Spinal Problems & Back Pain

Transcription

1 Spinal Problems & Back Pain Lee Breakwell Consultant Orthopaedic Spinal Surgeon Sheffield Children s Hospital Northern General Hospital Sheffield Orthopaedics Ltd

2 Back pain & Pathways Common spinal problems Assessment strategies Evidence based approach to treatment Financial aspects Pathway design and delivery

3 Back Pain Common & disabling problem 2313 disability adj life years per 100,000 (2013) 911 rest of MSK 704 depression 337 diabetes 11% entire disability burden 12% increase 1990 to %

4 When to refer? 3 priority levels of referral Emergency = Phone call NOW to Orthopaedic SpR (at NGH) Urgent = Faxed referral to NGH Acute Spinal Clinic x2 each week Routine = SPA

5 Where is the pain Back (Neck) Buttock Leg (Arm): distribution % back v % leg eg 80% right leg: 20% back How long How severe is it and how disabling Weakness Bladder / Bowel function Medical co-morbidities All in the History

6 Leg Pain L4 L5 S1

7 History - extra Myelopathy Clumsy hands Unsteady legs (ataxia) Spinal Stenosis Buttock, thigh, calf pain / aching / heaviness / deadness / numbness on standing and walking Eases with sitting / bending forward few mins

8 Examination in a chair Watch them walk in Point to pain tenderness SLR may help in sciatica but doesn t exclude Power (myotomes): Unless patient complains of specific weakness. Ankle dorsiflexion (L4) EHL (L5) Tip toe stance (S1) Reflexes Pulses / Hips If suspect myelopathy: Tone Plantars Clonus Romberg s

9 L2 hip flexion Myotomes: Lower limb L3 knee extension L4 ankle dorsiflexion L5 extensor hallucis longus (EHL) S1 ankle plantarflexion / tip toe stance

10 Myotomes: Upper limb C5 shoulder abduction C6 elbow flexion C7 elbow extension C8 long finger flexors T1 hand intrinsics (resisted finger abduction)

11 Muscle power MRC Grade 5/5 = normal 4/5 = power reduced but against resistance 3/5 = movement against gravity 2/5 = movement with gravity eliminated 1/5 = flicker 0/5 = zero

12 Lower Limb Reflexes Knee = L3/4 Ankle = S1

13 Biceps = C6 Reflexes Triceps = C7 Brachioradialis = C5/6

14 Management: Axial Pain Red flags could this be tumour or infection urgent referral STarT Back Tool

15 STarT Back Scoring Single session manual therapy & advice Manual therapy & advice sessions Low intensity combined physical and psychological programme

16 General principles Analgaesia Reassure Axial and Radicular pain 85% settle in 2-3 month Pain is not damaging Stay mobile CES warnings if radicular pain No imaging Reassess Getting better? Any radicular pain? Red flags? Rheumatological presentation?

17 Imaging Radiographs not indicated (suspected osteoporotic #) MRI not recommended in National Pathway as difficult to interpret What is normal?

18 MRI in Asymptomatic People Disc degeneration: 50% of year olds Disc bulge 38% Disc protrusion 29% (age 30-50) 7% with root displacement or compression Spondylolysis 11.5% Lytic spondylolisthesis 8% Degenerative spondylolisthesis % with degenerative spondylolisthesis by age

19 Sheffield Pathways

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22 When to refer? 3 priority levels of referral Emergency = Phone call NOW to Orthopaedic SpR (at NGH) Urgent = Faxed referral to NGH Acute Spinal Clinic x2 each week Routine = SPA

23 Referral to MSK Services (SPA) Suspected CES / spinal cord compression - EMERGENCY Severe radicular pain at any time despite analgaesia URGENT (2w) Radicular weakness URGENT (2w) Non-tolerable radicular pain at 6 weeks not improving Non-tolerable axial pain depends on STarT Back score

24 Referral to Spinal Surgeon - Back Pain Reassurance Investigation for possible surgery if short history (<2yrs) and well motivated. Must have failed conservative measures including CPPP: Spondylolisthesis Localised degenerative change

25 Referral to Spinal Surgeon - Radicular Pain Severe radicular pain / Radicular weakness (?URGENT) Non-resolving, non-tolerable pain at 6-8 weeks Screening service get MRI Equivocal cases discussed at a monthly MDT (12 cases) Ideal time for surgery 3-4 months unless severe pain

26 Management of radicular pain Epidural or nerve root injection 20% chance improvement Microdiscectomy = 85% chance significantly improving leg symptoms Small operation, back to work 4-6 weeks, low risk

27 National database of all patients having surgery Developed in Sheffield Collects procedures, complications, PROMS, PREMS Patients sent web-links to questionnaires All SOL/ Sheffield Spinal data since May 2012

28 Financial considerations

29 Case for Change: Back Pain Costs CG88 NICE estimated that the cost of Back Pain to the NHS in 2008 was: 2.1 billion Which is: 4,133, per 100,000

