Referral criteria from primary care - acute low back pain

The majority of patients with acute low back pain can be managed in primary care. NICE have provided guidance as to when acute lower back pain should be referred for specialist review if (1):

**** they have neurological features of cauda equina syndrome (sphincter disturbance, progressive motor weakness, saddle anaesthesia, or evidence of bilateral nerve root involvement)

**** serious spinal pathology is suspected

*** they develop progressive neurological deficit (weakness, anaesthesia)

*** they have nerve root pain that is not resolving after 6 weeks

** an underlying inflammatory disorder such as ankylosing spondylitis is suspected

• axial presentations of spondyloarthritis are often misdiagnosed as mechanical low back pain, leading to delays in access to effective treatments. Peripheral presentations are often seen as unrelated joint or tendon problems, and can be misdiagnosed because problems can move around between joints (4)
• Referral for suspected axial spondyloarthritis (4)
  • if a person has low back pain that started before the age of 45 years and has lasted for longer than 3 months, refer the person to a rheumatologist for a spondyloarthritis assessment if 4 or more of the following additional criteria are also present:
    • low back pain that started before the age of 35 years (this further increases the likelihood that back pain is due to spondyloarthritis compared with low back pain that started between 35 and 44 years)
    • waking during the second half of the night because of symptoms
    • buttock pain
    • improvement with movement
    • improvement within 48 hours of taking non-steroidal anti-inflammatory drugs (NSAIDs)
    • a first-degree relative with spondyloarthritis
    • current or past arthritis
    • current or past enthesitis
    • current or past psoriasis
  • If exactly 3 of the additional criteria are present, perform an HLA-B27 test. If the test is positive, refer the person to a rheumatologist for a spondyloarthritis assessment
    • if the person does not meet the criteria in recommendation above but clinical suspicion of axial spondyloarthritis remains, advise the person to seek repeat assessment if new signs, symptoms or risk factors listed in recommendation above develop
    • may be especially appropriate if the person has current or past inflammatory bowel disease (Crohn's disease or ulcerative colitis), psoriasis or uveitis

** they have simple back pain and have not resumed their normal activities in 3 months. The effects of pain will vary and could include reduced quality of life, functional capacity, independence or psychological well-being. Where possible, referral should be to a multidisciplinary back pain team

+ they develop a serious unwanted effect from drug therapy

Key to referral times:

**** immediate referral (a)

*** urgent referral (b)

** soon (b)

* routine (b)

+ times will be discretionary and depend on clinical circumstances

(a) within a day

(b) Health authorities, trusts and primary care groups should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary groups considered that a maximum waiting time of 2 weeks is appropriate for the urgent category

A review also has considered advice concerning secondary referral of simple low back pain (2):

• manipulative treatment by a properly trained practitioner is worth trying within the first 6 weeks in patients who need additional support with pain relief (2)
• if there is still pain and disability after 6 weeks then back exercises may help (2)
• if patient with simple low back pain has not returned to work with 3 months then a second opinion should be sought from a specialist, with the objectives of checking the diagnosis and seeking advice and assistance on management (2)

See "back pain red flags" below for more information regarding possible conditions that require immediate specialist review.

Reference:

1. NICE (May 2000). Referral Practice A guide to appropriate referral from general to specialist services.
2. Drug and Therapeutics Bulletin 1998; 36: 12, 93-4.
3. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Clinical Guidelines for the Management of Acute Low Back Pain. London: Royal College of General Practitioners, 1996.
4. NICE (2017). Spondyloarthritis in over 16s: diagnosis and management