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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

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.

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Low Back Pain

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
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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

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Low Back Pain

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)

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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
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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 V544 Appendix 5
injection/medial branch
block
Radiofrequency V485, V486, V487, V488, V489 Appendix 5
denervation lumbar facet
joint
Posterior lumbar spinal V382-6, V388, V404 Appendix 5
fusion

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Lumbar disc replacement V363*


Anterior lumbar spinal V333-6*
fusion
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 HES/Quality Dashboard
and sex (Appendix 4)
Average length of stay Total spell duration/total number of HES/Quality Dashboard
patients discharged (Appendix 4)
Day case rate Number of patients admitted and HES/Quality Dashboard
discharged on the same day/total (Appendix 4)
number of patients discharged
Short stay rate Number of patients admitted and HES/Quality Dashboard
discharged within 48 hours/total (Appendix 4)
number of patients discharged
7/30 day readmission rate Number of patients readmitted as HES/Quality Dashboard
an emergency within 7/30 days of (Appendix 4)
discharge/total number of patients
discharged excludes cancer,
dementia, mental health

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Re-operations within 30 Number of patients re-operated HES/Quality Dashboard


days/1 year during an emergency readmission (Appendix 4)
within 30 days/ 1 year/total number
of patients discharged
In hospital mortality rate Number of patients who die while in HES/Quality Dashboard
hospital /total number of patients (Appendix 4)
discharged

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 Secondary care providers should report
primary care 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 Use the two subscales of CCGs should report the percentage of
Tool the STarT Back Tool GPs using the STarT Back Tool
Establish back pain A spinal assessment service The service should report:
service in primary or should be developed to 1. Number of patients seen
secondary care assess all spinal referrals 2. Number of patients referred for low
offering assessment, unless emergency or urgent intensity CPPP
low intensity CPPP 3. Number patients referred for high
referral is required. Imaging
and access to imaging intensity CPPP
including MRI and investigations should be
4. Number of MRI scans performed
reporting to the spinal requested as required and a 5. Number of patients referred to spinal
MDT regular MDT set up to MDT
discuss cases for referral. 6. Number of patients referred to spinal
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This service should This should have strong surgeon


be established for links with the spinal surgery 7. Number of patients referred to pain
back pain (cervical, network management
thoracic and lumbar)
and radicular pain
(cervical and lumbar)
Access to CPPP Each CCG should have The CPP service should report:
access to low and high 1. STarT Back score on referral
intensity CPPP. These may 2. ODI and EQ-5D before and after
have different providers treatment
3. Return to work
Established Include all personnel Number of MDT meetings held
secondary care involved in the provision of Number of patients discussed
spinal MDT meeting spinal services in a Trust.
Spinal Task Force Spinal Taskforce: guide for
standards commissioners
“Commissioning Spinal
Services”
http://www.nationalspinalt
askforce.co.uk/
Access to spinal Spinal surgeons able to All patients having surgical interventions
surgeons perform the required including injections should have
surgery should be part of the Patient Reported Outcome Measures
regional spinal network as all (PROMs) before surgery and at 1 and 2
cases for surgery should be
years after surgery (6 months after
discussed within the setting
of a spinal MDT 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

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Training and Community and AQP may Staff training, revalidation, indemnity,
governance of provide: quality of service delivery and collection
community 1. Low intensity CPPP and reporting of outcome measures must
providers and other 2. High intensity CPPP be the same for all providers (see above)
3. Non-specialised spinal
AQP
surgery
4. Pain management
services
Access to pain Patients with low back pain All patients should have patient
services may access pain services for: reported outcome measures (PROMs)
1. high intensity CPPP, on referral and on discharge.
optimisation of These should include either:
pharmacotherapy or spinal
o COMI (Core Outcome Measures
injections
Index) and EQ-5D or
2. if unsuitable for spinal
o VAS back and leg, Oswestry Disability
surgery (a decision which
Index and EQ-5D
must be made by a spinal
(This is now the international
surgeon) or the patient does
standard outcome measure set
not want to consider surgery
approved by ICHOM. COMI on its
3.after unsuccessful spinal
own does not meet all the
surgery
requirements)

4.2 Quality Specification/CQUIN (Commissioning for Quality and Innovation)

Measure Description Data specification


(if required)
Success of spinal This will inform outlier The service should report:
assessment service identification and scrutiny 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

