How do you decide whether a patient with back and neck problems should see an orthopedic (ortho) specialist or a neurologist?

Deciding Between Orthopedic or Neurological Referral for Back and Neck Problems

Referral decisions for back and neck problems should be based on the patient's specific symptoms, suspected pathology, and response to initial management, with orthopedic specialists generally more appropriate for structural issues and neurologists for neurological symptoms or deficits. 1

Initial Assessment and Triage

• Classify patients with back/neck pain into one of three categories: nonspecific pain, pain potentially associated with radiculopathy or spinal stenosis, or pain potentially associated with another specific spinal cause 2
• Use the STarT Back tool at 2 weeks from onset of pain to predict risk of developing persistent disabling pain and guide appropriate referrals 1
• Assess for red flags requiring urgent evaluation: rapidly progressive neurological deficits, motor deficits at multiple levels, bowel/bladder dysfunction, or cauda equina syndrome 2

When to Refer to Orthopedic Specialists

• Patients with structural abnormalities such as herniated discs, spinal stenosis, or vertebral compression fractures that may require surgical intervention 1
• Patients with persistent nonspecific low back pain after 3-12 months of failed nonsurgical interventions 1
• Patients with shoulder dysfunction, decreased range of motion, or impingement signs related to neck issues 1
• Patients with pain that is primarily musculoskeletal in nature and affects joints, bones, or soft tissues 1

When to Refer to Neurologists

• Patients with neurological symptoms such as radiculopathy, myelopathy, or neuropathic pain 2
• Patients with cervical dystonia or neuropathies related to neck problems 1
• Patients with symptoms suggestive of multiple sclerosis, amyotrophic lateral sclerosis, or other neurological conditions 3
• Patients with headaches or other neurological symptoms accompanying neck pain 4

Specific Clinical Scenarios

For Back Pain:

• Orthopedic referral indicated for:

  • Pain with mechanical features (worse with activity, better with rest) 1
  • Failed conservative management after 12 weeks with persistent disability 1
  • Structural deformities visible on imaging 1
  • Patients who may benefit from surgical intervention 1

• Neurological referral indicated for:

  • Progressive neurological deficits 2
  • Neuropathic pain not responding to first-line treatments 2
  • Atypical presentation suggesting central nervous system involvement 3
  • Complex pain syndromes requiring specialized neurological management 3

For Neck Pain:

• Orthopedic referral indicated for:

  • Spinal accessory nerve (SAN) palsy with decreased range of motion 1
  • Structural abnormalities of the cervical spine 1
  • Shoulder dysfunction related to neck problems 1
  • Trismus (limited jaw opening) related to neck issues 1

• Neurological referral indicated for:

  • Cervical dystonia characterized by painful dystonic spasms 1
  • Neuropathic pain requiring specialized management 1
  • Headaches or other neurological symptoms accompanying neck pain 4
  • Symptoms suggesting nerve root compression or inflammation 2

Common Pitfalls in Referral Decisions

• Delayed referral: Waiting too long to refer patients with progressive neurological symptoms can lead to permanent deficits 2
• Inappropriate imaging: Ordering unnecessary imaging before appropriate clinical assessment can lead to incidental findings and unnecessary interventions 5
• Overlooking psychosocial factors: These are stronger predictors of outcomes than physical examination findings or pain severity 2
• Fragmented care: Referring to multiple specialists without coordination can lead to conflicting recommendations and patient confusion 6

Algorithm for Referral Decision-Making

1. Assess for red flags requiring emergency referral 2

   • If present → Emergency department or urgent specialist referral

2. Determine predominant symptom pattern 2, 3

   • Primarily musculoskeletal/structural → Consider orthopedic referral
   • Primarily neurological → Consider neurology referral

3. Evaluate response to initial management 1

   • Good response → Continue primary care management
   • Poor response after 12 weeks → Consider specialist referral based on symptom pattern

4. Consider specific treatment needs 1

   • Potential surgical candidate → Orthopedic referral
   • Complex pain management → Pain specialist or neurologist
   • Rehabilitation needs → Physical therapy before specialist referral

By following this approach, primary care providers can make more appropriate referral decisions that optimize patient outcomes while using healthcare resources efficiently 7.