SPINE Volume 38, Number 7, pp E402–E408

©2013, Lippincott Williams & Wilkins

HEALTH SERVICES RESEARCH

Surgeon Attitudes Toward Nonphysician Screening

of Low Back or Low Back–Related Leg Pain
Patients Referred for Surgical Assessment
A Survey of Canadian Spine Surgeons

Jason W. Busse, DC, PhD,*† John J. Riva, DC,†‡ Jennifer V. Nash, DC,§ Sandy Hsu, BA,¶
Charles G. Fisher, MD, FRCSC,**¶¶ Eugene K. Wai, MD, FRCSC,†† David Brunarski, DC, MSc, FCCS (C),‡‡
Brian Drew, MD, FRCSC, Jeffery A. Quon, DC, PhD, FCCS (C),**§§¶¶ Stephen D. Walter, PhD,†
Paul B. Bishop, DC, MD, PhD,**¶¶ and Raja Rampersaud, MD, FRCSC

to screen patients with low back and leg pain referred for elective
Study Design. Questionnaire survey.
surgical assessment.
Objective. To explore spine surgeons’ attitudes toward the
Results. Eighty-five spine surgeons completed our survey, for a
involvement of nonphysician clinicians (NPCs) to screen patients
response rate of 84.1%. Most respondents (77.6%) were interested
with low back or low back–related leg pain referred for surgical
in working with an NPC to screen patients with low back–related
assessment.
complaints referred for elective surgical assessment. Perception of
Summary of Background Data. Although the utilization of
suboptimal wait time for consultation and poor screening efficiency
physician assistants is common in several healthcare systems, the
for surgical candidates were associated with greater surgeon
attitude of spine surgeons toward the independent assessment of
interest in an NPC model of care. We achieved majority consensus
patients by NPCs remains uncertain.
regarding the core components for a low back–related complaints
Methods. We administered a 28-item survey to all 101 surgeon
history and examination, and findings that would support surgical
members of the Canadian Spine Society, which inquired about
assessment. A majority of respondents (75.3%) agreed that they
demographic variables, patient screening efficiency, typical wait
would be comfortable not assessing patients with low back–related
times for both assessment and surgery, important components of
complaints referred to their practice if indications for surgery were
low back–related complaints history and examination, indicators
ruled out by an NPC.
for assessment by a surgeon, and attitudes toward the use of NPCs
Conclusion. The majority of Canadian spine surgeons were
open to an NPC model of care to assess and triage nonurgent or
From the *Department of Anesthesia; †Department of Clinical Epidemiology emergent low back–related complaints. Clinical trials to establish
and Biostatistics; ‡Department of Family Medicine; §Faculty of Health the effectiveness and acceptance of an NPC model of care by all
Sciences; ¶Department of Oncology; and Department of Surgery, McMaster stakeholders are urgently needed.
University, Hamilton, Ontario, Canada; **Department of Orthopaedics,
University of British Columbia, Combined Neurosurgical and Orthopaedic Key words: orthopedics; neurosurgery, low back pain, attitude of
Spine Program, Vancouver Hospital and Health Sciences Centre, Vancouver, health personnel, survey. Spine 2013;38:E402–E408
British Columbia, Canada; ††Ottawa Hospital, Ottawa, Ontario, Canada; Level of Evidence: 1
‡‡Ontario Chiropractic Association, Toronto, Ontario, Canada; §§School
of Population and Public Health, Faculty of Medicine, University of

