….14
7.2 Other recommendations……………………………………………………………………………………………………………………….14
7.3 Evidence base……………………………………………………………………………………………………………………………………… 14
7.4 Guide development group for low back pain…………………………………………………………………………………………15
7.5 Funding statement ……………………………………………………………………………………………………………………………….17
7.6 Methods statement ……………………………………………………………………………………………………………………………..17
7.7 Conflicts of Interest Statement …………………………………………………………………………………………………………….17
The Royal College of Surgeons of England, 35-43 Lincoln’s Inn Fields, London WC2A 3PE..
Commissioning guide 2013 Low Back Pain
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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.
Commissioning guide 2013 Low Back Pain
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1 High Value Care Pathway for Low Back Pain
1.1 Primary Care
This is a guide for commissioners of clinical services and not a clinical tool. Clinical pathways include the Map
of Medicine Pathway (http://bps.mapofmedicine.com/evidence/bps/low_back_and_radicular_pain1.html)
and the Spinal Pathfinder Project (in development).
See diagram of the full clinical pathway in Appendix 1
PRIMARY CARE
Assessment:
history – ask about previous history, local/referred leg pain, radicular pain, bladder/bowel/sexual
dysfunction, systemic symptoms, Yellow Flags (see Appendix 2)
examination – look for neurological signs and postural changes
do not request plain X-rays or MRI scans at this stage
the GP may use the STarT Back Tool6 7 at this stage available at http://www.keele.ac.uk/sbst/
Emergency referral to Spinal Surgeon (same day):
possible unstable fracture: severe low back pain after history of significant trauma
Cauda Equina Syndrome: bladder/bowel/sexual dysfunction/loss or altered sensation wiping
bottom (saddle anaesthesia)
acute spinal cord compression: new/progressive neurological deficit (consider any previous history of
cancer)
Urgent referral to Spinal Surgeon (<2 weeks): (Red Flags, see Appendix 2)
spinal metastases: history of cancer e.g., lung, breast, prostate, unexplained weight loss, progressive
non mechanical back pain, thoracic back pain. Recent guidance (NICE quality standard 56,
www.nice.org.uk/guidance/QS56) suggests these patients have an MRI scan of the whole spine and
treatment plan agreed within 1 week of the suspected diagnosis
spinal infection: history of fever, IV drug use, recent infection, immunocompromised patients i.e.,
those on steroids, and those with diabetes
Fracture: history of sudden onset severe back pain with/without minor trauma, and/or recent onset
deformity where there is suspicion that there may be something other than a simple osteoporotic
fracture
Commissioning guide 2013 Low Back Pain
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severe radicular pain: not responding to treatment after 6-8 weeks
Routine referral to secondary care (4-6 weeks):
suspected rheumatological condition (refer to rheumatology): younger patient, prolonged early
morning stiffness, alternating buttock pain, symptoms improve with exercise, or systemic symptoms
e.g., uveitis, inflammatory bowel disease, psoriasis, (more urgent referral may be needed for severe
symptoms)
spinal deformity detected clinically or radiologically (refer to spinal surgeon): severe low back pain
with spinal deformity including scoliosis or anterior sagittal imbalance (excluding suspected discogenic
pain with lateral shift)
High grade spondylolisthesis (grade 3,4,5) confirmed on radiograph
Osteoporotic vertebral/sacral fracture remaining painful after 6-8 weeks. Most osteoporotic fractures
should be initially managed with adequate analgesia and DEXA scan (unless the patient is already on
treatment for osteoporosis)
Management:
risk assessment using STarT6 Back tool: http://www.keele.ac.uk/sbst/
reassurance, encouragement to stay active, early managed return to work
simple analgesia including weak opioids
strong opioids should not be recommended at all in the non-specialised setting unless for short-term
use with severe acute pain of 2 weeks duration. The principles of managing ongoing analgesic therapy
include the 4‘A’s: Analgesia, adverse effects, activity, and adherence.
provide patient information for education, reassurance and to allow shared decision making
IF low risk
referral to GP practice physiotherapy for one 30 minute session
allow self-referral for one session of therapy and advice (this may be through a musculoskeletal or
spinal triage service).
