Referral Criteria: Inflammation of the Spine Feb

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1 Referral Criteria: Inflammatin f the Spine Feb Inflammatin f the Spine Backgrund Ankylsing spndylitis and axial spndylarthrpathy are fund in arund % f the ppulatin. Spndylarthritis encmpasses a grup f inflammatry cnditins with sme shared features, including extra-articular manifestatins. Bth peripheral and axial jints can be affected. The spndylarthritides are distinct frm rheumatid arthritis but are as imprtant t recgnise and manage early in their presentatin t imprve health utcmes. Mst peple with these cnditins have either psriatic arthritis r axial spndylarthritis, which includes ankylsing spndylitis. Ankylsing spndylitis and nn-radigraphic axial spndylarthritis primarily affect the spine, in particular the sacriliac jint. Bth cnditins present in similar ways; the primary classificatin difference is whether sacriliitis is detectable n X-ray. Cntrary t cmmn miscnceptins, axial spndylarthritis affects similar numbers f wmen and men, is nt always apparent n plain X-ray, and ccurs in peple wh are sernegative fr human leuccyte antigen B27 (HLA-B27). N single test has been shwn t have sufficient sensitivity r specificity t diagnse r rule ut spndylarthritis. HLA-B27 is fund in 75% f peple with axial spndylarthritis and up t 20% f asymptmatic peple, and varies with ethnicity. Imaging is nly recmmended in specialist (cmmunity r hspital) settings. D nt delay referral n the grunds f nrmal bld tests. Diagnsis: histry and examinatin The diagnsis is frequently made late. Suspect in a persn wh has had lw back pain that started befre the age f 45 years and has lasted fr lnger than 3 mnths, with: 4 r mre f the additinal criteria belw r Exactly 3 f the additinal criteria belw and a psitive HLA-B27 test (perfrmed frm primary r cmmunity care). Cnsider additinal risk factrs such as pain in the finger r te jints, enthesitis (inflammatin where tendns r ligaments insert int the bne), dactylitis (inflammatin f the whle finger r te sausage digits ), uveitis, psriasis including nail disease, recent geniturinary infectin, r a family histry f spndylarthritis r psriasis. If tw r fewer criteria are present, then the GP shuld reassess if new symptms, signs r risk factrs emerge. Additinal criteria are: Lw back pain that started befre the age f 35 years (this further increases the likelihd that back pain is due t spndylarthritis cmpared with lw back pain that started between 35 and 44 years) Waking during the secnd half f the night because f symptms Buttck pain Imprvement with mvement Imprvement within 48 hurs f taking nn-steridal anti-inflammatry drugs (NSAIDs) A first-degree relative with spndylarthritis Current r past arthritis Current r past enthesitis Current r past psriasis. Cmplete an examinatin, particularly lking fr lss f spinal mvements in at least tw planes and a psitive Schber s test (a test fr restricted lumbar flexin) that might supprt a diagnsis f axial spndylarthritis.

2 Referral Criteria: Inflammatin f the Spine Feb Identifying and referring Spndylarthritis

3 Referral Criteria: Inflammatin f the Spine Feb Referral t the General Practitiner (Referral frm triage, cmmunity, r hspital services specifically fr primary care medical review) Assessment and management f multi-mrbidity and psychiatric c-mrbidity. Medicatin reviews and nn-urgent prescriptins. Nte, fr disease-mdifying drugs and immunsuppressants initiated in secndary care, there must be an shared care prtcl that has been agreed and accepted by bth the primary and secndary care clinician respnsible fr an individual patient. Advice regarding achieving and maintaining ptimal weight, nutritin, physical activity and healthy lifestyle, including smking cessatin advice. Discussin abut fitness fr wrk and sickness certificatin. Management fllwing discharge frm cmmunity r secndary care where n further interventin planned. Patients referred back frm cmmunity services with knwn r suspected serius underlying pathlgy where nn-urgent (fr re-evaluatin and pssible referral t secndary care). Patients seen in cmmunity r secndary care settings wh need emergency r urgent assessment e.g. suspicin f inflammatry jint disease, peripheral vascular disease r fracture. Cases where there is significant threat t life, limb, r vital rgan. (Emergency referral t A&E r ambulatry care). Neurlgical invlvement, where investigatins, injectins r surgery are planned.