British Columbia, Vancouver, British Columbia, Canada; ¶¶International
Collaboration on Repair Discoveries (ICORD), University of British Columbia,
Vancouver, British Columbia, Canada; Department of Surgery, Divisions
of Orthopedic Surgery and Neurosurgery, University of Toronto, Toronto,
Ontario, Canada.
Acknowledgment date: November 28, 2012. Revision date: January 2, 2013.
Acceptance date: January 4, 2013.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work.
Relevant financial activities outside the submitted work: consultancy, grants,
royalties, board membership, expert testimony.
Address correspondence and reprint requests to Jason W. Busse, DC, PhD,
Department of Anesthesia, McMaster University, HSC-2U1, 1200 Main
St. West, Hamilton, Ontario, Canada, L8S 4K1; E-mail: bussejw@mcmaster.ca
DOI: 10.1097/BRS.0b013e318286c96b
E402 www.spinejournal.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
I
t is estimated that 50% to 80% of the adult population
will experience low back pain (LBP) in their lifetime,1 and
patients whose symptoms fail to resolve in a timely man-
ner or who present with neurological involvement are often
referred for surgical assessment. Spinal surgeons typically
have substantial waiting lists,2,3 although a majority of the
patients referred for assessment will not require surgery. As a
result, patients who are good candidates for surgery have lon-
ger waits to see surgeons, and thus to have surgery scheduled,
and patients who are not good candidates for surgery have to
wait to receive this information, which delays the initiation
of optimal conservative care.3 In addition, there is evidence
that longer delays for decompressive surgery are associated
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 HEALTH SERVICES RESEARCH
with worse outcomes, including less pain relief4,5 and reduced
likelihood of return to work.6 This problem is further exacer-
bated in rural and remote communities that often have limited
surgical resources.
One possible solution would be to have nonphysician clini-
cians (NPCs) with training in spinal complaints (henceforth
referred to as low back pain [LBP] clinicians) screen waiting
list patients, to identify those who are not surgical candidates
so that surgeons could restrict their assessments to patients
more likely to benefit from surgical procedures. Some pre-
liminary work has been done to explore the possible role of
physiotherapists,7 chiropractors,8 and nurse practitioners9
as screeners of spinal surgeon waiting list patients; however,
important questions remain to be answered before definitive
testing of this model can be undertaken. Specifically, there is
limited information regarding spine surgeons’ perceptions of
outpatient wait times and the efficiency of their current screen-
ing for surgical candidates, whether they would be agreeable
to having their patients screened by a LBP clinician, and if
there are core components of a patient history and examina-
tion that most surgeons would support. Finally, widespread
variation between surgeons in rates of low back surgery have
been well-established,10 and it remains uncertain if there are
core features indicative of the need for surgical assessment on
which surgeons could agree. The aim of the current study was
to survey Canadian spine surgeons to inform these issues, spe-
cifically with respect to patients with a primary complaint of
low back or low back–related leg pain.
MATERIALS AND METHODS
Questionnaire Development
With the assistance of epidemiologists and content experts, and
reference to the previous literature,7–9 we developed a 28-item,
English language questionnaire to examine current practices
for spine surgeons’ assessment and management of patients
with low back or low back–related leg pain, and their atti-
tudes toward the involvement of LBP clinicians to screen such
patients referred for surgical assessment. The final question-
naire framed response options for attitudinal questions with
a 5-point Likert scale (strongly agree, agree, undecided, dis-
agree, strongly disagree) because a previous report has shown
that close-ended questions result in fewer incomplete question-
naires than open-ended formats (see the Supplemental Digital
Content, available at: http://links.lww.com/BRS/A730).11
We pretested the final questionnaire on a group of 3 spine
surgeons to evaluate if the questionnaire as a whole seemed
to measure current management adequately of patients with
low back or low back–related leg pain referred for surgi-
cal assessment (face validity), and if the individual questions
adequately reflected the domains of current timeliness of
patient care, optimal history of patients with low back or
low back–related leg pain and examination, core indicators
for surgical assessment, and involvement of LBP clinicians
for screening waitlist patients (content validity).12 The pre-
test participants also commented on the clarity and compre-
Spine
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS205459.indd E403
Screening of Low Back Pain Patients • Busse et al
hensiveness of the questionnaire, and the time required to
complete it.
Questionnaire Administration
We used SurveyMonkey (http://www.surveymonkey.com/)
to facilitate online completion of our questionnaire. We
approached the Canadian Spine Society (CSS), an organiza-
tion comprised primarily of spine surgeons (http://www.spin-
ecanada.ca/), and obtained permission to survey their mem-
bers. From January to February 2012, a representative from
the CSS (Jennifer Edwards) sent a link to our online survey
to all 105 of their members. Participants who logged on to
the link were provided with a disclosure letter detailing the
intent of the survey and explicit instructions that, should they
choose not to complete the survey, they could convey their
decision to us by e-mail or fax. At 3 and 6 weeks after the
initial e-mailing, the CSS representative sent another e-mail
requesting completion of the questionnaire to all nonre-
sponders who had not indicated that they did not wish to
participate. The Canadian Memorial Chiropractic College
Research Ethics Board approved our study.
Analysis
We generated frequencies for all collected data. We hypothe-
sized, a priori, the following associations of respondents’ will-
ingness to work with LBP clinicians to screen patients with
low back or low back–related leg pain referred to their prac-
tices: (1) older surgeons would be more reluctant; (2) more
favorable attitudes would be held by surgeons who attended
a larger proportion of patients with low back or low back–
related leg pain; (3) surgeons who endorsed that their wait
times of outpatients with low back or low back–related leg
pain patient’s outpatient wait times were not optimal; and
(4) surgeons who thought their screening efficiency was not
optimal. We entered these variables into a generalized linear
model. The dependent variable was interest in working with
a LBP clinician (specifically a chiropractor or physical thera-
pist) to screen patients with low back or low back–related leg
pain referred for surgical assessment. We calculated that we
would require at least 40 completed surveys to ensure that
our regression model was reliable (10 respondents for each
independent variable considered).13
All comparisons were 2 tailed and a variable was consid-
ered statistically significant if it had a P < 0.05 in the final
multivariable model. We report the unstandardized regression
coefficient and 95% confidence interval (CI) for each signifi-
cant variable in the analysis. The value of the unstandard-
ized regression coefficient represents the change in response
score on the dependent variable, which was measured as a
continuous variable on a 5-point Likert scale from “strongly
disagree” to “strongly agree.” We plotted residuals from the
regression analyses to ensure that their distributions were rea-
sonably normal. Multicollinearity was deemed concerning
if the variance inflation factor for any independent variable
was greater than 5.14 We performed all analyses using PASW
Statistics 18 statistical software (SPSS Inc., Quarry Bay, HK).
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 HEALTH SERVICES RESEARCH Screening of Low Back Pain Patients • Busse et al