IF medium risk (and low risk non responders)
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
Commissioning guide 2013 Low Back Pain
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with links to psychology services8,9.
If symptoms still significant, despite the above management, refer to intermediate care.
1.2 Intermediate Care1
In acute low back pain, a decision can be made for an early review at 2 weeks before active management.
Assessment
review and assess improvement
refer if emergency/urgent/routine referral criteria
routine referral to a spinal surgeon if suspected spondylolisthesis or spondylolysis i.e,. young
sportsperson
inadequate improvement
Management
refer for high intensity CPPP (Combined Physical and Psychological Programme) likely to be different to
the service providing low intensity
this is up to 100 hours of group treatment with high intensity CPPP over a period of up to 8 weeks but
often delivered on a full-time basis over 2-3 weeks (NICE CG88)
the format of high intensity CPPP varies widely and may operate as pain management, functional
restoration, or ‘Return to Work’ programmes
these programmes may be available in primary, intermediate or secondary care
Referral to secondary care or MDT
failure to respond to high intensity CPPP (or other therapy if no high intensity CPPP available)
timing of MRI scan, spinal surgeon review and pain clinic involvement to be organised locally, but a spinal
surgeon should be involved in the decision making at this stage
1.3 Secondary Care
Whilst few patients will need referral to secondary care, this is a high value part of the pathway hence the
detail.
Assessment
patients should be assessed by a multi-disciplinary team (MDT) that is part of a spinal network including:
1 Those services that do not require the resources of a general hospital, but are beyond the scope of the traditional
primary care team (René JFM, Marcel GMOR, Stuart GP, et al. What is intermediate care? BMJ 2004;329(7462):360-61)
Commissioning guide 2013 Low Back Pain
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spinal surgeons, interventional radiologists, pain specialists, physiotherapists, clinical psychologists,
rheumatologists and extended scope practitioners
history and examination: see Assessment
MRI scanning same day for emergency referral and within one week for urgent referrals
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
Commissioning guide 2013 Low Back Pain
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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
1.4 Secondary Care: Specialised Surgery
Specialised surgery
more than two level posterior and/or anterior surgery is considered specialised surgery and is
commissioned by NHS England
lumbar disc replacement may be considered an alternative for spinal fusion but should be
commissioned with prudence from Specialist Spinal Centres and is ‘specialised’ surgery which should
be commissioned by NHS England
2 Procedures explorer for Low Back Pain
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 OPCS4 codes Exclusions
Facet joint
injection/medial branch
block
V544 Appendix 5
Radiofrequency
denervation lumbar facet
joint
V485, V486, V487, V488, V489 Appendix 5
Posterior lumbar spinal
fusion
V382-6, V388, V404 Appendix 5
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Lumbar disc replacement V363*
Anterior lumbar spinal
fusion
V333-6*
Revision lumbar fusion 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).
3 Quality dashboard for low back pain
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 Definition Data Source
Standardised activity rate Activity rate standardised for age
and sex
HES/Quality Dashboard
(Appendix 4)
Average length of stay Total spell duration/total number of
patients discharged
HES/Quality Dashboard
(Appendix 4)
Day case rate Number of patients admitted and
discharged on the same day/total
number of patients discharged
HES/Quality Dashboard
(Appendix 4)
Short stay rate Number of patients admitted and
discharged within 48 hours/total
number of patients discharged
HES/Quality Dashboard
(Appendix 4)
7/30 day readmission rate Number of patients readmitted as
an emergency within 7/30 days of
discharge/total number of patients
discharged excludes cancer,
dementia, mental health
HES/Quality Dashboard
(Appendix 4)
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Re-operations within 30
days/1 year
Number of patients re-operated
during an emergency readmission
within 30 days/ 1 year/total number
of patients discharged
HES/Quality Dashboard
(Appendix 4)
In hospital mortality rate Number of patients who die while in
hospital /total number of patients
discharged
HES/Quality Dashboard
(Appendix 4)
Areas for development of dashboard in future
Measure Evidence Base Data Source*
Time off work GP Data
*includes data from HES, National Clinical Audits, Registries
4 Levers for implementation
4.1 Audit and peer review measures
Levers for Implementation are tools for commissioners and providers to aid implementation of high value
care pathways.
