First line management – spinal pain Return to flow chart
- Check for the presence of red flags
- Provide advice including reassurance, to stay as active as possible, continue with normal daily activities, increase physical activity progressively over a few days to weeks, stay at work if possible or return to work as soon as possible.
- Ensure adequate analgesia has been prescribed especially in cases of sciatica/ stenosis with use of neuropathic medication
- Symptom control measures: local cold pack (particularly early days – care that skin protected with damp layers and short duration e.g. 5-20 mins with minimum 2 hr break) or heat e.g. 10-20 mins (ensure skin protection e.g. through towelling). Check skin regularly throughout application.
- Advise: Nerve root pain may take a few months to settle. Most back pain settles within 6/52
- Patient information / Cauda Equina Syndrome warning (with translation available in 27 languages) that helps inform in the event of deterioration can be accessed at: Cauda Equina
- Consider psychosocial factors e.g. attitudes and beliefs about back/neck pain, behaviour, compensation issues, diagnosis and treatment, emotions, family, relationships, work, sleep, mood, disability etc. · Direct patients to advice / education resources
- Direct patient to via NHS Inform Musculoskeletal Helpline for self-management advice and self-referral information https://www.nhsinform.scot/care-support-and-rights/nhs-services/helplines/musculoskeletal-msk-helpline.
- Consider directing patients to the App "NHS 24 MSK Help" https://www.nhsinform.scot/care-support-and-rights/tools-and-apps/nhs-24-msk-help-app.
- Failure to respond to 1st line management - consider referral to physiotherapy / Specialist Spinal Physiotherapy – SCI Gateway
- Employees within a small to medium sized enterprise who are struggling at work or are off work due to ill-health can access Workplace Health Services or NHS Borders staff can access Occupational Health Services by simply calling 01896 825983 (Mon - Fri 08.30 - 16.30 answer-machine available out of hours)
NICE Clinical Knowledge Summaries
NICE Guidance back pain – low (without radiculopathy) Available at: https://cks.nice.org.uk/back-pain-low-without-radiculopathy#!topicSummary
Sciatica ﴾lumbar radiculopathy﴿ Available at: https://cks.nice.org.uk/sciatica-lumbar-radiculopathy#!topicSummary
Neck pain – non-specific Available at: https://cks.nice.org.uk/neck-pain-non-specific#!topicSummary
Neck pain – cervical radiculopathy Available at: https://cks.nice.org.uk/neck-pain-cervical-radiculopathy#!topicSummary
RADIOLOGY GUIDELINES - local info reference table P.6 Spinal Pathway NHSB 2019.To access current full national iRefer Adult Musculoskeletal Guidelines: Guidelines | iRefer) Ensure IP address logging in from is recognised by NHS Borders or from an NHSB device.
- Patients with persistent low back pain in the absence of radiation, red flags or raised inflammatory markers do not require any X-Ray or MRI.
- X-Ray – There is no indication in chronic or persistent pain unless suspicion of vertebral collapse/fracture, spondylolisthesis or spinal infection (Note: plain films can be normal in early TB spine or infection).
- MRI – In the absence of red flags or severe deteriorating neurology, a referral for a radicular pain presentation should be typical and genuine nerve root presentation, 6-12 weeks conservative therapy (including Physiotherapy) with NO improvement, and where surgery is appropriate with patient willing to consider this option.
- Please consider timing of MRI requests – Neurosurgery team require MRI within 6 months when considering surgical intervention, therefore if requested in the absence of red flags and no physiotherapy received it may result in repeat MRI for the same condition.
If any doubt about choice of investigation please discuss with radiology department Radiologist.Advice@borders.scot.nhs.uk
Patient Information
NHS Inform – Back problems
Available at: https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/back-problems
Exercises for Back Pain
Available at: https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/exercises/exercises-for-back-pain
[Caution with exercise 5 and 6 for sciatica – advise to ease off or stop any exercise if initially makes leg pain worse in the short-term]
Available at: https://www.versusarthritis.org/about-arthritis/conditions/back-pain/
NHS Inform – Neck problems
Neck pain | The Chartered Society of Physiotherapy
Available at: https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/neck-problems
Exercises for Neck Problems
[Caution – advise to ease off or stop a particular exercise or direction of an exercise if initially makes any arm pain worse – e.g. left side neck bend making left arm pain worse, but right side bend helps ease pain, therefore it is fine to continue with right side movement, but ease off left side bend in the short-term]
Available at: https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/exercises/exercises-for-neck-problems
Available at: https://www.versusarthritis.org/about-arthritis/conditions/neck-pain/
NHS Inform Musculoskeletal Helpline for self management advice and self referral information: https://www.nhsinform.scot/care-support-and-rights/nhs-services/helplines/musculoskeletal-msk-helpline.
Borders Ref Help Toolkit