RESULTS participate. Eighty-five surgeons provided a completed survey

for a response rate of 84.1% (85 of 101). Most respondents
Characteristics of Respondents were male (97.6%) and approximately half (48.2%) had been
Ninety-one of 105 CSS members replied to our request, with in practice for more than 20 years (Table 1).
4 advising that they were not spine surgeons (and hence
not eligible for our survey) and 2 surgeons declining to
TABLE 2. Practice Characteristics (n = 85)
Proportion of patients with a primary complaint of low back or
TABLE 1. Demographic Characteristics of low back–related leg pain, n (%)
Respondents (n = 85) <20% 4 (4.7)
Age, Mean (SD) 50.7 (10.1) 21%–40% 6 (7.1)
Sex, n (%) 41%–60% 22 (25.9)
Male 83 (97.6) 61%–80% 35 (41.2)
Female 2 (2.4) >80% 18 (21.2)
Type of surgeon, n (%) Proportion of practice spent on elective spine surgery
Orthopedic surgeon 59 (69.4) <25% 6 (7.1)
Neurosurgeon 26 (30.6) 25%–50% 20 (23.5)
Postgraduate training, n (%)* 51%–75% 29 (34.1)
Fellowship 42 (49.4) >75% 30 (35.3)
Master’s degree (MSc) 14 (16.5) Proportion of patients with LBP referred to your practice, but not
Doctoral degree (PhD) 5 (5.9) accepted

Years in practice, n (%) 0% 20 (23.5)

<5 yr 9 (10.6) 1%–5% 12 (14.1)

