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Commissioning guide 2013

Low Back Pain


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
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

Introduction ............................................................................................................................................... 1

High Value Care Pathway for Low Back Pain ........................................................................................ 2

1.1 Primary Care2

1.2 Intermediate Care4
1.3 Secondary Care.4
2 Procedures explorer for Low Back Pain ................................................................................................ 6

Quality dashboard for low back pain ................................................................................................... 7

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 pain12
5.2 Clinician information for low back pain 12
6 Benefits and risks.............................................................................................................................. 13

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 pain15
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 Lincolns Inn Fields, London WC2A 3PE..

Commissioning guide 2013

Low Back Pain

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.

Commissioning guide 2013

Low Back Pain

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
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
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

Commissioning guide 2013

Low Back Pain

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
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)
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 4As: 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

Commissioning guide 2013

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.
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
inadequate improvement
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
patients should be assessed by a multi-disciplinary team (MDT) that is part of a spinal network including:

Those services that do not require the resources of a general hospital, but are beyond the scope of the traditional
primary care team (Ren JFM, Marcel GMOR, Stuart GP, et al. What is intermediate care? BMJ 2004;329(7462):360-61)

Commissioning guide 2013

Low Back Pain

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

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
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

Commissioning guide 2013

Low Back Pain

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

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:

Facet joint
injection/medial branch
denervation lumbar facet
Posterior lumbar spinal

OPCS4 codes

Appendix 5

V485, V486, V487, V488, V489

Appendix 5

V382-6, V388, V404

Appendix 5

Commissioning guide 2013

Low Back Pain

Lumbar disc replacement

Anterior lumbar spinal
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).

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)
Standardised activity rate
Average length of stay
Day case rate

Short stay rate

7/30 day readmission rate

Activity rate standardised for age
and sex
Total spell duration/total number of
patients discharged
Number of patients admitted and
discharged on the same day/total
number of patients discharged
Number of patients admitted and
discharged within 48 hours/total
number of patients discharged
Number of patients readmitted as
an emergency within 7/30 days of
discharge/total number of patients
discharged excludes cancer,
dementia, mental health

Data Source
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)
HES/Quality Dashboard
(Appendix 4)

Commissioning guide 2013

Low Back Pain

Re-operations within 30
days/1 year

In hospital mortality rate

Number of patients re-operated

during an emergency readmission
within 30 days/ 1 year/total number
of patients discharged
Number of patients who die while in
hospital /total number of patients

Areas for development of dashboard in future

Evidence Base

HES/Quality Dashboard
(Appendix 4)

Data Source*
GP Data

Time off work

*includes data from HES, National Clinical Audits, Registries

HES/Quality Dashboard
(Appendix 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.
Missed Red Flags in
primary care


Use of STarT Back

Establish back pain
service in primary or
secondary care
offering assessment,
low intensity CPPP
and access to imaging
including MRI and
reporting to the spinal

Use the two subscales of

the STarT Back Tool
A spinal assessment service
should be developed to
assess all spinal referrals
unless emergency or urgent
referral is required. Imaging
investigations should be
requested as required and a
regular MDT set up to
discuss cases for referral.

Where data should be obtained from:

Secondary care providers should report
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,
CCGs should report the percentage of
GPs using the STarT Back Tool
The service should report:
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
6. Number of patients referred to spinal

Commissioning guide 2013

Low Back Pain

This service should

be established for
back pain (cervical,
thoracic and lumbar)
and radicular pain
(cervical and lumbar)
Access to CPPP

This should have strong

links with the spinal surgery

7. Number of patients referred to pain

Each CCG should have

access to low and high
intensity CPPP. These may
have different providers

secondary care
spinal MDT meeting
Spinal Task Force

Include all personnel

involved in the provision of
spinal services in a Trust.
Spinal Taskforce: guide for
Commissioning Spinal
Spinal surgeons able to
perform the required
surgery should be part of the
regional spinal network as all
cases for surgery should be
discussed within the setting
of a spinal MDT

The CPP service should report:

1. STarT Back score on referral
2. ODI and EQ-5D before and after
3. Return to work
Number of MDT meetings held
Number of patients discussed

Access to spinal

All patients having surgical interventions

including injections should have
Patient Reported Outcome Measures
(PROMs) before surgery and at 1 and 2
years after surgery (6 months after
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