30 England average Newark & Sherwood Rushcliffe North Derbyshire South Lincolnshire Dudley Corby Nottingham City North East Essex South West Lincolnshire Erewash Southend Herts Valleys East & North Hertfordshire Luton Cambridgeshire & Bedfordshire South East Staffordshire & Walsall Birmingham Crosscity Telford & Wrekin Stafford & Surrounds Solihull South Norfolk North Staffordshire Herefordshire Southern Derbyshire East Leicestershire & Rutland Norwich North East Lincolnshire Coventry & Rugby South Warwickshire National variation Facet Joint Injection numbers per 100,000 pop. by Midlands and East Region CCGs (2014/15) per

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32 CCG Data in Public Domain

33 GP Practice Elective Admissions Heywood, Middleton & Rochdale CCG

34 GP Practice Elective Admissions North Derbyshire CCG

35 GP Practice Elective Admissions Sheffield CCG

36 Elective Spinal Surgery by Trust for each CCG

37 Elective Spinal Admissions by Trust for each CCG

38 Elective Spinal Injections by Trust for each CCG

39 Regional Comparison CCG Costs South Yorkshire and Bassetlaw Hospital admissions Total Cost for low back and radicular pain in people aged 16 years and over (April March 2015) Responsible CCG Name All Admissions Elective Admissions Emergency Admissions Cost per head of Population Total Cost Cost per head of Population Total Cost Cost per head of Population Total Cost Registered Population (Ages 15+) Sheffield ,932, ,332, , ,340 Rotherham ,376, ,079, , ,243 Barnsley ,821, ,423, , ,119 Bassetlaw , , ,479 95,517 Doncaster ,619, ,061, , ,700 South Yorkshire & Bassetlaw Total ,670, ,726, ,821,559 1,265,919

40 National Pathways

41 National Back Pain Pathway Goals Generic pathway, from the general practitioner to specialised care Agreed by all stakeholders Basis for collaborative commissioning: CCGs Area Teams NHS England Specialised Services. Commissioning vehicle for new evidence. A vehicle for implementation of evidence based care

42 Pathway Objectives Provides patients with: An effective and timely end to end care pathway Provides healthcare professionals with: An evidence-based, comprehensive care pathway that integrates care from the GP surgery through to the specialists in hospital

43 Triage and Treat Practitioner Bio-Psycho-Social Assessment Highly Skilled Highly Autonomous Diagnostics: Arranges, Interprets, Acts Protected MRI Slots Advice and Education Referring Appropriately Core Therapy, Therapeutic Injection, Pain Services, CPPP, Spinal Surgery Single Point of Contact Directs the Patients Pathway Rapid Access Therapeutic Injection MDT Regional Spinal Network

44 National Back & Radicular Pain Pathway

45 National Back Pain Pathway (1)

46 National Back Pain Pathway (2)

47 National Radicular Pain Pathway

48 Evidence?

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50 Pathway Benefits Realisation Average performing CCG savings of 250,000 per 100,000 population per annum by reductions in referrals and surgery

51 Results for Triage & Treat Service Sheffield 2 CCGs in NE Spinal referrals per year 10,000 3,300 % of population 1.8% 0.8% % of referrals having MRI 12.5% 13.5% % referred to surgery 5.7% 6.7% % referred to pain management 1% 1.6% % referred to CPPP Not available 1.2% EQ5-D improvement 0.22 (n=2,971) = 86% 0.22 (n=326) Financial savings 558, ,000

52 CPPP First 4 Programmes 31 patients Delivered over 5 residential days Self Management 60 % Referred to surgery none PROMS: NICE target Achieved EQ5D p<0.05 Pain VAS p<0.05 ODI p>0.05

53 North Derbyshire

54 Referral patterns

55 Injections

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57 England average Newark & Sherwood Rushcliffe North Derbyshire South Lincolnshire Dudley Corby Nottingham City North East Essex South West Lincolnshire Erewash Southend Herts Valleys East & North Hertfordshire Luton Cambridgeshire & Bedfordshire South East Staffordshire & Walsall Birmingham Crosscity Telford & Wrekin Stafford & Surrounds Solihull South Norfolk North Staffordshire Herefordshire Southern Derbyshire East Leicestershire & Rutland Norwich North East Lincolnshire Coventry & Rugby South Warwickshire National variation Facet Joint Injection numbers per 100,000 pop. by Midlands and East Region CCGs (2014/15) per

58 Total cost

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60 The Future???

61 Tools to Support Implementation A Franchise Model Generic Business Case Cost Saving Calculator Value Impact Analysis Training Support IT Support Step by Step Guide Bespoke support from The National Team

62 Spinal problems Most patients do NOT have serious pathology Most pts do NOT require intervention Reassure Assess as per pathway Consider referral patterns

63 Further Information Send a pack with your data showing how the pathway can help you Discuss local circumstances Support discussions with CCGs to explore the opportunities for change d.waddingham@nhs.net sarah.kirkland3@nhs.net