5–10 yr 21 (24.7) 6%–10% 7 (8.2)

11–20 yr 14 (16.5) 11%–15% 10 (11.8)

41 (48.2) 16%–20% 10 (11.8)

>20 yr
>20% 26 (30.6)
Practice environment, n (%)*
Academic 57 (67.1) Outpatient wait time

Hospital based 42 (49.4) 1 wk–1 mo 2 (2.4)

Private practice 17 (20.0) 1–3 mo 5 (5.9)

Community 16 (18.8) 3–6 mo 31 (36.5)

Multidisciplinary 9 (10.6) >6 mo 47 (55.3)

Patient population, n (%) Number of patients with LBP or low back–related leg pain
screened to identify a surgical candidate*
Adult 75 (18.8)
<5 15 (17.9)
Adult and pediatric 6 (7.1)
5–10 34 (40.5)
Pediatric 3 (3.5)
11–20 27 (32.1)
Clinical area, n (%)*
>20 8 (9.5)
Reconstructive 68 (80.0)
Surgical wait time
Trauma 57 (67.1)
1 wk–1 mo 2 (2.4)
Oncology 44 (51.8)
1–3 mo 21 (24.7)
Worker’s compensation 35 (41.2)
3–6 mo 25 (29.4)
Sports injuries 22 (25.9)
>6 mo 37 (43.5)
Other 14 (16.5)
*One respondent did not provide an answer for this question. LBP indicates
*Respondents could choose more than one option. low back pain.

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 HEALTH SERVICES RESEARCH Screening of Low Back Pain Patients • Busse et al

TABLE 3. Variables Associated With Spine Surgeons’ Interest Toward Working With LBP Clinicians to
Screen Their Patients With Low Back or Low Back–Related Leg Pain
Unstandardized Regres- Unstandardized
sion Coefficient From Regression Coefficient
Univariable Analysis From Multivariable
Variable (95% CI) P Analysis (95% CI) P
Age (for each 10-yr increment) 0.19 (−0.04 to 0.43) 0.10 0.16 (−0.06 to 0.37) 0.16
Proportion of patients with a primary complaint of low −0.12 (−0.35 to 0.11) 0.30 0.06 (−0.15 to 0.27) 0.58
back or low back–related leg pain
Perception that outpatient wait times are not optimal 0.49 (0.26–0.71) <0.01 0.46 (0.23–0.69) <0.01
Perception that screening efficiency of patients with 0.29 (0.10–0.48) <0.01 0.20 (0.01–0.39) 0.04
low back or low back–related leg pain is not optimal
95% CI indicates 95% confidence interval.