Commissioning guide 2013

Low Back Pain

Training and
governance of
providers and other

Access to pain

Community and AQP may

1. Low intensity CPPP
2. High intensity CPPP
3. Non-specialised spinal
4. Pain management
Patients with low back pain
may access pain services for:
1. high intensity CPPP,
optimisation of
pharmacotherapy or spinal
2. if unsuitable for spinal
surgery (a decision which
must be made by a spinal
surgeon) or the patient does
not want to consider surgery
3.after unsuccessful spinal

Staff training, revalidation, indemnity,

quality of service delivery and collection
and reporting of outcome measures must
be the same for all providers (see above)

All patients should have patient

reported outcome measures (PROMs)
on referral and on discharge.
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

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



Success of spinal
assessment service

This will inform outlier

identification and scrutiny

Data specification
(if required)
The service should report:
1. Number of patients seen
2. Number of patients
referred for low intensity
3. Number patients referred
for high intensity CPPP
4. Number of MRI scans
5. Number of patients
referred to spinal MDT
6. Number of patients
referred to spinal
7. Number of patients
referred to pain

Commissioning guide 2013

Low Back Pain

Success of low intensity


Measures to be reported by each


Success of high intensity


Measures to be reported by each


Success of spinal injections

for back pain

Lumbar facet joint injections

Medial branch block
Lumbar facet joint radiofrequency

Success of spinal surgery

Spinal surgery for back pain

The low intensity CPPP

service should report:
1. STarT Back score on
2. ODI and EQ-5D, VAS back
and VAS leg before and
after treatment
3. Return to work
The high intensity CPP service
should report:
1. ODI and EQ-5D, VAS back
and VAS leg before and
after treatment
2. Return to work
All patients having these
injections should have
patient reported outcome
measures (PROMs) before
and at 6 months after
These should include either:
o COMI (Core Outcome
Measures Index) and EQ5D or
o VAS back and leg,
Oswestry Disability Index
and EQ-5D
This data along with the
surgical procedure and any
complications (see Appendix
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

Commissioning guide 2013

Low Back Pain

(British Spine Registry or

Spine Tango see Appendix
All hospitals treating CES
should complete the audit
and submit data for central
reporting. The data can be
input directly into the British
Spine Registry (see Appendix

British Association of Spine

Surgeons audit of
suspected cauda equina
syndrome (CES)



Patient Information for low back pain

Back Pain
Nonspecific low back pain
in adults
Back Pain


NHS Choices


Research UK


Clinician information for low back pain

Sheffield Back Pain
The Back Book
Low back pain and
Back Care
Red Flags (Appendix 2)



Royal College of General

NHS Clinical Knowledge
Back Pain Association
British Pain Society 2012

ISBN 0-11-702949-1
British Pain Society Spinal Pain Working Group
consensus opinion (2012)

Commissioning guide 2013

Low Back Pain

Yellow Flags
(Appendix 2)

Royal College of

Nice Guidance CG88

Early Management of
Persistent NonSpecific low back pain
NICE quality standard
56 Metastatic spinal
cord compression
NICE interventional
procedure guidance
451 Peripheral nervefield stimulation for
chronic low back pain
STarT back pain
screening tool
Oswestry Disability
Index (ODI) v2.1a







Keele University

Hill et al 2011

MAPI Trust


Benefits and risks

Benefits and risks of commissioning the pathway are described below.

Patient outcome

Patient safety

Equity of access

Getting patients back to work
Improved outcome
Prevention of chronicity
Avoiding use of addictive and morphine
based analgesia11-13

Long term unemployment

Early treatment and advice

Illness behaviour with increased

demand on primary and
secondary care
Patient participation

Even geographical spread of services and

excellent quality of service throughout

Current service provision is

Risk of chronicity and drug

Commissioning guide 2013

Low Back Pain

Resource impact

Patient choice of
provider and
location of

Reduce long-term morbidity

Reduced attendance at emergency
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
Improves patient satisfaction and access to

Further information


Research recommendations



Cost of CPP programmes
Cost of supporting MDT

Risk of not providing this

increases DNA rates

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

Other recommendations
Improved patient information
Patient Decision Aid for Low Back Pain

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

Commissioning guide 2013

Low Back Pain

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
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;3789802:1560-71.
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;1124:777-8.


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.