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Success of low intensity Measures to be reported by each The low intensity CPPP
CPPP provider 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 Measures to be reported by each The high intensity CPP service
CPPP provider should report:
1. ODI and EQ-5D, VAS back
and VAS leg before and
after treatment
2. Return to work
Success of spinal injections Lumbar facet joint injections All patients having these
for back pain Medial branch block injections should have
Lumbar facet joint radiofrequency patient reported outcome
denervation 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
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(British Spine Registry or


Spine Tango – see Appendix
7)
British Association of Spine All hospitals treating CES
Surgeons audit of should complete the audit
suspected cauda equina and submit data for central
syndrome (CES) 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 EMIS www.patient.co.uk
in adults
Back Pain Arthritis www.arthritisresearchuk.org
Research UK

5.2 Clinician information for low back pain

Name Publisher Link


Sheffield Back Pain www.sheffieldbackpain.com
Service
The Back Book Royal College of General ISBN 0-11-702949-1
Practitioners
Low back pain and NHS Clinical Knowledge http://www.cks.nhs.uk/back_pain_low_and_sciatica
sciatica Summaries
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)
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www.britishpainsociety.org
Yellow Flags Royal College of www.sheffieldbackpain.com/professional-
(Appendix 2) Anaesthetists resources/learning/in-detail/yellow-flags-in-back-
pain
Nice Guidance CG88 NICE www.nice.org.uk/cg88
Early Management of
Persistent Non-
Specific low back pain
NICE quality standard NICE http://www.nice.org.uk/guidance/QS56
56 Metastatic spinal
cord compression
NICE interventional NICE http://publications.nice.org.uk/peripheral-nerve-
procedure guidance field-stimulation-for-chronic-low-back-pain-ipg451
451 Peripheral nerve-
field stimulation for
chronic low back pain
STarT back pain Keele University www.keele.ac.uk/sbst/
screening tool Hill et al 2011
Oswestry Disability MAPI Trust http://www.mapi-trust.org/
Index (ODI) v2.1a

6 Benefits and risks


Benefits and risks of commissioning the pathway are described below.

Consideration Benefit Risk


Patient outcome Getting patients back to work Long term unemployment
Improved outcome
Prevention of chronicity
Patient safety Avoiding use of addictive and morphine Illness behaviour with increased
based analgesia11-13 demand on primary and
secondary care
Patient Early treatment and advice Patient participation
experience
Equity of access Even geographical spread of services and Current service provision is
excellent quality of service throughout sporadic
England Risk of chronicity and drug

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Reduce long-term morbidity dependency


Resource impact Reduced attendance at emergency Cost of CPP programmes
department Cost of supporting MDT
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
Patient choice of Improves patient satisfaction and access to Risk of not providing this
provider and services increases DNA rates
location of
intermediate
care

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
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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.

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Name Job Title/Role Affiliation


John Carvell Chair Chair Spinal Taskforce DH and
Emeritus Consultant Spinal Chair CRG Complex Spinal
and Orthopaedic Surgeon Surgery
Ashley Cole Consultant Orthopaedic and Member Spinal Taskforce DH
Spinal Surgeon and CRG Complex Spinal
Surgery Orthopaedic Expert
Working Group
Joe Dias Chair, Musculoskeletal British Orthopaedic
Commissioning Guidance Association and
Development Project; Musculoskeletal CCG
Consultant Orthopaedic Development Chair
Surgeon
Nigel Henderson Consultant Orthopaedic and Member Spinal Taskforce DH
Spinal Surgeon 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 Royal College of General
member of Medway Practitioners
Commissioning Board
Paul May Chair of Trauma Programme The Walton Centre
of Care Board, NHS England;
Consultant Neurosurgeon
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 C412 Malignant neoplasm of vertebral column
osseoligamentous origin D166 Benign neoplasm of vertebral column
D480 Neoplasm uncert or unknown behaviour of bone
& artic cart
Primary malignant tumours of C701 Malignant neoplasm of spinal meninges
neurological origin 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 S120 Fracture of first cervical vertebra
evidence of osteoporosis 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 Codes for Vertebral column injury (as set out above)
of osteoporosis 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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