Practice Characteristics Desired Components of a Patient History Obtained by

The majority of respondents (69.4%) dedicated more than LBP Clinicians
half their practice to elective spine surgery, and reports of The majority of respondents endorsed all 13 patient history
inefficiency were common (Table 2). Approximately a third components that we proposed (Table 4); however, only 4
of spine surgeons turned away more than 20% of patients were endorsed by a large majority (≈90% or greater endorse-
with low back or low back–related leg pain who were ment): location of dominant pain, history of presenting com-
referred to their practice, wait times for patients to be seen plaint, and symptoms of “red” or “yellow flags.” We defined
that were accepted typically exceeded 6 months, and 89.4% “red flags” as symptoms associated with cauda equina syn-
(76 of 85) acknowledged that their outpatient waiting time drome, fracture, infection, or cancer. We defined “yellow
was not optimal. Only 29.5% of respondents (25 of 85)
reported that their screening efficiency for patients with low
back or low back–related leg pain was optimal, with 41.6% TABLE 4. Desired Features of the History of a
screening more than 10 patients to identify a single surgical Patient With Low Back or Low Back–
candidate. Once a patient’s complaint was identified as ame- Related Leg Pain History (N = 85)
nable to surgery, many respondents (43.5%) reported that
patients waited for more than 6 months for their procedure Level of
Endorsement,
and only 16.5% of surgeons (14 of 85) characterized their
Patient History Component n (%)
surgical wait times as optimal.
Location of dominant pain 80 (94.1)
Willingness to Have LBP Clinicians Screen Patients History of presenting complaint 78 (91.8)
Most spine surgeons (77.6%; 66 of 85) were either willing
Symptoms of “red flags”* 77 (90.6)
to work with LBP clinicians to screen their patients with
low back or low back–related leg pain (n = 54) or were Symptoms of “yellow flags”† 76 (89.4)
already doing so (n = 12). Only 7 respondents (8.2%) Prior treatment for presenting complaint 72 (84.7)
were opposed to considering this arrangement, with
Current physical function 65 (76.5)
14.1% undecided. In our adjusted model, only a surgeon’s
endorsement that outpatient wait time was not optimal Current psychosocial function 61 (71.8)
and acknowledgement that screening of patients with low Prior history of presenting complaint 59 (69.4)
back or low back–related leg pain was not efficient were
Fear avoidance beliefs and behaviors 57 (67.1)
associated with greater interest in working with LBP cli-
nicians to screen patients (Table 3). Standardized residual Occupational demands 55 (64.7)
plots showed no violation of model assumptions. The Patient demographics 52 (61.2)
variance inflation factor was less than 2 for each indepen-
dent variable, suggesting no issues with multicollinearity. Current use of intravenous drugs or steroids 45 (52.9)
Our model explained approximately 23% of the varia- Review of imaging findings 45 (52.9)
tion (adjusted R2 = 0.23) in respondents’ interest toward *Red flags were defined as symptoms associated with cauda equina syn-
working with LBP clinicians to screen patients with low drome, fracture, infection, or cancer.
back or low back–related leg pain referred for surgical †Yellow flags were defined as receipt of disability benefits, ongoing litigation,
assessment. current smoker, or high emotional stress.

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 HEALTH SERVICES RESEARCH Screening of Low Back Pain Patients • Busse et al

flags” as receipt of disability benefits, ongoing litigation, cur-

rent smoker, or high emotional stress.15 Only 11 respondents TABLE 6. History and Examination Findings
suggested additional history components, suggesting that our Requiring Surgical Assessment
list was comprehensive. Most surgeons (85.9%; 73 of 85) (N = 84)
agreed that if the items they endorsed in the patient history Level of
could be reliably captured in an assessment by a LBP clinician, History or Examination Finding Endorsement, n (%)
it would facilitate triaging of their patients with low back or
low back–related leg pain; 8 respondents were undecided and Signs or symptoms associated with a 80 (95.2)
“red flag” condition*
4 disagreed.
Leg dominant pain 77 (91.7)
Desired Components of a Patient Examination Low back or low back–related leg pain 74 (88.1)
Conducted by LBP Clinicians with correlating neurological findings
More than 60% of surgeons endorsed each of the 8 patient- Low back or low back–related leg pain 73 (86.9)
examination components that we proposed (Table 5), and with correlating findings on imaging
only 9 respondents suggested additional items, suggesting
The absence of “yellow flags”† 31 (36.9)
that our list was comprehensive. A clear majority (89.4%; 76
of 85) agreed that if the items they endorsed in the patient Severe low back pain that is unresponsive 26 (30.1)
examination could be reliably captured in an assessment by a to conservative care
LBP clinician, it would facilitate triaging of their patients with *Red flag conditions were defined as cauda equina syndrome, fracture,
low back or low back–related leg pain; 7 respondents were infection, or cancer.

