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Spinal pain

Red flags

Refer to alternate diagnostic services

Consider urgent (orthopaedic) referral for patients with the following :

  • With respect to severe back/neck pain, presence of ≥ 1 factors that apply to symptoms:
    • follows a fall, blow to the back/neck or other injury
    • is constant or intense
    • worsens during rest or at night
    • severe pain that spreads down one or both legs/arms
    • causes persistent weakness, numbness or tingling in one or both legs/arms
    • is associated with new bowel or bladder problems
    • is accompanied by fever
    • is associated with pain or throbbing in the abdomen
    • is accompanied by unexplained weight loss
    • a history of cancer, osteoporosis, steroid use, or drug or alcohol abuse

Features that may lead to more urgent PPMS categorisation

  • Escalating opioid drug use
  • Psychological/psychiatric/occupational barriers to recovery
  • Development of features suggestive of complex regional pain syndrome
    • Vasoconstriction/dilation, sweating in area of pain, trophic changes

Most spinal pain will previously have been seen by a spinal orthopaedic specialist before referral to Persistent Pain Management Services. Do not refer unless the pain has been present for more than 6 weeks and the cause has been diagnosed.

Spinal pain conditions include:

  • Chronic neck pain
    • Degenerative (OA, disc degeneration, osteoporotic)
    • Whiplash/traumatic/post-surgical related
    • Inflammatory (rheumatological conditions)
  • Chronic low back pain
    • Degenerative (OA, disc degeneration, osteoporotic)
    • Traumatic/post-surgical
    • Inflammatory (rheumatological conditions)

Other important information for referring practitioners

Lifestyle changes

  • Encourage healthy activity within pain limits
    • Consider physio referral
    • Hydrotherapy
  • Weight reduction especially for low back pain
    • Dietician referral
  • Ensure adequate sleep
  • Check for mood disturbances and relationship difficulties
    • Consider psychology referral for any mood disturbances

Medical management

  • Ensure no evidence of serious neurological compromise
    • Weakness, sensory involvement
    • Bowel and bladder dysfunction
    • Exclude neuropathic pain (use the DN4 questionnaire)
  • Do not continue to investigate chronic spinal pain if initial investigations exclude serious pathology
  • Use a logical graded approach to pain relief with particular focus on:
    • Maintaining activity
    • Maintaining social functioning
    • Ensuring adequate sleep
    • Set realistic treatment goals
    • Avoid undue reliance on medication for symptom control
    • Avoid medication overuse
      • If using opioid medication try to use only for acute exacerbations
      • Consider pain modifying agents to avoid chronic opioid use
        • Amitriptylene/Nortriptylene (may have positive effects on anxiety and sleep)
        • Duloxetine (may help with associated anxiety and depression and is  recommended for neuropathic pain)
        • Pregabalin (now PBS listed for neuropathic pain in primary care)

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • Persistent Pain Management Service eReferral form
  • Reason for referral
    • Management plan
    • Specific concerns re medication overuse/dependence
    • Specific interventions
  • History of condition
    • Date of onset
    • Mechanism of injury (if relevant)
  • Current and previous relevant medical conditions
  • Management of condition including treatments trialled and reasons for failure
    • Include relevant specialist letters or opinions
  • Any forensic and current medicolegal issues
  • Current medications and past drugs used to control pain
  • Allergies
  • List drug dependencies, inappropriate drug use and prescribed drug misuse e.g. nicotine, alcohol, cannabis, opioids
  • History of treatment within Alcohol and Drug Services or notifications to Medicines Regulation authorities
  • Relevant examination findings
    • Evidence of neurological damage
      • Wasting, fasciculation, reflex changes, hypersensitivity
  • Investigations
    • FBC, E/LFT, BS
    • Relevant imaging

Additional referral information (useful for processing the referral)

  • Patient to complete entry patient questionnaire prior to first consultation
  • Investigations related to co-morbidities e.g. diabetic control

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.

  • 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

  • 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

  • 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

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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