Lumbosacral pain: Delivery of care to patients in the United Kingdom Podchufarova E.

Musculoskeletal pain syndromes are one of the most common causes of disability and referral to a medical specialist. Seven million consultations for lumbosacral pain are annually carried out in the United Kingdom.

Examination of patients with back pain. Three levels of health care delivered to patients with back pain in the United Kingdom may be arbitrarily identified. Level 1 is outpatient: a general practitioner jointly with a manipulative therapist, a physiotherapist, a rehabilitation specialist, and mid-level health workers render care to patients with insignificant and mild pain syndrome; Level 2 is also outpatient, which involves the participation of a hospital or multidisciplinary team consultant, for example, in a musculoskeletal pain service or a specialized pain center; Level 3 is to deliver care at neurosurgical or orthopedic hospital, by applying invasive interventions. Acute back pain is a benign condition in the vast majority of cases; there is no need for additional instrumental and laboratory studies; but spinal X-ray study, computed tomography (СT scan), or magnetic resonance imaging (MRI), general blood and urine tests are required when marked neurological and somatic disorders are present.

Management of patients with acute lumbosacral pain is to inform a patient about the benign nature of the disease; to exclude bed rest; to explain the need to maintain normal activity; to train how to correctly lift weights and to maintain normal posture; to refer for manual and exercise therapy in order to return to normal motor activity; to use proven effective medication. In most cases, acute back pain goes away spontaneously for a short period of time; an active treatment approach is considered to be optimal. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are used for analgesia if required. Patients who show no improvement after 4 weeks of treatment need rescreening for markers of potentially dangerous spinal diseases, as well as determination of the signs of psychosocial ill-being and correction of therapy with consideration for identified disorders.

Management of patients with subacute and chronic pain (persisting for >6 weeks, but <1 year) involves the regular reconsideration of whether the diagnosis of nonspecific back pain is correct in order to rule out possible specific causes. MRI is indicated when a patient is decided to be referred for surgical treatment or there is presumptive evidence for spinal tumors, infectious, inflammatory, or traumatic injury, or cauda equina syndrome. It is optimal to start treatment with a program of therapeutic exercises, manual therapy, or acupuncture. Drug therapy encompasses NSAIDs, acetaminophen, and opioids to treat intensive pain syndrome.

1. Rivero-Arias O, Gray A, Frost H, et al. Costutility analysis of physiotherapy treatment compared with physiotherapy advice in low back pain. Spine. 2006;31(12):1381–7. DOI: http://dx.doi.org/10.1097/01.brs.0000218486.13659.d5.

2. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain. 2000;84(1):95–103. DOI: http://dx.doi.org/10.1016/S0304-3959(99)00187-6.

3. Foster N, Hartvigsen J, Croft P. Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis. Arthritis Res Ther. 2012;14(1):205. DOI:10.1186/ar3743.

4. National Institute for Health and Care Excellence (2009). Low back pain: Early management of persistent non-specific low back pain. CG88 London: National Institute for Health and Care Excellence. Available from: http://publications.nice.org.uk/low-back-pain-cg88.

5. Van Tulder M, Becker А, Bekkering T, et al. European guidelines for the management of acute nonspecific low back pain in primary care. European Spine. 2006;15 Suppl 2:169–91.

6. Savigny P, Kuntze S, Watson P, et al. Low Back Pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2009. 235 p.

7. National Institute for Clinical Excellence. Acute low back pain referral advice A guide to appropriate referral from general to specialist services. London: National Institute for Health and Care Excellence; 2001. 50 p.

8. National Institute for Health and Care Excellence. Osteoarthritis: the care and management of osteoarthritis in adults' CG59, London: National Institute for Health and Care Excellence; 2009. Available from: http://guidance.nice.org.uk/CG59

9. Colberg K, Hettich M, Sigmund R, Degner FL. The efficacy and tolerability of an 8-day administration of intravenous and oral meloxicam: a сomparison with intramuscular and oral diclofenac in patients with acute lumbago. German Meloxicam Ampoule Study Group. Curr Med Res Opin. 1996;13(7):363–77. DOI: http://dx.doi.org/10.1185/03007999609111556.