Measure Standard Where data should be obtained from:
Missed Red Flags in
primary care
Secondary care providers should report
annually the number of cases where
there has been a significant delay in
referral for patients with red flags
including: the red flag, length of delay,
pathology
Use of STarT Back
Tool
Use the two subscales of
the STarT Back Tool
CCGs should report the percentage of
GPs using the STarT Back Tool
Establish back pain service in primary or secondary care offering assessment, low intensity CPPP and access to imaging including MRI and reporting to the spinal MDT
A spinal assessment service
should be developed to
assess all spinal referrals
unless emergency or urgent
referral is required. Imaging
investigations should be
requested as required and a
regular MDT set up to
discuss cases for referral.
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
Commissioning guide 2013 Low Back Pain
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This service should
be established for
back pain (cervical,
thoracic and lumbar)
and radicular pain
(cervical and lumbar)
This should have strong
links with the spinal surgery
network
surgeon 7. Number of patients referred to pain
management
Access to CPPP Each CCG should have
access to low and high
intensity CPPP. These may
have different providers
The CPP service should report:
1. STarT Back score on referral 2. ODI and EQ-5D before and after
treatment 3. Return to work
Established
secondary care
spinal MDT meeting
Spinal Task Force
standards
Include all personnel
involved in the provision of
spinal services in a Trust.
Spinal Taskforce: guide for
commissioners
“Commissioning Spinal
Services”
http://www.nationalspinalt
askforce.co.uk/
Number of MDT meetings held
Number of patients discussed
Access to spinal
surgeons
Spinal surgeons able to perform the required surgery should be part of the regional spinal network as all cases for surgery should be discussed within the setting of a spinal MDT
All patients having surgical interventions
including injections should have
Patient Reported Outcome Measures
(PROMs) before surgery and at 1 and 2
years after surgery (6 months after
injections). These should include either:
o COMI (Core Outcome Measures Index) and EQ-5D or
o VAS back and leg, Oswestry Disability Index and EQ-5D. (This is now the international standard outcome measure set approved by ICHOM. COMI on its own does not meet all the requirements)
This data along with the surgical
procedure and any complications (see
Appendix 6) should be recorded in one
of the spinal databases
(British Spine Registry or Spine Tango –
see Appendix 7)
Analysis of this data will form part of revalidation for the surgeon
Commissioning guide 2013 Low Back Pain
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Training and
governance of
community
providers and other
AQP
Community and AQP may provide: 1. Low intensity CPPP 2. High intensity CPPP 3. Non-specialised spinal
surgery 4. Pain management
services
Staff training, revalidation, indemnity, quality of service delivery and collection and reporting of outcome measures must be the same for all providers (see above)
Access to pain
services
Patients with low back pain may access pain services for: 1. high intensity CPPP, optimisation of pharmacotherapy or spinal injections 2. if unsuitable for spinal surgery (a decision which must be made by a spinal surgeon) or the patient does not want to consider surgery 3.after unsuccessful spinal surgery
All patients should have patient
reported outcome measures (PROMs)
on referral and on discharge.
