When to refer back pain to orthopedic (ortho) specialist versus neurologist?

When to Refer Back Pain to Orthopedic vs Neurologist

Refer patients with back pain to orthopedics for structural/mechanical issues and to neurology for neurological deficits or radicular symptoms that fail conservative management.

Initial Assessment and Triage

The decision to refer a patient with back pain to either orthopedics or neurology should follow a systematic approach based on clinical presentation:

Refer to Orthopedics When:

• Structural or mechanical issues are the primary concern
• Failed conservative management with persistent mechanical pain
• Suspected instability requiring surgical intervention
• Compression fractures or traumatic injuries
• Severe degenerative changes with functional limitations
• Recurrent disc herniations with evidence of instability 1
• Manual laborers with severe degenerative changes 1

Refer to Neurology When:

• Significant neurological deficits are present
• Radiculopathy with persistent symptoms despite conservative treatment
• Suspected myelopathy
• Cauda equina syndrome (urgent referral)
• Complex neuropathic pain requiring specialized management
• Bilateral radiculopathy 1

Timing of Referrals

The British Pain Society and American College of Physicians recommend:

• For severe radicular pain or neurological deficits: Consider specialist referral within 2 weeks of presentation 2, 1
• For non-specific low back pain: Refer after 3 months of failed conservative management 1
• For patients at high risk on STarT Back tool: Consider earlier specialist referral 2

Red Flags Requiring Urgent Referral

Immediate referral (often to neurosurgery) is warranted for:

• Cauda equina syndrome (new bladder dysfunction, perineal sensory loss)
• Progressive neurological deficits
• Suspected malignancy or infection
• Severe trauma with instability 1

Decision-Making Algorithm

1. Initial Presentation:

   • Assess for red flags requiring urgent referral
   • Use STarT Back tool to stratify risk 2, 1
   • Begin conservative management for 4-6 weeks

2. After 4-6 Weeks:

   • If improving: Continue conservative management
   • If persistent symptoms: Consider imaging (MRI if neurological symptoms)

3. After 3 Months of Conservative Management:

   • For predominantly mechanical/structural issues → Orthopedics
   • For predominantly neurological symptoms → Neurology

Evidence-Based Considerations

Research suggests that neurologists may not significantly affect outcomes for most back pain patients 3. The majority of patients with back pain seen by neurologists (approximately two-thirds) have non-neurologic conditions that could be managed by primary care physicians 3.

Orthopedic referral is more appropriate for patients requiring surgical intervention for structural issues, while neurology referral is more suitable for complex neurological presentations or when diagnosis is unclear.

Common Pitfalls to Avoid

1. Premature Imaging: Avoid routine imaging for non-specific back pain without red flags 1
2. Delayed Referral: Don't delay referral for patients with progressive neurological deficits
3. Inappropriate Specialist Selection: Matching the specialist to the predominant symptom pattern improves outcomes
4. Overlooking Psychosocial Factors: These significantly impact prognosis and should be addressed regardless of referral 2, 1
5. Failure to Try Conservative Management: Most guidelines recommend 3 months of conservative treatment before specialist referral unless red flags are present 1, 4

Remember that most back pain (97%) is mechanical in nature 5, and only a minority of patients with chronic low back pain benefit from surgical procedures 6. The decision between orthopedic and neurological referral should be based on the predominant clinical features and suspected underlying pathology.