4 Referral Criteria: Inflammatin f the Spine Feb Referral t Cmmunity Physitherapy r First Cntact Physitherapy in Primary Care Assessment and treatment f functinal impairment. Assessment fr exercises fr peple with axial spndylarthritis: Stretching, strengthening and pstural exercises. deep breathing exercises. Spinal extensin exercises Range f mtin exercises fr the lumbar, thracic and cervical sectins f the spine Aerbic exercise. If hydrtherapy available: Cnsider hydrtherapy as an adjunctive therapy t manage pain and maintain r imprve functin fr peple with axial spndylarthritis. Cases where there is significant threat t life, limb, r vital rgan. (Emergency referral t A&E r ambulatry care). Severe acute pain r inflammatin. Patient needs medical pinin. Diagnstic uncertainty abut spndylarthritis

5 Referral Criteria: Inflammatin f the Spine Feb Referral t Musculskeletal r Rheumatlgy Interface (May nt be available in every CCG) If rheumatlgical physitherapy, hand therapy, ccupatinal therapy, pdiatry and psychlgy available fr peple with spndylarthritis: Assessment and treatment f functinal impairment. Assessment f gait and stability, prvisin f rthtics. Assessment f activities f daily living Advice t assist activities f daily living and prmte independence. Psychlgical interventins (fr example, relaxatin, stress management) and cgnitive cping skills. If rheumatlgy nurse r therapist with rheumatlgy training available: Symptm and medicatin mnitring under shared care arrangement with primary and secndary care. If rheumatlgist r GP with a special interest available: Diagnstic assessment and management advice. Patients particularly suited t cmmunity assessment are thse with vague and undifferentiated symptms where clinically there is a lwer index f suspicin f inflammatry disease. (Patients clinically with a high index f suspicin shuld be referred t secndary care, unless a cmmunity service is specifically cmmissined fr this grup f patients.). Suspected infective r neplastic pathlgy. Cases where there is significant threat t life, limb, r vital rgan. (Emergency referral t A&E r ambulatry care). Severe acute pain r inflammatin, unless service cmmissined fr acute assessment. Patient needs medical pinin, unless a medical pinin cmmissined.

6 Referral Criteria: Inflammatin f the Spine Feb Referral t Secndary Care Rheumatlgy Investigatin and management f spinal inflammatin. Suspect spndylarthritis in a persn wh has had lw back pain that started befre the age f 45 years and has lasted fr lnger than 3 mnths, with: Fur r mre f the additinal criteria belw r Exactly three f the additinal criteria belw and a psitive HLA-B27 test (perfrmed frm primary r cmmunity care). Cnsider additinal risk factrs: small jint pains, enthesitis, dactylitis, uveitis, psriasis including nail disease, recent geniturinary infectin, r a family histry f spndylarthritis r psriasis. If tw r fewer criteria are present, then the GP shuld reassess if new symptms, signs r risk factrs emerge. Additinal criteria are: Lw back pain that started befre the age f 35 years (this further increases the likelihd that back pain is due t spndylarthritis cmpared with lw back pain that started between 35 and 44 years) Waking during the secnd half f the night because f symptms Buttck pain Imprvement with mvement Imprvement within 48 hurs f taking nn-steridal anti-inflammatry drugs (NSAIDs) A first-degree relative with spndylarthritis Current r past arthritis Current r past enthesitis Current r past psriasis. Diagnstic uncertainty, particularly in patients clinically with a high index f suspicin, unless a cmmunity service is specifically cmmissined fr this grup f patients. Flare-up f inflammatry arthritis. (See exclusins belw where very urgent treatment may be needed). Any imaging perfrmed in primary r cmmunity care shuld be available n IEP/receiving unit, and the reprts frwarded with the referral. Any bld tests and pathlgy perfrmed in primary r cmmunity care shuld be available n ICE/OpenNet and key results frwarded with the referral. Any previus relevant utpatient summary letters and imaging reprts shuld be frwarded with the referral. D nt delay referral n the grunds f nrmal bld tests. (Decisin aids fr discussing disease mdifying anti-rheumatic drugs and bilgics are nt required fr referral int secndary care. A variety f decisin aids may be used in secndary care): Suspected infective r neplastic pathlgy. Patient unable t manage at hme due t severe symptms. Discuss with rheumatlgy service in wrking hurs; ut f hurs cnsider intermediate care assessment r ther admissin avidance scheme, emergency admissin r ambulatry care if critically unwell. Neurlgical invlvement (Refer t musculskeletal interface clinic unless requires urgent surgical decmpressin. See lw back pain and sciatica pathway.)

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