These should include either:
o COMI (Core Outcome Measures Index) and EQ-5D or
o VAS back and leg, Oswestry Disability Index and EQ-5D (This is now the international standard outcome measure set approved by ICHOM. COMI on its own does not meet all the requirements)
4.2 Quality Specification/CQUIN (Commissioning for Quality and Innovation)
Measure Description Data specification
(if required)
Success of spinal
assessment service
This will inform outlier
identification and scrutiny
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
Commissioning guide 2013 Low Back Pain
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Success of low intensity
CPPP
Measures to be reported by each
provider
The low intensity CPPP service should report: 1. STarT Back score on
referral 2. ODI and EQ-5D, VAS back
and VAS leg before and after treatment
3. Return to work Success of high intensity
CPPP
Measures to be reported by each
provider
The high intensity CPP service should report: 1. ODI and EQ-5D, VAS back
and VAS leg before and after treatment
2. Return to work Success of spinal injections
for back pain
Lumbar facet joint injections Medial branch block Lumbar facet joint radiofrequency
denervation
All patients having these injections should have patient reported outcome measures (PROMs) before and at 6 months after injection These should include either: o COMI (Core Outcome
Measures Index) and EQ-5D or
o VAS back and leg, Oswestry Disability Index and EQ-5D
This data along with the
surgical procedure and any
complications (see Appendix
6).
Success of spinal surgery Spinal surgery for back pain All patients having surgical interventions should have PROMS before surgery and at 1 and 2 years after surgery. These should include either: o COMI and EQ-5D o VAS back and leg,
Oswestry Disability Index and EQ-5D
This data along with the
surgical procedure and any
complications (see Appendix
6) should be recorded in one
of the spinal databases
Commissioning guide 2013 Low Back Pain
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(British Spine Registry or
Spine Tango – see Appendix
7)
British Association of Spine
Surgeons audit of
suspected cauda equina
syndrome (CES)
All hospitals treating CES
should complete the audit
and submit data for central
reporting. The data can be
input directly into the British
Spine Registry (see Appendix
7)
5 Directory
5.1 Patient Information for low back pain
Name Publisher Link
Back Pain NHS Choices www.nhschoices.nhs.uk
Nonspecific low back pain
in adults
EMIS www.patient.co.uk
Back Pain Arthritis
Research UK
www.arthritisresearchuk.org
5.2 Clinician information for low back pain
Name Publisher Link
Sheffield Back Pain
Service
www.sheffieldbackpain.com
The Back Book Royal College of General
Practitioners
ISBN 0-11-702949-1
Low back pain and
sciatica
NHS Clinical Knowledge
Summaries
http://www.cks.nhs.uk/back_pain_low_and_sciatica
Back Care Back Pain Association www.backcare.org.uk
Red Flags (Appendix 2) British Pain Society 2012 www.sheffieldbackpain.com/professional-resources/learning/in-detail/red-flags-in-back-pain British Pain Society Spinal Pain Working Group consensus opinion (2012)
Commissioning guide 2013 Low Back Pain
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www.britishpainsociety.org
Yellow Flags
(Appendix 2)
Royal College of
Anaesthetists
www.sheffieldbackpain.com/professional-
resources/learning/in-detail/yellow-flags-in-back-
pain
Nice Guidance CG88
Early Management of
Persistent Non-
Specific low back pain
NICE
www.nice.org.uk/cg88
NICE quality standard
56 Metastatic spinal
cord compression
NICE http://www.nice.org.uk/guidance/QS56
NICE interventional
procedure guidance
451 Peripheral nerve-
field stimulation for
chronic low back pain
NICE http://publications.nice.org.uk/peripheral-nerve-
field-stimulation-for-chronic-low-back-pain-ipg451
STarT back pain
screening tool
Keele University www.keele.ac.uk/sbst/ Hill et al 2011
Oswestry Disability
Index (ODI) v2.1a
MAPI Trust http://www.mapi-trust.org/
6 Benefits and risks
Benefits and risks of commissioning the pathway are described below.
