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Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 143-146

Management of spinal disorders by primary care providers in Saudi Arabia: Treatment options and referral patterns

1 Department of Orthopedics, King Khalid University Hospital; Department of Orthopedics, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia
2 Department of Orthopedics, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia
3 Department of Orthopedics, King Khalid University Hospital, Riyadh 11472, Saudi Arabia

Date of Web Publication9-Dec-2015

Correspondence Address:
Khalid Abdulrazzak Alsaleh
Department of Orthopedics, College of Medicine, King Saud University, P.O. Box 7805, Riyadh 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-0521.171437

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Background: Primary care providers are responsible for providing initial diagnosis and treatment for most ailments. The management and referral patterns related to spinal disorders vary significantly. Aims: To assess primary care practitioners management of low back pain (LBP) including referral patterns. Materials and Methods: A cross-sectional study was conducted to assess primary care practitioner's management of LBP and their awareness of the options, risks, and outcomes of spine surgery. Results: Eighty respondents completed the questionnaire. There was significant heterogeneity concerning their management of LBP. Their views of the options, outcomes, and risks of spinal surgery were not consistent with the available medical literature. Conclusion: Variability in referral patterns is influenced by both lack of implementation of clinical practice guidelines and lack of awareness of spine surgery risks and outcomes among some practitioners in the primary care setting.

Keywords: Low back pain, primary care, spine

How to cite this article:
Alsaleh KA, Alluhaidan AS, Alsaran YK, Alrefayi HS, Algarni NA, Chaudhry H, AlAhaideb AS. Management of spinal disorders by primary care providers in Saudi Arabia: Treatment options and referral patterns. Saudi J Health Sci 2015;4:143-6

How to cite this URL:
Alsaleh KA, Alluhaidan AS, Alsaran YK, Alrefayi HS, Algarni NA, Chaudhry H, AlAhaideb AS. Management of spinal disorders by primary care providers in Saudi Arabia: Treatment options and referral patterns. Saudi J Health Sci [serial online] 2015 [cited 2020 May 28];4:143-6. Available from: http://www.saudijhealthsci.org/text.asp?2015/4/3/143/171437

  Introduction Top

In the public health system, primary care providers (PCPs) are responsible for providing initial diagnosis and treatment for most disorders. Management of common spinal complaints - Such as low back pain (LBP) is handled in the primary care setting first. Many PCP manage LBP cases well according to the national or institutional clinical practice guidelines (CPGs). CPG for LBP have existed for some time, but the lack of awareness and physician attitude have limited their implementation.[1],[2] Some cases are eventually referred to the spine surgeon for specialist opinion and management, but the referral patterns are not consistent, and CPG are not implemented universally.[3],[4]

The objective of this study was to survey the opinions of PCPs concerning their management of spinal disorders and their perceived benefits, risks, and complications of spinal interventions.

  Materials and Methods Top

A self-reported questionnaire composed of 17 questions was distributed to 80 physicians in Riyadh, Saudi Arabia working in a primary care setting. The questionnaire aimed to (a) establish the management – including referral pattern for spinal pathology (b) address the awareness of the benefits and risks of spinal procedures among PCPs.

The questionnaires were presented to 80 primary health physicians by personal visits, and the physician's responses were collected at the time of visit with a response rate of 100%.

  Results Top

Investigating the LBP patient, around one-third of the respondents (36%) will request an X-ray routinely, while one-fifth (21%) will request routine magnetic resonance imaging for LBP [Figure 1].
Figure 1: Usage of routine imaging for spine patients

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The respondent's conservative management options for LBP varied. A majority of respondents - 82.5% will utilize physical therapy, and 73.8% will utilize analgesia for the management of nonspecific low back. Half the respondents (50%) will prescribe lumbar support, while only 33.8% will consider a spinal injection.

Concerning common reasons for referral, 61% of the respondents will refer disc herniations while 47% will refer spinal deformity - such as scoliosis, and 43% will refer vertebral fractures. A smaller percentage - 15% will refer back or neck pain to the surgeon.

