Back and/or Neck Pain (Orthopaedics)

ADULT

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    The list below includes common traumatic injuries that require referral to emergency and should not be referred for elective / fracture clinic categorisation

    Adult

    Shoulder and elbow conditions

    • Clinically indicated e.g. suspected septic arthritis
      • Evidence of acute inflammation e.g: haemarthrosis, tense effusion
    • Irreducible glenohumeral dislocation with or without fracture
    • Upper limb vascular compromise
    • Elbow conditions - Dislocation with or without fracture
    • Elbow conditions - Trauma with acute neurological or vascular compromise

    Wrist and hand

    • Uncontrolled sepsis including hand infections
    • Upper limb radiculopathy in the presence of suspected cervical spine infection
    • Acute development of peripheral nerve compression symptoms following trauma or acute event
    • Suspected flexor sheath infection
    • Suspected Septic arthritis

    Bone & Soft Tumour

    • Suspected malignancy

    Hip and knee

    • Suspected septic arthritis
    • Knee extensor mechanism rupture
    • Fracture
    • Evidence of acute inflammation for example
      • haemarthrosis
      • tense effusion
    • Suspected infection or sudden pain in arthroplasty
      • if joint infection is suspected refer immediately to emergency or contact the orthopaedic registrar on call.  Do not commence antibiotics unless delay to specialist review is likely

    Foot and ankle

    • Suspected septic arthritis
    • Infected diabetic ulceration (systemic signs/symptoms)
    • Displaced fracture of the ankle or hindfoot
    • Acute achilles tendon rupture (if no fracture clinic available)
    • Avulsion fracture of achilles tendon from calcaneus

    Back and/or Neck Pain

    • Cauda equina syndrome
    • High energy spinal trauma
    • Suspected epidural abscess or discitis

    Trauma and fractures

    • Acute cervical myelopathy
    • Acute back or neck pain secondary to neoplastic disease or infection
    • Spinal injuries
    • Suspected open fracture
    • Fracture requiring manipulation or operation
    • Suspected acute bone or joint infection
    • Acute high energy fracture with/without neurological abnormality
    • Injury associated with vascular compromise
    • Clavicle fracture
    • Osteoporotic / pathological fracture new abnormal neurology
    • Joint dislocations
    • Open injuries with possible tendon or joint involved
    • Nail bed injuries or retained foreign body
    • Knee extensor mechanism rupture
    • Acute peripheral nerve injury
    • Suspected acute compartment syndrome

    Hand Trauma

    • Acute ligament injury
    • Tendon rupture
    • Open 'tooth knuckle' injury

    Upper and lower limb trauma

    • Open, unstable or suspected fractures

    Other referrals to emergency not covered within these conditions

    • Suspected open fracture
    • Fracture requiring manipulation or operation
    • Suspected acute bone or joint infection
    • Acute high energy fracture with/without neurological abnormality
    • Injury associated with vascular compromise
    • Clavicle fracture
    • Osteoporotic / pathological fracture new abnormal neurology
    • Suspected infection or sudden pain in arthroplasty
    • If joint infection is suspected refer immediately to emergency or contact the orthopaedic registrar on call
      • do not commence antibiotics unless delay to specialist review is likely
    • Joint dislocations
    • Open injuries with possible tendon or joint involved
    • Nail bed injuries or retained foreign body
    • Knee extensor mechanism rupture
    • Acute peripheral nerve injury
    • Suspected acute compartment syndrome

    Timing of first review appointments at orthopaedic outpatient's/fracture clinic

    • if there is documentation indicating adequate alignment and satisfactory initial treatment of fracture – to be seen within 14 days of referral
    • all other fracture cases, delayed presentation of tendon and nerve injuries - to be seen within 7 days of referral

    Paediatric

    Limping child/reluctant to weight bear

    • Limping child with signs of:
      • Being unwell, flushed, lethargic, fever, flat, anorexic and/or
      • Irritable and stiff joint and/or
      • Not improving
    • Systemically unwell, febrile or suspicion of septic arthritis
    • Concern of infection or trauma
    • Suspicion or concern of non-accidental injury

    NB See Slipped upper femoral epiphysis (SUFE) CPC

    Slipped upper femoral epiphysis (SUFE)

    • All suspected or confirmed SUFE should be referred to the ED or local orthopaedic on call registrar service no matter the chronicity