Consideration Benefit Risk
Patient outcome Getting patients back to work Improved outcome Prevention of chronicity
Long term unemployment
Patient safety Avoiding use of addictive and morphine
based analgesia11-13
Illness behaviour with increased
demand on primary and
secondary care
Patient
experience
Early treatment and advice Patient participation
Equity of access Even geographical spread of services and excellent quality of service throughout England
Current service provision is sporadic Risk of chronicity and drug
Commissioning guide 2013 Low Back Pain
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Reduce long-term morbidity dependency
Resource impact Reduced attendance at emergency department Reduced time off work Reduction in prescriptions Reduction in spinal injections Reduction in GP attendances Reduction in drugs prescribed and investigations done Improved outcomes Reduced chronic pain management
Cost of CPP programmes Cost of supporting MDT
Patient choice of
provider and
location of
intermediate
care
Improves patient satisfaction and access to services
Risk of not providing this increases DNA rates
7 Further information
7.1 Research recommendations
Clinical effectiveness and cost effectiveness of treatments: CPPPs, injections, surgery
Assess impact on return to work
Cost effectiveness of changes in system
Effective methods of education to support implementation
7.2 Other recommendations
Improved patient information
Patient Decision Aid for Low Back Pain
7.3 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
Commissioning guide 2013 Low Back Pain
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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;378-
9802:1560-71.
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;112-
4:777-8.
7.4 Guide development group for low back pain
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.
Commissioning guide 2013 Low Back Pain
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Name Job Title/Role Affiliation
John Carvell Chair Emeritus Consultant Spinal
and Orthopaedic Surgeon
Chair Spinal Taskforce DH and
Chair CRG Complex Spinal
Surgery
Ashley Cole Consultant Orthopaedic and
Spinal Surgeon
Member Spinal Taskforce DH
and CRG Complex Spinal
Surgery Orthopaedic Expert
Working Group
Joe Dias Chair, Musculoskeletal
Commissioning Guidance
Development Project;
Consultant Orthopaedic
Surgeon
British Orthopaedic
Association and
Musculoskeletal CCG
Development Chair
Nigel Henderson Consultant Orthopaedic and
Spinal Surgeon
Member Spinal Taskforce DH
and CRG Complex Spinal
Surgery
Rick Nelson Consultant Neurosurgeon President of Society of British
Neurological Surgeons
Richard Smith Consultant Rheumatologist British Society for
Rheumatology
Awadh Jha General Practitioner and
member of Medway
Commissioning Board
Royal College of General
Practitioners
Paul May Chair of Trauma Programme
of Care Board, NHS England;
Consultant Neurosurgeon
The Walton Centre
Martin Hey Physiotherapist Chair Physiotherapy Pain
Association
Christopher Mercer Physiotherapist Consultant Physiotherapist
Debbie Cook Patient Director National Ankylosing
Spondylitis Society
Judith Fitch Patient BOA Patient Liaison Group
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.
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7.5 Funding statement
The development of this commissioning guidance has been funded by the following sources: DH-RightCare funded the costs of the Guideline Development Group, the literature searches and
provided staff support; The Royal College of Surgeons of England (RCSEng) and the British Orthopaedic Association (BOA)
provided staff to support the guideline development and performed the quality assurance.
7.6 Methods statement
The development of this guidance has followed a defined, NICE Accredited process. This included a
systematic literature review, public consultation and the development of a Guidance Development
Group which included those involved in commissioning, delivering, supporting and receiving surgical
care as well as those who had undergone treatment. An essential component of the process was to
ensure that the guidance was subject to peer review by senior clinicians, commissioners and patient
representatives. Details are available at this site:
www.rcseng.ac.uk/providers-commissioners/docs/rcseng-ssa-commissioning-guidance-process-
manual/at_download/file
7.7 Conflicts of Interest Statement
Individuals involved in the development and formal peer review of commissioning guides are asked to complete a conflict of interest declaration. It is noted that declaring a conflict of interest does not imply that the individual has been influenced by his or her secondary interest, but this is intended to make interests (financial or otherwise) more transparent and to allow others to have knowledge of the interest. Professor Joe Dias (Chair, Musculoskeletal Commissioning Guidance Development Project; Consultant Orthopaedic Surgeon) has seen and approved these. All records are kept on file, and are available on request.
