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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 ** 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)
Reference: - NICE (May 2000). Referral Practice A guide to appropriate
referral from general to specialist services.
- Drug and Therapeutics Bulletin
1998; 36: 12, 93-4.
- 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.
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