Asked about their opinions about the outcomes of spinal surgery, around half the respondents (47%) reported that the outcomes were "good." Twenty-two percent believed the outcomes to be "very good" while only 5% believed it to be "excellent." Six percent believed the outcomes to be poor while 17% did not know the answer to that question.

When asked about risks of spinal surgery, 72% identified the risk of neurologic deficit postoperatively while 47% identified disability as a risk. Thirty percent identified infection as a risk while 21% only identified vascular insults as a risk postspinal surgery [Figure 2]. To further elaborate on the percentage of each of the risks mentioned the respondents were asked to give a percentage of three of the four risks associated with spinal surgery from their perspective, and this can be viewed in [Figure 3],[Figure 4],[Figure 5].
Figure 2: Respondent's view of the risks associated with spine surgery

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Figure 3: Respondent's view of the risk of paraplegia due to spine surgery

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Figure 4: Respondent's view of the risk of vascular injury due to spinal procedures

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Figure 5: Respondent's view of the risk of disability due to spine surgery

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Given four choices of rehabilitation protocols, 38% of the respondents answered that usually no bed rest is required, and the patient should mobilize as soon as possible. Thirty-five percent of the respondents believed that spinal surgery patients required a period of rest from 1 to 6 weeks while much smaller group - 22% believed that 6–12 weeks of bed rest is required. Only 4% of the respondents believed that over 3 months of bed rest are required.

When asked if they know anyone who underwent spinal surgery recently and what their outcome was 50% had no personal experience with spinal surgery. Twenty-seven percent answered yes and mentioned that their outcomes were good. Nine percent also had some personal experience and relayed that the outcomes were excellent. A smaller percentage of the respondents divulged having had personal experience with spinal surgery and that the outcomes were unchanged - 7% or worse - 6% for the patients they personally know.

The last question was about exposure to orthopedics or neurosurgery as a trainee, and 60% of the respondents answered yes. When asked if they would be interested in updates about the management of spinal pathology 83% of the respondents expressed interest.

  Discussion Top

This survey was designed to address two key issues: The lack of awareness about spinal pathology in the primary care setting in Saudi Arabia as well as the lack of adherence to CPG that cover management of LBP.

The results of the survey clearly show that there is a knowledge gap related to the management of spinal pathology manifesting itself in the small number of respondents who answered correctly about their management of LBP. The management options were mostly in agreement with the standard of care and most CPG, but there remains a large percentage of primary care physicians - 50% who prescribe lumbo-sacral support while there is no evidence to support its use, and there is evidence to prove it may cause harm.[5],[6] In addition, half the respondents would request imaging routinely for spine patients while this is not supported by any existing guideline.[6],[7],[8],[9] In the absence of implementation of such guidelines, routine imaging results in increased cost to the health care provider and unwarranted radiation exposure to the patients.

Reasons for referral to the surgeon were variable, but around half of the respondents will refer disc herniation, spinal fracture, and deformity. This begs the question of how the other 50% of PCPs will manage such pathologies without a referral.

The most significant finding of this survey from a surgeon's perspective might be the awareness of the outcomes and risks of spinal surgery. While 40% of respondents never had any exposure in training to either neurosurgery or orthopedic, and only 50% had personal experience from a friend or colleague. Based on that, it is not difficult to understand why 27.5% of the participants had believed the risk of paralysis following spine surgery to be 10–25%. This is far from what the most recent literature provides us, as the percentage risk of neurologic deficit is <1% in primary spinal procedures.[10],[11],[12] Furthermore, of note is the large percentage of respondents - 63.3% who think that bed rest is a requirement following spinal surgery when early mobilization is now a standard of care for spinal surgery. Even for the management of acute LBP with sciatica, it is now well-established that early activity is superior to bed rest.[13],[14],[15],[16] In fact, almost all-but not all [17] International CPG for the management of LBP have recommended against prolonged bed rest.[14]

In comparison to other published surveys focusing on the same subject,[3], 4, [18],[19],[20] our results was consistent with their findings that primary care practitioners vary in their adherence to CPG and the latest clinical evidence concerning the management of spinal diseases, especially that of LBP.