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Appendix 2: Red and Yellow Flags
Red Flags
History and Examination in a patient with back pain which indicates possible serious spinal pathology
History:
- age 16< or >50 with NEW onset back pain - non-mechanical pain (worse at rest, interferes with sleep) - thoracic pain - previous history of malignancy (however long ago) - weight loss (unexplained) - previous long standing steroid use - recent serious illness - recent significant infection - fevers/rigors - urinary retention/incontinence - faecal incontinence - altered perianal sensation (wiping bottom) - limb weakness
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-Psycho-Social 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:
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- 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. Appendix 3: STarT Back Tool management based on stratification. 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 patient’s experiences. b. Conduct a comprehensive biopsychosocial assessment (physical examination, exploration of the impact that pain is having on the patient’s physical and psychosocial functioning, identification of the patient’s beliefs and expectations regarding LBP and its
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management and structured identification of potential obstacles to recovery). c. Address gaps in patients’ knowledge, correct possible misunderstandings and provide a credible explanation for their pain (e.g. cause, mechanisms, prognosis, role of investigations and treatments). d. Create opportunities for patients to respond differently to difficult internal experiences (thoughts, feelings and bodily sensations) and to maintain or alter activity in keeping with their goals. e. Provide guidance on a variety of pain rehabilitation techniques including pacing and graded activity. f. Provide support in returning to usual activities, sleep and work. g. Specifically focus on the psychological prognostic indicators (catastrophysing, low mood, anxiety and pain related fear) with the adoption of simple cognitive behavioural techniques. h. Encourage patients to put skills into practice between sessions, review and reinforce progress and problem solve difficulties. Emphasise the role of active self-management of on-going or future episodes. Appendix 4: Quality Observatory dashboard for commissioners
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
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Example CCG
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Appendix 5: Excluded diagnostic codes
Radicular pain G551 Nerve root and plexus compressions in intervertebral disc disorder G552 Nerve root and plexus compressions in spondylosis M472 Other spondylosis with radiculopathy M480 Spinal Stenosis M501 Cervical disc disorder with radiculopathy M502 Other cervical disc displacement M510 Lumbar and other intravertebral disc disorders with mylopathy M511 Lumbar and other intervertbral disc disorders with radiculopathy M512 Other specified intervertebral disc displacement M541 Radiculopathy M543 Sciatica M544 Lumbago with sciatica
Cauda Equina Syndrome G834
Primary malignant tumours of osseoligamentous origin
C412 Malignant neoplasm of vertebral column D166 Benign neoplasm of vertebral column D480 Neoplasm uncert or unknown behaviour of bone & artic cart
Primary malignant tumours of neurological origin
C701 Malignant neoplasm of spinal meninges C720 Malignant neoplasm of spinal cord C721 Malignant neoplasm of cauda equina D320 Benign neoplasm of cerebral meninges D321 Benign neoplasm of spinal meninges D329 Benign neoplasm of meninges, unspecified D334 Benign neoplasm of spinal cord D361 Benign neoplasm of periph nerves & autonomic nervous system D421 Neoplasm uncert/unkn behav spinal meninges D434 Neoplasm uncert/unkn behav spinal cord D437 Neoplasm uncert/unkn behav oth part of central nervous sys D439 Neoplasm uncert/unkn behav central nervous system, unsp
Secondary malignant tumours M495 Metastatic fracture of vertebra C77x,C78x, C79x, C80x Secondary malignant neoplasm
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Spinal infection M462 Osteomyelitis of vertebra M463 Infection of intervertebral disc (pyogenic) M464 Discitis, unspecified M465 Other infective spondylopathies M490 Tuberculosis of spine M491 Brucella spondylitis M492 Enterobacterial spondylitis, and M493 Spondylopathy in other infectious and parasitic diseases NEC
Spinal cord injury S140 Concussion and oedema of cervical spinal cord S141 Other and unspecified injuries of cervical spinal cord S240 Concussion and oedema of thoracic spinal cord S241 Other and unspecified injuries of thoracic spinal cord S340 Concussion and oedema of lumbar spinal cord S341 Other injury of lumbar spinal cord S343 Injury of cauda equina, T093 Injury of spinal cord, level unspecified
Vertebral column injury with no evidence of osteoporosis
S120 Fracture of first cervical vertebra S121 Fracture of second cervical vertebra S122 Fracture of other specified cervical vertebra S127 Multiple fractures of cervical spine S128 Fracture of other parts of neck S129 Fracture of neck, part unspecified S130 Traumatic rupture of cervical intervertebral disc S131 Dislocation of cervical vertebra S132 Dislocation of other and unspecified parts of neck S133 Multiple dislocations of neck S220 Fracture of thoracic vertebra S221 Multiple fractures of thoracic spine S230 Traumatic rupture of thoracic intervertebral disc S231 Dislocation of thoracic vertebra S232 Dislocation of other and unspecified parts of thorax S320 Fracture of lumbar vertebra S321 Fracture of sacrum S322 Fracture of coccyx S330 Traumatic rupture of lumbar intervertebral disc S331 Dislocation of lumbar vertebra S332 Dislocation of sacroiliac and sacrococcygeal joint S344 Injury of lumbosacral plexus T021 Fractures involving thorax with low back and pelvis AND absence of codes indicating osteoporosis
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(as set out below).
