Inflammatory Back Pain in Adults
When to refer to rheumatology?
If low back pain started aged <45yrs and lasted >3months & if at least 4 of the following:
- LBP started <35yrs old
- Waking during second half of night due to symptoms
- Buttock pain
- Improvement with movement
- Improves within 48hrs of NSAID use
- 1st degree relative with spondyloarthopathy
- Current/past psoriasis
- Current/past enthesitis
- Current/past inflammatory arthritis
If exactly 3 of the above list present- check HLA-B27 and if positive refer .
IfRed flags/High complexity ie. Impending/established cauda equine; conus medullaris
If there is no evidence of inflammatory symptoms, please consider following the Adult Low Back Pain pathway.
Investigations pre referral
FBC, U&E, LFTS, Bone, ESR, CRP
DO NOT REQUEST PLAIN FILM X RAYS
Primary Care management
Consider NSAIDS at lowest effective dose taking into account risk factors for Renal/ cardiac/ Gastrointestinal toxicity +/- gastroprotective treatment
May be helpful but should not delay referral to rheumatology if high index of suspicion of inflammatory cause for back pain.
NICE NG65, Feb 2017
Personal communication David Hutchinson, Consultant Rheumatologist, RCHT, Aug 2018
Guidelines reviewed 01/04/2019
Next review due 01/04/2020
Dr B Wesson ( RMS GP Lead for Rheumatology)