  Conclusion Top

The current management of spinal disorders by PCP in Saudi Arabia is variable and not conforming to any national or international guideline. Referral patterns are influenced by this variability and by the PCPs personal impression of the risk of spinal surgery. The pressure to adopt and implement CPG by both peers and administrators should help close the gap and provide a more standard management protocol for such patients in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Arnau JM, Vallano A, Lopez A, Pellisé F, Delgado MJ, Prat N. A critical review of guidelines for low back pain treatment. Eur Spine J 2006;15:543-53.  Back to cited text no. 1
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458-65.  Back to cited text no. 2
Di Iorio D, Henley E, Doughty A. A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med 2000;9:1015-21.  Back to cited text no. 3
Bederman SS, McIsaac WJ, Coyte PC, Kreder HJ, Mahomed NN, Wright JG. Referral practices for spinal surgery are poorly predicted by clinical guidelines and opinions of primary care physicians. Med Care 2010;48:852-8.  Back to cited text no. 4
Jellema P, van Tulder MW, van Poppel MN, Nachemson AL, Bouter LM. Lumbar supports for prevention and treatment of low back pain: A systematic review within the framework of the Cochrane Back Review Group. Spine (Phila Pa 1976) 2001;26:377-86.  Back to cited text no. 5
Bigos SJ, Bowyer OR, Braen GR, Brown K, Deyo R, Haldeman S, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, (AHCPR Publication No 95-0642); 1994.  Back to cited text no. 6
NICE CG88. Low Back Pain: Early Management of Persistent Non-specific Low Back Pain. London: National Institute for Health and Care Excellence; 2009.  Back to cited text no. 7
van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006;15 Suppl 2:S169-91.  Back to cited text no. 8
Brooks P, Macrh L, Bogduk N, Bellamy N. Evidence-based management of acute musculoskeletal pain. Bowen Hills: Australian Academic Press; 2003.  Back to cited text no. 9
Hamilton DK, Smith JS, Sansur CA, Glassman SD, Ames CP, Berven SH, et al. Rates of new neurological deficit associated with spine surgery based on 108,419 procedures: A report of the scoliosis research society morbidity and mortality committee. Spine (Phila Pa 1976) 2011;36:1218-28.  Back to cited text no. 10
Diab M, Smith AR, Kuklo TR; Spinal Deformity Study Group. Neural complications in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2007;32:2759-63.  Back to cited text no. 11
Qiu Y, Wang S, Wang B, Yu Y, Zhu F, Zhu Z. Incidence and risk factors of neurological deficits of surgical correction for scoliosis: Analysis of 1373 cases at one Chinese institution. Spine (Phila Pa 1976) 2008;33:519-26.  Back to cited text no. 12
Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev 2004;6:CD001254.  Back to cited text no. 13
Malmivaara A, Häkkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, et al. The treatment of acute low back pain – Bed rest, exercises, or ordinary activity? N Engl J Med 1995;332:351-5.  Back to cited text no. 14
Wiesel SW, Cuckler JM, Deluca F, Jones F, Zeide MS, Rothman RH. Acute low-back pain. An objective analysis of conservative therapy. Spine (Phila Pa 1976) 1980;5:324-30.  Back to cited text no. 15
Wilkinson MJ. Does 48 hours' bed rest influence the outcome of acute low back pain? Br J Gen Pract 1995;45:481-4.  Back to cited text no. 16
Negrini S, Giovannoni S, Minozzi S, Barneschi G, Bonaiuti D, Bussotti A, et al. Diagnostic therapeutic flow-charts for low back pain patients: The Italian clinical guidelines. Eura Medicophys 2006;42:151-70.  Back to cited text no. 17
Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075-94.  Back to cited text no. 18
Breen A, Austin H, Campion-Smith C, Carr E, Mann E. "You feel so hopeless": A qualitative study of GP management of acute back pain. Eur J Pain 2007;11:21-9.  Back to cited text no. 19
Bishop A, Foster NE, Thomas E, Hay EM. How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists. Pain 2008;135:187-95.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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