Direct access for spinal imaging

Modality

Indication

Comments

Xrays

Vertebral Fragility Fractures

 

MRI
  • Serious spinal pathology (see below)
  • New objective neurological deficit on clinical examination

Follow clinical pathway below
  • Spinal imaging is an overused investigation in primary care and should be reserved for patients with red flags where serious underlying pathology is suspected.
  • Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica.​​​​​​​
  • Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging.​​​​​​​

X-Rays

X-Ray is rarely indicated but may be helpful if osteoporotic fracture is suspected.

MRI

Consider spinal imaging in the following circumstances:

A) Features of serious spinal pathology

Red Flag Symptoms

  • Trauma
  • Constant, progressive, non-mechanical pain
  • Previous history of carcinoma, systemic steroids, drug abuse, HIV
  • Systemically unwell/weight loss
  • Persisting severe restriction of lumbar flexion
  • Widespread neurology
  • Structural deformity
  • Cauda equina syndrome
  • Inflammatory pain – night pain, morning stiffness

B) Red flags for people with sciatica

  • Bowel/bladder dysfunction (most commonly urinary retention)
  • Progressive neurological weakness
  • Saddle anaesthesia
  • Bilateral radiculopathy
  • Incapacitating pain
  • Unrelenting night pain
  • Use of steroids or intravenous drugs

Clinical pathway for serious spinal pathology

Suspected Serious Pathology

Pathway

Metastatic Spinal Cord Compression

Contact MSCC coordinator, Referral Medical Admissions Unit

Suspected Malignancy

breast, lung, gastrointestinal, prostate, renal, and thyroid cancers

Investigate in Primary Care and 2-week rule referral

Infection

Investigate in Primary care and/or referral via Medical Admissions Unit

Fracture (Low Energy Trauma)

Investigate in primary care.

Work up patients with osteoporotic fractures for secondary osteoporosis.

Refer to GIRFT Vertebral Fragility Fracture pathway

Myeloma

Investigate in Primary Care and 2-week rule referral- Haematology

Cauda Equina Syndrome / Cord lesion

Refer to A&E/Urgent care centre

Inflammatory back pain

Advice and guidance from Rheumatology prior to referral

 

Clinical pathway for low back pain with radiculopathy

New objective neurological deficit on clinical examination

Consider MRI and Referral to IMPReS SPOA or Spinal surgeons

Severe radicular pain not improved despite adequate measures

Referral to IMPReS through SPOA

Referral to IMPReS through single point of access in the following circumstances

Patients who:

  • Have Unresolved back pain with or without sciatica
  • Have had adequate first line management for the condition, but not responded to it
  • Severe radicular pain not improved despite adequate measures

And:

  • Red flags and non MSK causes of low back pain ruled out

And/or:

  • There is an uncertainty of diagnosis
  • There is a need to consider further imaging/investigation
  • There is a need for further management
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