    Scoliosis / Kyphosis

    • Systemically unwell
    • Abnormal neurological reason

    Back pain

    • Systemically unwell

    Tumour – bone and soft tissue

    • Suspected malignancy
    • Determine the potential for underlying sinister pathology
    • Many Category 2 and most Category 3 patients referred for a surgical opinion will not require surgery. Evidence demonstrates that active non-surgical management is as effective for a number of spinal conditions.
    • Appropriate category 2 and 3 patients will initially be assessed / reassessed and case managed by an expert musculoskeletal physiotherapist. Outcomes may include provision of appropriate non-surgical management plans, discussion or appointment with a spinal surgeon or discharge.
    • Consider referral to persistent pain management early as necessary

    Medical management

    • Caution should be used in prescribing opiates for spinal pain which should be prescribed in line with current guidelines
    • Anti-inflammatory and analgesia may be considered
    • Advice, education and reassurance
      • Heat, activity modification, normal activity
    • Physiotherapy and exercise

    Clinical Resources

    Patient Resources

Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)

Request for advice /eConsult

  • Where diagnosis of the following Minimum referral consult conditions is equivocal, eConsult is available to provide timely advice in regard to diagnosis, investigations, or management or
  • May be provided on receipt of a referral if eConsult is deemed to better meet the needs of the patient.

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  • Significant spinal nerve root compression or spinal cord compression with evolving neurological signs/symptoms
    • Severe sciatica with new neurological deficit eg. Foot drop
    • Severe neck & arm pain with new neurological deficit
  • New onset or radiologically proven Cervical Degenerative Myelopathy with symptoms of spinal cord dysfunction
  • Spinal tumours (benign or malignant)
  • Spinal Infection
  • Stable spinal fractures without evolving neurological deficit
Category 2
(appointment within 90 calendar days)
  • Acute cervical & lumbar disc prolapse with moderate to severe radicular symptoms and stable neurological signs
  • Significant neurogenic claudication/limitation of walking distance with stenosis on imaging.
Category 3
(appointment within 365 calendar days)
  • Moderate neurogenic claudication/limitation of walking distance with stenosis on imaging.
  • Anterolisthesis/spondylolisthesis
  • Severe scoliosis (>50 degrees)
  • Coccydynia refractory to 6 months of conservative management including injection

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Non-surgical Pathways

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • 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

2. Essential referral information Referral will be returned without this

  • Presence and duration of neurological signs and symptoms
  • Presence or absence of concerning features
    • age (at onset) < 16 or > 50 with new onset pain
    • motor deficit e.g. foot weakness
    • recent significant trauma
    • weight loss (unexplained)
    • previous history malignancy (however long ago)
    • history of IV drug use
    • previous longstanding steroid use
    • recent serious illness
    • recent significant infection
  • Mechanism of injury
  • Functional status
  • Management to date (including previous spinal surgery and non-operative management)
  • General medical history

NB: Imaging of the spine is not recommended in most patients with an acute presentation or with a stable chronic presentation unless there is the indication of sinister or serious pathology (concerning features). If there are no signs of sinister or serious pathology imaging may be indicated after a trial of conservative therapy. (Diagnostic Imaging Pathway)

  • Relevant imaging results
    • Xray/CT  only where suspected sinister or serious pathology (concerning features)
    • MRI for suspected nerve pathology

3. Additional referral information Useful for processing the referral

  • FBC, ELFT, ESR, CRP results, rheumatoid serology, Calcium and
    phosphate, electrophoresis, immunoglobin’s, PSA (IF RELEVANT to their
    presentation)
  • Other relevant reports from any providers in a public or private sector
    related to the presenting problem

NB: Imaging of the spine is not recommended in most patients with an
acute presentation or with a stable chronic presentation unless there is
the indication of sinister or serious pathology (concerning features). If
there are no signs of sinister or serious pathology imaging may be
indicated after a trial of conservative therapy. (Diagnostic Imaging
Pathway)

  • For any lumbar spondylolisthesis plain lateral standing films in flexion
    and extension are helpful in addition to the CT/MRI

4. Request

  • Patient's Demographic Details

    • 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

    Referring Practitioner Details

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

    Relevant clinical information about the condition

    • 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

    Reason for request

    • 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 modifiers

    • 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

    Other relevant information

    • 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.)

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

    • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

    • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Last updated: 23 January 2023

© State of Queensland (Queensland Health) 2023

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