Who to refer
When assessing a patient with back pain, here are some general referral criteria for some of the more commonly seen spinal conditions:
Cervical Spondylopathy or Disc Prolapse
- Intolerable or persistent (>4 - 6 weeks) Brachialgia.
- Upper or lower limb weakness.
- Cervical Myelopathy: Brisk reflexes, limb hypertonia, impaired hand dexterity, imbalance and walking difficulties, urinary frequency and urgency.
- Intolerable side effects from strong analgesia
Lumbar Disc Prolapse
- Persistent (>4 - 6 weeks) or intolerable Sciatica (L5, S1) or Femoralgia (L1 - 4).
- Leg or ankle weakness.
- Intolerable side effects from strong analgesia.
Lumbar Spinal Stenosis
The natural history is usually that of fluctuating symptoms and a trend of gradual deterioration over 6 to 18 months. The indications for referral to a spinal specialist for further assessment and surgical intervention are:
- Failure of conservative management with progressive neurogenic claudication
- Incapacitating neurogenic leg pain, leg weakness or imbalance upon standing or walking
- Bowel or bladder dysfunction
GP referral form
Red flags for Serious Spinal Pathology
The presence of the following may indicate a serious underlying spinal pathology. If a serious condition is suspected, an urgent or emergency referral directly to the local spinal unit may be necessary.
Red Flags for Spinal Metastases
- Constant severe mechanical spinal pain
- Progressive spinal pain despite conservative treatment
- Persistent thoracic spine pain
- Patient is under 20 or over 50 with back pain for the first time
- Personal or family history of cancer.
- Unexplained weight loss, cachexia, loss of apetite.
- Structural deformity of spine
Red Flags for Spinal Infection
- Constant severe spinal pain which continues when resting and may worsen at night
- Unexplained fever, malaise or lethargy
- Recent bacteraemic infection, UTI, or endoscopic procedure
- Immune suppression risk factors: Diabetes, alcohol dependence, IV drug misuse or HIV
- Structural deformity of spine
Red Flags for Cauda Equina Syndrome
- Recent onset urinary retention with overflow incontinence
- Recent onset faecal incontinence
- Bilateral sciatica, leg numbness or weakness
- Progressive neurological deficit in the legs
- Perineal / saddle anaesthesia
- Lax anal sphincter
Red Flags for Spinal Fracture
- History of fall or spinal trauma
- History of osteoporosis
- Long-term steroid medication