Spinal pain poses a common challenge for medical practitioners, especially GPs in Australia, where it stands as the most prevalent musculoskeletal issue encountered by healthcare providers.
Approximately 16% of the population grapples with back problems, underscoring the need for effective and value-driven management strategies. Recent guidance from the Australian Commission on Safety and Quality in Health Care advocates for a comprehensive, multidisciplinary approach to patient care, steering away from low-value medical interventions.
It’s important to note that pediatric patients with spinal pain, often having underlying pathologies, require distinct consideration and prompt investigation.
While acute low back pain usually resolves without intervention, the presence of thoracic back pain is a red flag and should raise concerns about potential sinister causes. Considering specific anatomical causes:
Facet joint arthritis: Causes pain or stiffness, with cervical or lumbar facet pain radiating to the occiput or buttock, respectively.
Discogenic pain: Causing discomfort without muscle guarding, is often worse in the morning and may be referred to the groin from the lumbar spine.
Neuropathic pain: Nerve root compression produces typical dermatomal distributions of pain such as C6 radiculopathy to the dorsal thumb/index finger, L5 radiculopathy to the lateral calf/great toe and S1 radiculopathy to the posterior calf /heel.
Lumbar claudication: High-grade lumbar stenosis results in lumbar claudication, characterised by pain or heaviness, limiting walking or standing.
Recent clinical care standards advocate for a selective approach to imaging, emphasising that often, no pathology is found or age-related degenerative changes may induce unnecessary anxiety. In the absence of red flags, imaging is only requested after a trial of therapy.
GP referral for MRI of the cervical spine in the presence of suspected radiculopathy is MBS funded. MRI of the lumbar spine is the imaging modality of choice recommended in the clinical care standards but the lack of MBS rebate for GP requested scans is limiting.
Codeine produces hyperalgesia and allodynia and should not be prescribed to spinal pain patients. Other conventional opioids such as oxycodone have unfavourable properties. Beyond simple analgesia, atypical opioids, orphenadrine and nortriptyline are preferred.
Allied health
Physiotherapy is the typical first recommendation for managing spinal pain in the absence of red flags. In Western Australia, referral acceptance to a public hospital spinal surgery service will require prior review and treatment by a physiotherapist, aligning with practices in the Eastern States.
When psychological factors (yellow flags) are identified, active treatment is initiated to prevent chronic pain development. Referral to a clinical psychologist proves valuable for many patients, helping develop strategies to mitigate the functional impact of pain during treatment.
Multidisciplinary allied health programs (e.g. STEPS, 360 Health, and Black Swan), have been established to manage chronic spinal pain, showcasing success. Recently, in the private sector, we have coordinated a multidisciplinary allied health team aiming to model this success involving physiotherapy, clinical psychology, and a pain nurse practitioner allowing either direct GP referral or diversion of suitable patients who are otherwise waiting to see a specialist surgeon.
Non-surgical interventions
Advancements in interventional techniques have provided additional options for managing spinal pain. Under CT guidance by an interventional radiologist, most patients will tolerate (and will receive MBS funding) for one injection. For patients requiring multiple injections, typically these are better tolerated (and receive MBS funding) when performed by a pain specialist or spinal surgeon under sedation.
Epidural injections: Injection of corticosteroids into the epidural space is particularly useful for discogenic pain or symptomatic spinal stenosis.
Nerve root sleeve injections: Targeting a specific compressed nerve root provides both diagnostic and therapeutic benefits, particularly useful in an acute disc prolapse.
Facet joint injections: A source of back pain without radiculopathy, while many find these helpful, health economists do not rate these as high value care.
Rhizotomy: For patients with chronic pain originating from the facet joints. This procedure involves disrupting the nerve supply to the affected joints with a needle, providing long-lasting pain relief. This procedure is usually performed under sedation.
Long-term preventation
Beyond providing symptomatic relief, managing spinal pain necessitates implementing long-term preventative measures. Lifestyle modifications, including regular exercise, maintaining a healthy weight, activity pacing, and ergonomic practices, play a pivotal role. Patient education is crucial in preventing recurrent episodes of spinal pain.
The management of spinal pain has evolved from outdated practices like bed rest and opioids. A recommended multidisciplinary approach involves allied health input, judicious imaging, and simple interventional techniques.
Key messages
- Spinal pain is the most prevalent musculoskeletal issue encountered by GPs, necessitating a multidisciplinary approach inclusive of physiotherapy, psychological intervention, patient education and lifestyle modifications
- Specific causes of spinal pain often include facet joint arthritis, discogenic pain, neuropathic pain or radiculopathy, and lumbar claudication
- Judicious use of preferably MRI imaging (including the GP rebatable cervical MRI) and accessing non-surgical interventions are valuable, while avoiding prescribing codeine is important.
Author competing interests – nil