Emergency Referrals to the On-call Team should come through an in-patient service or Emergency Department if you have concerns regarding cauda equina syndrome or metastatic cord compression please follow the national guidance and direct to the local Emergency Department for further investigation.
Who should be referred?
Acute severe radicular arm or leg pain, not showing any improvement with conservative measures (such as physiotherapy and analgesia including neuropathic agents) by six weeks following onset. Note that some improvement is likely to imply eventual resolution without requirement for surgery. Pain will be in a nerve root distribution. Neurological symptoms (paraesthesia, numbness and/or muscular weakness) will be in a nerve root distribution. With imaging demonstrating nerve root compression.
Progressive neurological symptoms and/or weakness 3/5 or less are indications for urgent referral.
Refractive longer term radicular pain (i.e. greater than three months), patient has trialled conservative treatment in accordance with the NHS England BestMSK pathway. Imaging correlates with the clinical picture and the patient wants to consider invasive management.
Significant spinal claudication, (i.e., radiating leg pain/paraesthesia/numbness coming on with walking and distance-limiting). Pain progression is normally from buttocks to the periphery. Relief is gained by rest and bending forwards. Neurological symptoms (paraesthesia, numbness and/or muscular weakness) also resolve with rest. Peripheral pulses are normal. Imaging reveals spinal stenosis.
Patients with signs of myelopathy. All patients should be referred urgently with positive long tract (or upper motor neurone) signs when an MRI has been done and where, there is cord signal change at a stenotic spinal level. Symptoms include numb, clumsy hands, jumping, stiff legs, falls, poor balance and urinary frequency.
Spinal deformity patients who have had appropriate imaging (MR/X ray) and wish to discuss surgical intervention. All patients should have physiotherapy input along with the surgical referral.
Urgent elective referrals should be directed to the local MSK interface service
Presentation younger than age 20 with onset of unexplained spinal pain
Constant, progressive non-mechanical pain especially thoracic pain
Patients who are using systemic steroids with new spinal pain
History of HIV and/or drug abuse and new spinal pain
Patients with unexplained weight loss and new spinal pain
Patients with inflammatory disorders such as ankylosing spondylitis
Past medical history of carcinoma with new onset of non-mechanical pain
Who shouldn’t be referred?
Patients with referred pain. For the purposes of differential diagnosis, referred arm, leg or neck pain is more generalised in distribution and does not follow a specific nerve root distribution. Pain does not generally spread below the elbow or knee.
Patients with degenerative neck or back pain including those with spondylosis generally have no surgically remedial cause and so should not be referred. Patients should be managed with analgesia, advice, physiotherapy and pain management if required.
Patients with non-specific neurological symptoms/somatisation disorder. Such patients should be referred to a neurologist or to the pain clinic.
Where radicular pain is significantly improving or resolved.
Where there is residual dermatomal numbness following a previous radicular pain episode.
Where the patient does not want any surgery (other than patients who are considered to be myelopathic).
Investigations required (prior to referral)
The MSK service will arrange an MRI scan of the relevant spinal area to be available by the time of triage. The referral letter should contain sufficient information for the referral to be processed, e.g., pattern of pain radiation, neurological assessment, management to date. If scans have been performed prior to first out patient appointment, the images should be made available on GM Sectra PACs. The scan report should, if possible, accompany the images but should not be a substitute for them.
Note that if a patient has had previous spinal surgery the details of the surgery should be provided.
Consider prescribing a trial of neuropathic analgesia if radicular symptoms in addition to standard analgesics (i.e., compound analgesic and strong anti-inflammatory . Tell patients about Transcutaneous Electrical Nerve Stimulation.
Routine Referrals: Referred via NHS eRS via Spinal Assessment Service (Under Orthopaedics, Spines) or Spinal Neurosurgery (Under Neurosurgery, Spinal)
Urgent Referrals - to be marked Urgent:
Referred via NHS eRS via Spinal Assessment Service (Under Orthopaedics, Spines) or Spinal Neurosurgery (Under Neurosurgery, Spinal)
Urgent Referrals or clinical discussions can be done via consultant connect.
Other Relevant Information
Management of those Patients who should not be Referred
Patients with either acute or chronic neck or back pain and no neurological signs and symptoms rarely have a surgically remedial problem. Such patients need a clear and informative explanation of why surgical intervention will not be of benefit. They are then best managed in primary care through a combination of advice, appropriate medication and access to physiotherapy and chronic pain specialists.
Referrers who have concerns regarding individual patients are encouraged to discuss the case at the MSK interface service spinal MDT meeting.