Back pain

Emergency referrals

All urgent cases must be discussed with the on call Neurosurgery Registrar. Contact through Royal Brisbane and Women's Hospital (07) 3646 8111 to obtain appropriate prioritisation and treatment.

Urgent cases accepted via phone must be accompanied with a written referral and a copy faxed immediately to the Central Patient Intake Unit: 1300 364 952.

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

Risk irreversible deficit if not seen within 1-4 weeks
Significant spinal nerve root compression or spinal cord compression with slower evolving neurological signs/symptoms
Severe pain with significant functional impairment
Suspected spinal tumours (benign or malignant)
Moderate to severe sciatica with recent reflex and muscle power deficit eg. foot weakness
Moderate to severe neck and arm pain with recent reflex and muscle power deficit

Category 2

Appointment within 90 days is desirable

Less severe and more long-standing pain with significant functional impairment
Acute cervical & lumbar disc prolapse with stable neurological signs/symptoms
Severe degenerative spinal disorders with limitation of activity of daily living (ADL)
Acute cervical or lumbar disc prolapse with mod-severe limb pain but minimal neurological deficit
Documented severe lumbar canal stenosis with significant neurogenic claudication/limitation of walking distance
Acute Pars defect in young adult
Anterolisthesis/spondylolisthesis with lower limb neurology and/or instability on flex/ext x-rays

Category 3

Appointment within 365 days is desirable

Mechanical lower back pain without lower limb pain
Stable mild neurological symptoms/signs which is unlikely to progress if left untreated or in whom a good surgical outcome is uncertain
Pain that is manageable or reasonably controlled with analgesia
Chronic LBP/neck pain (without leg or arm pain)
Most cases of chronic cervical and lumbar disc prolapse and degenerative spinal disorders with no to stable mild neurological deficit
Long-standing spondylolisthesis with stable neurology

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an exhaustive list

NB: Back pain with red flags – if clinical circumstances indicate the patient requires immediate treatment, refer to emergency.

Sheffield back pain red flags:

age (at onset) < 16 or > 55
motor deficit e.g. foot weakness
recent significant trauma
unexplained weight loss
history of cancer
history of IV drug use
prolonged use of corticosteroids
severe night pain
infection/fever
Many Category 2 and 3 patients referred for a surgical opinion do not require surgery or a surgical opinion. Evidence demonstrates that non-surgical management is as effective for a number of spinal conditions.
Where services are available, category 2 and 3 patients will initially be assessed / reassessed and case managed by an expert musculoskeletal physiotherapist. Outcomes from this or subsequent review may include discharge, provision of appropriate non-surgical management plans, discussion or appointment with a spinal surgeon.

Management

Analgesia/anti-inflammatories/ NSAIDs as appropriate
Physiotherapy/hydrotherapy/ back education group (if available) – minimum 6 week program
Strengthening exercises and aerobic fitness training
Activity modification (remain comfortably active)
Heat/gentle massage/acupuncture
Monitor neurological function
Complete ‘Keele STarT Back’ screening tool to identify risk of developing chronic spinal pain. Low to medium risk suggests ongoing management in primary care is appropriate.

Referral requirements

A referral may be rejected without the following information.

Essential referral information

General referral information
Presence and duration of neurological signs and symptoms
Weight loss, loss of appetite and lethargy
Fever and sweats
Management to date (including previous spinal surgery)
History of malignant disease / IV drug use
Recurrence of injury and mechanism
Severity or evolution of injury
General medical condition
Continence difficulties/sexual function
Work status, functional impairment/time of work
X-ray results – AP & lateral spine including standing views and CT/MRI results (if available)
FBC, ELFT, ESR, CRP results, rheumatoid serology (in specific cases)

Additional referral information (useful for processing the referral)

Plain lateral standing X-rays in flexion and extension for lumbar spondylolisthesis
Spinal referral questionnaire
Calcium and phosphate, electrophoresis, immunoglobins, PSA, Rheumatoid serology (in specific cases)
Physiotherapist report

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

Clinical Modifiers (where relevant)

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Reason for Referral (essential)

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can’t order, or the patient can’t afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical Information (essential)

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use