Clinical Study
Low back pain in neurosurgical outpatients: An audit

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Abstract

Low back pain is a common condition. This is a retrospective study of new referrals to neurosurgical outpatients at the Western Hospital, Victoria, Australia. Two hundred and fifteen histories were systematically reviewed. Statistical analysis was performed using univariate and multivariate analyses. Patients who had tried physiotherapy, epidural injection or had no pre-outpatient imaging were more likely to get MRI (p < 0.02). Patients with clinical features of neurogenic claudication (p < 0.01) or with neurological signs (p = 0.02) were more likely to proceed to surgery. CT scan demonstrated significant correlation to MRI for lumbar canal stenosis, disc disease or the absence of disease (p < 0.01). Referral guidelines for general practitioners regarding back pain are proposed. Recommendations are also made to facilitate the selected use of CT scan and MRI.

Introduction

Low back pain (LBP) is a term used to describe lumbar spinal pain, sacral spinal pain or lumbosacral pain.1 It is a common condition, with an estimated lifetime prevalence of 60–80%.2 While most episodes are self-limiting, the tendency for LBP to undertake a prolonged or relapsing course translates to it being the most common cause of disability across all age groups.3 This disease burden presents as a significant health problem, and has ramifications for health policies, economic planning and research.

The cause of LBP is non-specific in about 95% of people. Serious conditions are rare, with tumours, fractures and infections accounting for less than 1% in general practice settings.4 Guidelines on the management of both acute and chronic back pain place an emphasis on the safe management of LBP by a careful history and examination without resorting to special investigations.

This is a retrospective review of all new referrals to the neurosurgical outpatients at the Western Hospital, Victoria, Australia, for low back pain. Patient parameters are recorded, with a view to identifying clinical variables that influence the request for MRI and surgical intervention. The secondary aim is in correlation of the reporting of disc disease, canal stenosis and nerve root impingement between CT scan and MRI. Referral guidelines for general practitioners regarding low back pain are proposed, aiming to facilitate more appropriate specialist referrals to outpatient clinics. Suggestions for the selected use of CT scan and MRI in LBP are also recommended.

Section snippets

Inclusion and exclusion criteria

The study included all new referrals of patients with LBP presenting to the neurosurgical outpatients at the Western Hospital, Victoria, Australia, between January 2004 and December 2005. Of the 592 new referrals to the clinic, 262 were for LBP. Exclusion criteria were: (i) patients whom after being seen in the public outpatient system, were followed up privately; (ii) patients who were first consulted privately and then referred for follow-up in the public system; and (iii) patients who failed

Patient characteristics

Of the 262 patients referred with LBP to the neurosurgical outpatients clinic, 47 were excluded: 41 failed to attend their appointments and six had their initial or subsequent follow-up privately. The hospital serves the north-western suburbs of Melbourne, where patients were primarily from immigrant backgrounds or low-middle socio-economic class.

Table 1 provides a summary of the patient demographics and outcomes. Of the 215 patients in the study, the mean age was 56 years; the median age was

Discussion

Patients included in the study encompassed all new referrals seen in a specialist outpatient setting between January 2004 and December 2005. This group of patients represents a proportion of the patients with LBP in the community. Patient demographic analysis demonstrated similar characteristics to risk factors for the development of LBP: female and age. Other predictors, not measured in the study, include lower socio-economic class, lack of physical activity, obesity and smoking.6

Conclusion

In conclusion, LBP is a common condition that presents as a significant health burden to both individuals and society alike. General practitioners play a critical role in the conservative treatment of LBP. Selective careful referrals of patients for surgical assessment after the failure of conservative measures, and the more judicious use of radiological imaging, would bring about a relief to public health resources. This would serve to improve access for patients needing surgical intervention.

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