undecided and 2 disagreed. We also specifically asked if sur- †Yellow flags were defined as receipt of disability benefits, ongoing litigation,
current smoker, or high emotional stress.
geons would be interested in having LBP clinicians administer
a health-related quality of life instrument, such as the Short-
Form 36, or a psychological screening questionnaire to cap-
ture depressive symptoms or pain behaviours, to patients and and only 5 respondents suggested criteria other than what we
the majority of respondents endorsed these options (71.8% provided for consideration.
and 65.9%, respectively). A clear majority of surgeons advised they would want to
confirm an indication for surgery themselves, whether the
History and Examination Findings Requiring Surgical indication was clearly identified or suspected by a LBP clini-
Assessment cian (88.2% and 89.4%, respectively). However, a majority
Our respondents largely endorsed 4 findings that would of respondents (75.3%, 64 of 85) also agreed that they would
necessitate surgical assessment: signs or symptoms associated be comfortable not assessing a patient with low back or low
with a “red flag” condition, leg dominant pain, and low back back–related leg pain referred to their practice if clear indica-
or low back–related leg pain that was consistent with either tions for surgery were ruled out by a LBP clinician; 17.6%
neurological findings or imaging results (Table 6). Each of were unsure and 7.1% would still want to assess the patient
these items were endorsed by more than 85% of surgeons, themselves. Spine surgeons were divided as to whether their
patients would expect to be seen by them after an assessment
by a LBP clinician, with 40.0% (30 of 85) endorsing they
would, 25.9% being undecided, and 34.1% disagreeing.
TABLE 5. Desired Features of the Examination of
a Patient With Low Back or Low Back– DISCUSSION
Related Leg Pain (N = 84) Summary of Findings
Level of Our survey found that Canadian spine surgeons widely
Patient History Component Endorsement, n (%) acknowledge inefficiencies in the triage timeliness of patients
Standard orthopedic tests for low back 74 (88.1) with low back or low back–related leg pain referred to their
or low back–related leg pain practices. Many surgical referrals are inappropriate, out-
patient waiting times typically exceed 6 months, and most
Straight leg raise, supine 67 (79.8)
surgeons have to screen 5 to 10 patients to identify one sur-
Lower limb vascular examination 66 (78.6) gical candidate. Most surgeons (77.6%) were interested in
Orthopedic hip examination 64 (76.2) working with LBP clinicians to screen their patients with low
back or low back–related leg pain, and we identified a core
Lumbar spine range of motion 59 (70.2)
set of patient history and examination items, and indicators
Straight leg raise, seated 56 (66.7) for surgical assessment, that were endorsed by the major-
Measurement for lower limb atrophy 53 (63.1) ity of spine surgeons we surveyed. Most surgeons (75.3%)
were willing to forgo assessment of a referred patient if surgi-
Waddell’s signs for nonorganic pain 53 (63.1) cal indications were ruled out by a LBP clinician; however,
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 HEALTH SERVICES RESEARCH
respondents were less united on whether patients would
accept this model.
Strengths and Limitations
The strengths of our study include a comprehensive sampling
of Canadian spine surgeons from both academic and com-
munity practices, survey design and conduct consistent with
best practices,16 and a high survey response rate for health-
care professionals (84% provided completed surveys) that is
considerably higher than the mean physician response rate of
54% reported in the systematic review of postal surveys by
Asch et al.17 Our study does have limitations. Our results may
have limited generalizability to non-Canadian spine surgeons
in part due to the different health care systems in which they
function. Generally, in countries with private health care wait
times are not as long, but surgeons would probably welcome
a valid, safe triage system, which directs evidence based care
and increases the surgical yield of patients they see in con-
sultation. Our model exploring factors associated with spine
surgeons’ willingness to work with LBP clinicians explained
only 23% of the variation among respondents, suggesting
that other variables we did not assess are important in influ-
encing this decision.
Relevant Literature
There is general consensus that wait times for patients with
low back or low back–related leg pain referred for surgical
assessment in Canada are excessive.18 In recognition of this
problem, the Ontario Ministry of Health and Long-Term Care
has implemented “Ontario’s Wait Time Strategy” to improve
access to all surgeries, implement new initiatives to improve tri-
aging processes, and create a system of accountability through
transparent reporting of wait time information.19 The contri-