Vertebral column injury with evidence of osteoporosis
Codes for Vertebral column injury (as set out above) together with diagnosis codes M80.0-M80.9 M810-M819 M484 Fatigue fracture of vertebra M485 Collapsed vertebra not elsewhere classified
Appendix 6: Spinal Complications
DURAL TEAR
ICD-10 C960, T812
ICD-9
NERVE INJURY
ICD-10 S342, S344, T094
ICD-9
CAUDA EQUINA SYNDROME
ICD-10 G834, S341, S343
ICD-9
SPINAL CORD INJURY
ICD-10 T845, T093, S241
ICD-9
VASCULAR INJURY
ICD-10 T817
ICD-9
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INFECTION CAUSED BY THE PROSTHESIS
ICD-10 T845
ICD-9 9966
INFECTION RECORDED ELSEWHERE IN THE BODY
ICD-10 T814 G061
ICD-9 9985
DVT
ICD-10 I801, I802
ICD-9 4511
PE
ICD-10 I260, I269
ICD-9 4150, 4151
AMI
OPCS K40-, K41-, K42-, K43-, K44-, K45-, K46-, K49-, K50-, K63-
ICD-10 I200, I21-, I22-, I248, I460
GI BLEED
ICD-10 K920, K921, K922
STROKE
ICD-10 I60-, I61-, I62-, I63-, I64-, I65-, I66-, I670, I671, I672, I677, I678, I679, G451, G452,
G453, G454, G458, G459
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RENAL FAILURE
ICD-10 N17-, N19-
Appendix 7: British Spine Registry (www.bsrcentre.org.uk)
The British Spine Registry (BSR) was developed by the British Association of Spine Surgeons and
Amplitude and launched in May 2012 after 2 years of development involving input from patient
groups and surgeons. It is a secure, web-based registry with patients consenting to have their
data stored. The BSR is available and free-of-charge to all Spinal Consultants who are members
of the British Association of Spine Surgeons or the British Scoliosis Society. The BSR stores
patient demographics and Consultants can input details of diagnosis, surgical procedures,
complications and Patient Reported Outcome Measures (PROMs). The system can email the
patients to complete their PROMs at defined times after surgery. PROMs can also be collected
in clinics using kiosks or touchscreen tablets. This is an ideal system to allow spinal surgeons to
collect outcome data on the procedures they perform. It could also be easily modified for data
collection in MSK screening services and providers of CPPP.
Spine Tango is a similar system owned by the Spine Society of Europe with paper based data
collection. It is currently used by four large spinal centres in the UK.
ICHOM (http://ichom.org/) is an international organisation aimed at optimising and
harmonising outcome measures: “Our aim is to transform health care by making transparent
the results that really matter to patients. We're working with patients, leading providers, and
registries to create a global standard for measuring results by medical condition, from prostate
cancer to coronary artery disease.”
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