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A TRIAGE approach to diagnosing low back pain (LBP) supports GPs in providing efficient consultations, while minimising the risks of long term disability and chronic pain for patients, say experts.
Dr Andrew Zacest, clinical associate professor at the University of Adelaide and consultant neurosurgeon at the Royal Adelaide Hospital, told MJA InSight that “as a neurosurgeon, I continue to be referred many patients every week with non-specific LBP and wonder why I am seeing them, and so do the patients”.
“When we ask them by questionnaire what is their expectation of their consultation with me – a neurosurgeon – they consistently write, ‘to better understand my diagnosis or seek relief of pain’.”
A Narrative Review written by Dr Lynn Bardin, a consultant spine physiotherapist with Austin Health in Melbourne, Dr Peter King, a Melbourne-based GP, and Professor Chris Maher, director of the George Institute for Global Health, and published in the MJA, aims to provide GPs with a triage approach to the diagnosis of LBP that will increase their efficiency and lead to better outcomes for their back pain patients.
The goal of the approach was to exclude non-spinal causes and to allocate patients to one of three categories: specific spinal pathology, radicular syndrome, or non-specific LBP, which represents 90–95% of cases and is diagnosed by exclusion of the first two categories.
Bardin and colleagues wrote that most patients presenting to primary care with LBP did not require imaging or laboratory tests, and that a focused clinical assessment was sufficient to direct management.
“Diagnostic triage of LBP empowers GPs in their role as gatekeepers of LBP in primary care. Practical application of this tool is essential to anchor LBP diagnosis in primary care and to deal with the complexity of a presenting symptom that is vexing, costly and too prevalent to be ignored,” the authors wrote.
Professor Jane Latimer, principal research fellow and Head of the Paediatric Program in the Musculoskeletal Division at the George Institute for Global Health, told MJA InSight that the approach was comprehensive, yet also simplified the management of LBP and ensured that serious conditions were not missed.
“It suggests when there is a need for further diagnostic work-up and when tertiary referral is needed. This can help GPs with limited expertise in the management of back pain.”
The triage approach provided a framework which GPs could use to confidently reassert to most patients that they did not need imaging or a prescription for medication, Professor Latimer said.
“The use of this approach should also result in better outcomes for patients.”
Associate Professor Zacest said that the triage approach “stratifies the risk of patients with non-specific LBP into low to high risk, and suggests interventions appropriate to these to minimise the risks of long term disability and chronic pain”.
“It allows rapid triage into the three diagnostic groups, thereby individualising their treatment, improving outcomes, providing good education and setting realistic treatment expectations, and saves them from unnecessary and potentially harmful and expensive interventions.
“It allows most patients to be well managed in a primary care setting by their family medical practitioner,” Professor Zacest said.
Professor Latimer said that the triage approach should lead to less prescribing of complex pain medications at the first consultation, “reducing the likelihood of opioid misuse in this population”.
“If this approach is followed in busy GP practices, it is less likely that rare specific pathologies will be missed, such as epidural abscess.”
Professor Latimer said that there were several challenges that GPs had managing LBP in their patients.
“The limited amount of training in managing musculoskeletal disease provided in many medical schools means that GPs may feel ill-equipped to deal with patients with LBP.”
Added to this was pressure from patients “wanting both imaging and medication – often strong opioid medication – for their simple back pain with no red flags, when it is clearly not indicated”.
Another challenge was having sufficient time to provide reassurance, advice and education around LBP during a short consultation.
Associate Professor Zacest said the challenge was “further compounded by unrealistic demands from patients for cure, obtaining a simplistic biomechanical diagnosis, passive therapy and the availability of expensive medical imaging, such as CT, MRI, and radiological procedures such as steroid injection for back and neck pain”.
“For the time-conscious GP and specialist, it is much easier to write a script, send the patient for a scan or refer the patient with back pain, [rather] than discuss a more comprehensive strategy of managing a short term problem or chronic condition.
“Most importantly, this article states the fact that, after serious but rare conditions are excluded, non-specific LBP is the most common diagnosis and its treatment is a biopsychosocial approach directed by the GP.”
A podcast with Dr Lynn Bardin is available here.
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TRIAG approach may be helpful. I feel Ibuprofen is also an effective medication for treating lower back pain. Your physician will prescribe you the appropriate Ibuprofen dosage.
Sorry comprehensive examination just the same as no examination, read the literature
Great point Dr Harding. There is also the problem that low back pain tends to be a grumbling recurrent problem – bit like asthma. People need a LBP management plan just like they do for asthma, diabetes, IHD etc. At present it is a black hole in medical training. As the article suggests, it is ripe for primary care practice to grab and make it another one of the common problems that can be well managed with multidisciplinary care in GP land. As the above orthopaedic surgeon suggests, needs to be demedicalised in most cases. Not allowed to enter the medical wheel of misfortune (endless scans, specialist appointments etc)
The current wisdom is that 80% of acute low back pain is non-specific “and its treatment is a biopsychosocial approach directed by the GP.” Further this article recommends that patients with acute low back pain which falls into this category should be treated ( as one option ) in the first six weeks with education and reassurance (good in my view), hot packs, and simple analgaesics (fair enough). BUT try doing that with a self-employed worker (who is likely to not be at risk with his Orebro) and see how you go. Waiting 6 weeks before trying some simple interventions is a nonsense. No space is wasted in this article on outlining the essentials of a good musculoskeletal exam which CAN give clues as to whether or not you are dealing with facet joint, non-surgical disc (internal disc disruption or small annular tear), sacroiliac joint locking etc etc. Yes, there is no one single test but a comprehensive physical exam can give you clues as to the yet undefined pathology and allow some trial of targeted treatment before the patient goes broke, or loses faith and goes off to seek non-evidence-based treatments elsewhere.
And my epidural abscess was missed initially because the consultant cancelled my MRI as it ‘was unnecessary’. Only had three or more red flags.
As an orthopaedic surgeon, the greatest problem I see results from unnecessary CT scans.
The patient then told that they have a “bulging disc”. This leads to an injury/illness belief that is almost impossible to correct. In effect they then have an iatrogenic disease.
GPs should be subject to audit of their imaging requests.