bution of inappropriate referrals to this problem have recently
been quantified. Deis and Findlay reviewed 303 lumbar spine
referrals to 10 neurosurgeons in Alberta, Canada, and found
that only 26% were clearly appropriate (80 of 303).20 In
an effort to improve triaging of patients with LBP, the Sas-
katchewan Ministry of Health has recently launched the Sas-
katchewan Spine Pathway initiative which, in part, provides
education to clinicians involved in LBP care in an attempt to
improve the appropriateness of surgical referrals.21 The impact
of the pathway, however, has not yet been evaluated.
There has been very little formal research exploring the
role of LBP clinicians for screening patients referred for surgi-
cal consultation secondary to low back or low back–related
leg pain. One conference abstract has reported high inter-
observer reliability (κ > 0.9) between chiropractors and
spine surgeons for 8 of 10 neuromuscular assessment tests
and examination for “red flag” signs or symptoms. Agree-
ment was less for assessment of lower limb sensory deficits
(κ = 0.66) or interpreting femoral nerve stretch test find-
ings (κ = 0.47).8 Another conference abstract reported good
agreement (κ = 0.68) between an experienced physiotherapist
who had completed a 3 month clinical residency and a spine
surgeon for deciding who among 31 patients with LBP was a
surgical candidate.7 In the sole relevant peer-reviewed journal
Spine
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS205459.indd E407
Screening of Low Back Pain Patients • Busse et al
publication we are aware of, Sarro and et al9 found very high
patient satisfaction among 177 individuals with LBP, referred
for surgical assessment, who were screened by a nurse prac-
titioner. Only 26% of patients advised that they would have
preferred a longer waiting period for direct consultation with
a surgeon.
Recommendations and Conclusion
There is an urgent need to develop and rigorously evaluate
system-level changes to the current approach of managing
patients with low back or low back–related leg pain who are
referred for surgical assessment. One promising approach is
the use of LBP clinicians to screen waiting list patients, and
our findings suggest that the majority of Canadian spine sur-
geons would participate in this model of care. We have also
identified patient history and clinical examination compo-
nents that should form the basis for trials that evaluate the
effect of waiting list patient screening by LBP clinicians. A
more detailed evaluation of these core-screening procedures
will be a key component in designing an NPC screening pro-
gram. One of us (R.R.) is currently leading a pilot study spon-
sored by the Ontario Ministry of Health and Long Term Care
to explore the feasibility of engaging LBP clinicians to screen
and triage subacute patients with LBP attending their primary
care physician, and to screen spine surgeons’ waiting list of
patients with low back or low back–related leg pain (www.
isaec.org/). These findings will further inform the design of a
definitive trial.
An essential component of any efforts to explore NPC
screening of patients with low back or low back–related leg
pain referred for surgical assessment will be training in a stan-
dardized approach to taking a patient history and completing
an examination that incorporates items identified in our sur-
vey. Furthermore, most surgeons who responded to our survey
expressed concern or uncertainty as to whether patients would
accept assessment and triage by a LBP clinician without seeing
a surgeon. Although there is some evidence to suggest most
patients would find this model acceptable,9 future research
regarding screening by LBP clinicians should incorporate
patient’s values and preferences to further inform this area.
➢ Key Points
‰ Wait times for patients with low back and low back–
related leg pain referred for surgical assessment are
excessive, and many referred patients are not surgi-
cal candidates.
‰ Canadian spine surgeons agree on core criteria of a
patient history and examination for patients with low
back and low back–related leg pain, and indications
for surgical assessment.
‰ Most Canadian spine surgeons express a willingness
to work with NPCs (e.g., chiropractors and physical
therapists) to screen their low back and low back–
related leg pain waiting list patients to identify
individuals who are clearly not surgical candidates.
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 HEALTH SERVICES RESEARCH
Acknowledgments
The authors thank Dr. Hamilton Hall and the CSS Executive
for allowing our survey to be sent to the CSS membership, and
Ms. Jennifer Edwards, Assistant to the Director, CSS, for send-
ing the link for our survey to CSS members.
Supplemental digital content is available for this article.
Direct URL citations appearing in the printed text are pro-
vided in the HTML and PDF version of this article on the
journal’s web site (www.spinejournal.com).
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