Back pain referrals: getting the right care to the right patient

BACK pain specialists are asking GPs for more information on their referrals to help them prioritise patients once they reach the clinic.

A survey of nine neurosurgeons, orthopaedic spinal surgeons, rheumatologists and physiotherapists found that pain location, the presence of referred limb pain, limb weakness, assessment for “red flags” (indicating potentially sinister causes of low back pain), prior spinal surgery, and at least one form of spinal imaging were considered vital by the specialists.

“Symptom duration and altered limb sensation were also considered useful indicators,” according to the authors of a research letter published by the MJA.

The survey was part of a wider audit conducted by a team from the Royal Melbourne Hospital (RMH). They audited the clinical information in 300 randomly selected referrals for back pain to the RMH between 1 January 2014 and 31 December 2016.

“About one-quarter of referrals mentioned pain but provided no further clinical information,” the authors wrote. “Most referrals did not include information about red flags (83%) or examination findings (87%). In the 160 referrals for lumbar radiculopathy, findings of lower limb neurological examination and straight leg raise testing were respectively reported in 22% and 7.5% of referrals.”

Dr John Moi, a consultant rheumatologist and the director of the Back Pain Assessment Clinic at RMH, is a co-author of the research letter. Does he think the problem is a clerical one, or are patients not being properly assessed in the first instance?

“I think it’s entirely possible that both factors are in play,” Dr Moi told MJA Insight in an exclusive podcast.

“The nature of general practice these days is that it’s very busy. Where there is a lot of time pressure, and if the patient is in a lot of pain, the GP may find it [better] to refer the patient directly on to specialist care.

“We’re extrapolating from a paper referral, but what’s actually happening at the coalface in general practice [is that] time pressure is a big factor, and [it’s hard to know] how that is influencing both the physical examination and the communication of the results in the specialist referral.”

Dr Moi said that his clinic had run GP education courses teaching how to examine a back in 5 minutes.

“There’s a perception that when you have to examine someone’s spinal pain it’s going to take you a long time,” he said. “But there are shortcuts you can take so you elicit key clinical factors, such as [checking for] lower limb weakness, key things such as red flags. And it can be done efficiently, as long as you know what you’re looking out for.

“And as with all things, the more you practice, the more efficient you can be both in terms of history-taking and the physical examination of the patient.”

Online tools such as the adult pathway for low back pain, developed in New Zealand and adopted in Australia, can be helpful, Dr Moi said.

The RMH Back Pain Assessment Clinic is the only one of its kind in the country, according to Dr Moi, and he’s hopeful that other hospitals will adopt the model.

“We’re a bit of a sorting out service,” he said.

“When we set up the clinic, we were seeing an enormous backlog of patients who were waiting, on average, about 18 months to be seen. There was a high volume of referrals who were being sent to the wrong specialty.

“Surgeons want to see time-critical cases that need an operation. You can imagine that it would be very frustrating to wait sometimes up to 2 years to see a surgeon, only to be told you don’t need surgery.

“The back clinic is there to sort the people who really need a surgeon, and make sure they are seen by one very quickly. We assess the rest, and start them on a management plan, which may include a multidisciplinary approach.

“It’s much more efficient model which results in better care, and the patients are happy with our service.”

The clinic is based in the RMH’s community health service, moving back pain treatment out of the hospital and back into primary care.

“We hope to replicate that over time in other hospitals. Our colleagues in Queensland and New Zealand have expressed interest,” Dr Moi said.

“Back pain is a global problem – it’s the most common cause of disability worldwide, so we need to look at new models of care.

“We need to get the right patient to the right care at the right time.”

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