Commissioning guide 2013

Low Back Pain

John Carvell

Job Title/Role
Emeritus Consultant Spinal
and Orthopaedic Surgeon

Ashley Cole

Consultant Orthopaedic and

Spinal Surgeon

Joe Dias

Chair, Musculoskeletal
Commissioning Guidance
Development Project;
Consultant Orthopaedic
Consultant Orthopaedic and
Spinal Surgeon

Nigel Henderson

Rick Nelson

Consultant Neurosurgeon

Richard Smith

Consultant Rheumatologist

Awadh Jha

Martin Hey

General Practitioner and

member of Medway
Commissioning Board
Chair of Trauma Programme
of Care Board, NHS England;
Consultant Neurosurgeon

Christopher Mercer
Debbie Cook


Judith Fitch


Paul May

Chair Spinal Taskforce DH and
Chair CRG Complex Spinal
Member Spinal Taskforce DH
and CRG Complex Spinal
Surgery Orthopaedic Expert
Working Group
British Orthopaedic
Association and
Musculoskeletal CCG
Development Chair
Member Spinal Taskforce DH
and CRG Complex Spinal
President of Society of British
Neurological Surgeons
British Society for
Royal College of General
The Walton Centre

Chair Physiotherapy Pain

Consultant Physiotherapist
Director National Ankylosing
Spondylitis Society
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.


Commissioning guide 2013

Low Back Pain

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:

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.


Commissioning guide 2013

Low Back Pain


Commissioning guide 2013

Low Back Pain
Appendix 2: Red and Yellow Flags
Red Flags

History and Examination in a patient with back pain which indicates possible serious
spinal pathology


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
urinary retention/incontinence
faecal incontinence
altered perianal sensation (wiping bottom)
limb weakness


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-PsychoSocial 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'


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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
Work - The worse the relationship, the more likely they are to develop chronic LBP.

Appendix 3: STarT Back Tool management based on stratification.

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.
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
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
Build rapport, validate and normalise the patients experiences.
Conduct a comprehensive biopsychosocial assessment (physical examination,
exploration of the impact that pain is having on the patients physical and psychosocial
functioning, identification of the patients beliefs and expectations regarding LBP and its

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management and structured identification of potential obstacles to recovery).
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).
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.
Provide guidance on a variety of pain rehabilitation techniques including pacing
and graded activity.
Provide support in returning to usual activities, sleep and work.
Specifically focus on the psychological prognostic indicators (catastrophysing, low
mood, anxiety and pain related fear) with the adoption of simple cognitive behavioural
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.


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Example CCG


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Appendix 5: Excluded diagnostic codes

Radicular pain

Cauda Equina Syndrome

Primary malignant tumours of
osseoligamentous origin

Primary malignant tumours of

neurological origin

Secondary malignant tumours

G551 Nerve root and plexus compressions in

intervertebral disc disorder
G552 Nerve root and plexus compressions in
spondylosis M472
Other spondylosis with
M480 Spinal Stenosis
M501 Cervical disc disorder with radiculopathy
M502 Other cervical disc displacement
M510 Lumbar and other intravertebral disc disorders
M511 Lumbar and other intervertbral disc disorders
M512 Other specified intervertebral disc displacement
M541 Radiculopathy
M543 Sciatica
M544 Lumbago with sciatica
C412 Malignant neoplasm of vertebral column
D166 Benign neoplasm of vertebral column
D480 Neoplasm uncert or unknown behaviour of bone
artic cart
C701 Malignant neoplasm of spinal meninges
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

Metastatic fracture of vertebra C77x,C78x, C79x,

Secondary malignant neoplasm


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Spinal infection


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
S120 Fracture of first cervical vertebra
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
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

Vertebral column injury with no

evidence of osteoporosis

Osteomyelitis of vertebra
Infection of intervertebral disc (pyogenic)
Discitis, unspecified
Other infective spondylopathies
Tuberculosis of spine
Brucella spondylitis
Enterobacterial spondylitis, and
Spondylopathy in other infectious and parasitic
diseases NEC


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(as set out below).
Vertebral column injury with evidence
of osteoporosis

Codes for Vertebral column injury (as set out above)

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


C960, T812


S342, S344, T094



G834, S341, S343



T845, T093, S241




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T814 G061


I801, I802


I260, I269
4150, 4151


K40-, K41-, K42-, K43-, K44-, K45-, K46-, K49-, K50-, K63I200, I21-, I22-, I248, I460


K920, K921, K922


I60-, I61-, I62-, I63-, I64-, I65-, I66-, I670, I671, I672, I677, I678, I679, G451, G452,
G453, G454, G458, G459


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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.