Development of the Saskatchewan Spine Pathway:
In 2007, the Ministry of Health in the Saskatchewan, Canada asked the Province’s
spine surgeons (orthopedics and neurosurgery) to develop a care pathway for LBP and
leg pain. The Ministry had some previous success with a care pathway for hip and knee
disorders.1,2 Major motivators for developing the spine pathway included (1) long
waiting lists for spine surgery consultation, (2) over-utilization of imaging for LBP, and
(3) high prevalence of guidelines-discordant treatment for LBP.
The spine surgeons recognized that these problems were inter-related. Imaging
studies for LBP accounted for 36% of all MRI studies in Saskatchewan in 2008-09, prior
to implementation of the pathway. Several studies have shown that there is a high rate of
irrelevant imaging abnormalities in the lumbar spine.3-6 It has been suggested that
unnecessary imaging may be harmful as incidental “findings” may worsen patient
anxiety, dependence, fear/avoidance behavior, and lead to unnecessary tests or surgery.7,8
In addition, a large number of patients referred for surgical consultation suffered
from chronic pain disorder or other conditions that would be unlikely to benefit from
surgery.9-12 In 2008-09, prior to implementation of the pathway, only 16% of new
referrals to Saskatchewan spine surgeon were placed on the Provincial surgical waiting
list registry. Patients requested referral to the spine surgeon for many reasons, including:
(1) inadequate pain control, (2) incomplete or conflicting information about the source of
pain and prognosis, (3) requests for imaging or other tests to elucidate the source of the
pain, and (4) information about the relevance of imaging findings. Many patients
received guidelines-discordant primary care while waiting to see spine surgeons.
Although some patients had received exercise therapy or spinal manipulation, there was
no systematic approach to prescribing these treatments. Overwhelmingly, patients had
received limited information on LBP including self-care strategies.
The main objectives of the Saskatchewan Spine Pathway were (1) to encourage
evidence-based primary care for LBP, (2) to improve access to imaging and surgical
consultation for appropriately selected patients, and thus (3) to improve patient
satisfaction and outcomes.
The core pathway development team was multidisciplinary, including
neurosurgeons and orthopedic spine surgeons from the two major tertiary referral centers
in the Province (Saskatoon and Regina), representatives of the Chiropractors Association
of Saskatchewan, family physicians, physiotherapists, chronic pain clinics, Heath Region
officials and the Saskatchewan Ministry of Health. The team conducted evidence-based
systematic reviews of the evaluation and management of LBP including the history,
physical examination, investigations, and treatment (surgical and non-surgical). Current
international guidelines for LBP were also evaluated and compared. A draft of the care
pathway was developed and further refined through round-table meetings. A modified
Delphi method13 was used to integrate best evidence with best practice and address
patients’ expectations. In order to achieve consensus, many meetings took place over a
three-year period of pathway development.
Implementation Phase 1: Education
The greatest focus of the SSP is education of primary care providers and patients.
The assessment and treatment algorithms were implemented through a series of
continuing medical education (CME) presentations. Topics included (1) patient history
and physical examination including the early identification of “red flags”, (2)
classification of LBP by the mechanical patterns, (3) pattern-specific evidence-based
patient information and treatment algorithms, and (4) the process of referral for imaging
and surgical consultation in the SSP.
Phase One was implemented in March of 2010. Initially, weekend courses were
provided, but in order to facilitate the training of primary care providers (physicians,
nurse practitioners, chiropractors, physiotherapists), an on-line course was developed and
launched (www.spinepathwaysk.ca) in conjunction with live “hands-on” sessions
scheduled for smaller groups throughout the Province.
Implementation Phase 2: Spine pathway clinics
The first spine pathway clinic opened in May of 2011, staffed by physiotherapists
specially trained in spine assessment, pattern diagnosis, management, and surgical triage.
As discussed above, these are not “spine care” clinics, but rather: (1) function as a
reassessment center for the pattern diagnosis, (2) provide patients with additional
information about LBP and self-care, and (3) triage patients to additional mechanical
therapies, imaging studies, and/or assessment by spine surgery.
The pathway development team recognized the key role of primary care in the
management of LBP, which could not be simply replaced with spine clinics. If all
patients flowed through specialized clinics, the clinics would quickly become
overwhelmed. The pathway clinic is intended for patients who fail primary care patternspecific treatment algorithms.
As part of the outcomes assessment for the spine pathway, patient self-reported
outcomes collected in the pathway clinics include patient satisfaction questionnaires,
VAS for back and leg pain, ODI and EQ-5D.
References:
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Gooch KL, Smith D, Wasylak T, et al. The Alberta Hip and Knee Replacement
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Linstone FT. The Delphi Method: Techniques and Applications: AddisonWesley; 1975.