10. Bosch HC, Sigmund R, Hettich M. Efficacy and tolerability of intramuscular and oral meloxicam in patients with acute lumbago: a comparison with intramuscular and oral piroxicam. Curr MedRes Opin. 1997;14(1):29–38. DOI: http://dx.doi.org/10.1185/03007999709113340.

11. Шостак НА, Шеметов ДА. Эффективность и переносимость мелоксикама (мовалиса) при синдроме болей в нижней части спины в сравнении с диклофенаком. Научно-практическая ревматология. 2001;41(1):63-7. [Shostak NA, Shemetov DA. Efficiency and shipping meloxicam (movalis) at a syndrome of pains in the lower part of a back in comparison with diclofenac. Nauchnoprakticheskaya revmatologiya = Rheumatology Science and Practice. 2001;41(1):63–7. (In Russ.)]

12. Герасимова ОН, Парфенов ВА. Клинический опыт применения мелоксикама (Мовалис®) при неспецифической боли в спине и радикулопатии. Неврология, нейропсихиатрия, психосоматика. 2012;(2):68-73. [Gerasimova ON, Parfenov VA. Clinical experience with meloxicam (Movalis®) in nonspecific back pain and radiculopathy. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2012;(2):68–73. (In Russ.)]. DOI: http://dx.doi.org/10.14412/2074-2711-2012-387.

13. Алексеев ВВ, Подчуфарова ЕВ. Мелоксикам в лечении люмбоишиалгического синдрома. Боль. 2004;(2):49-53. [Alekseev VV, Podchufarova EV. Meloksikam in treatment of a lyumboishialgichesky syndrome. Bol'. 2004;(2):49–53.]

14. Chartered Society of Physiotherapy: a survey of NHS physiotherapy waiting times, workforce and caseloads in the UK. 2010–2011. Available from:

15. http://www.csp.org.uk/publications/survey-nhsphysiotherapy-waiting-times-workforce-caseloadsuk-2010-2011.

16. National Institute for Health and Care Excellence. Peripheral nerve-field stimulation for chronic low back pain, Interventional procedure guidance 451. London: National Institute for Health and Care Excellence; 2013. Available from: http://publications.nice.org.uk/peripheral-nervefield-stimulation-for-chronic-low-back-painipg451

17. National Institute for Health and Care Excellence. Percutaneous intradiscal electrothermal therapy for low back pain Interventional procedure guidance 319. 2009. Available from: http://publications.nice.org.uk/percutaneousintradiscal-electrothermal-therapy-for-low-backpain-ipg319

18. National Institute for Health and Care Excellence. Percutaneous disc decompression using coblation for lower back pain. Interventional procedure guidance 173. 2006. Available from: http://publications.nice.org.uk/percutaneous-discdecompression-using-coblation-for-lower-backpain-ipg173

19. National Institute for Health and Care Excellence. Percutaneous intradiscal laser ablation in the lumbar spine. Interventional procedure guidance 357. 2010. Available from: http://publications.nice.org.uk/percutaneous-intradiscal-laserablation-in-the-lumbar-spine-ipg357

20. Wilson N, Pope C, Roberts L, et al. Governing healthcare: finding meaning in a clinical practice guideline for the management of non-specific low back pain. Soc Sci Med. 2014;(102):138–45. DOI: http://dx.doi.org/10.1016/j.socscimed.2013.11.055.

21. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802):1560–71. DOI: http://dx.doi.org/10.1016/S0140-6736(11)60937-9.

22. National Institute for Health and Care Excellence. Sciatica (lumbar radiculopathy). 2009. Available from: http://http://cks.nice.org.uk/sciaticalumbar-radiculopathy