Referral to emergency

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

  • actual or threatened cauda equina syndrome:
    • unexplained or unexpected loss of bladder or bowel function
    • perianal anaesthesia
    • bilateral nerve pain (leg pain below the knees)
    • progressive weakness
    • clinical signs of spinal nerve root or spinal cord compression with severe/rapidly progressing neurological deficits including myelopathy
  • spinal tumour with significant pain and/or neurological deficit
  • spinal fracture/trauma with significant deformity, instability and/or neurological deficit
  • clinical suspicion of spinal infections
  • high risk of irreversible deficit if not assessed urgently
  • concerning features may include:
    • age at onset > 50
    • recent significant trauma
    • unexplained weight loss
    • history of cancer/malignancy
    • history of intravenous drug use
    • prolonged corticosteroid use
    • features of cauda equina
    • severe, worsening pain; especially at night
    • fever
    • recent serious illness/significant infection

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Exclusions

  • acute or sub-acute non-specific spinal pain
  • chronic non-specific spinal pain when surgical intervention is not a consideration
  • radiculopathy or spinal claudication when symptoms are not severe enough to consider surgical intervention
  • spinal pain with systemic inflammatory disorder suggested by symptoms or blood tests, refer to Central Adelaide Local Health Network rheumatology clinic
  • children with scoliosis can be directly referred to the Women’s and Children’s Hospital scoliosis clinic
  • ineligible patients include all overseas students and visitor from countries who do not have a Reciprocal Health Care Agreement with Australia
  • compensable patients, for example WorkCover are also not eligible to access this publicly funded service as compensation covers the cost of private medical expenses

Triage categories

Category 1 — appointment clinically indicated within 30 days

  • spinal disorder with accompanying red flags identified e.g. tumour, infection
  • significant spinal cord or nerve root compression with evolving neurological signs/symptoms
  • moderate to severe sciatica with new onset reflex and muscle power deficit
  • moderate to severe radicular arm pain with new onset reflex and muscle power deficit
  • spinal fractures with evolving neurological deficit

Category 2 — appointment clinically indicated within 90 days

  • radiculopathy (symptoms including pain, numbness, and weakness) ≥ 4-6 weeks unresponsive to maximal medical management
  • spinal claudication with symptoms of sufficient duration and severity unresponsive to maximal medical management
  • ineligible stable spinal fractures without neurological loss, managed via spinal virtual clinic (SVC) - refer to 'clinical management advice and resources — clinical resources’

Category 3 — appointment clinically indicated within 365 days

  • patients with non-specific spinal pain who are considering surgical treatment
  • significant or progressive deformity/scoliosis

Essential referral information

Completion required before first appointment to ensure patients are ready for care. 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.

  • spinal referral form, mandatory
  • relevant imaging results, e.g. plain X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) include radiological details/accession number
  • complete past medical history
  • current medication list
  • presence of red flags, complete relevant investigations:
    • complete blood examination (CBE)
    • electrolytes, urea, creatinine (EUC)
    • liver function tests (LFTs)
    • estimated glomerular filtration rate (eGFR)
    • erythrocyte sedimentation rate (ESR)
    • C-reactive protein (CRP)
    • smoking/vaping status - if active, strongly consider referral for smoking/vaping cessation

Clinical management advice

Spinal fractures should be referred to the Royal Adelaide Hospital Orthopaedic Spinal Surgical Service, or to the Flinders Medical Centre Neurosurgery Service if residing within the Southern Adelaide Local Health Network catchment area.

For resources regarding initial management and imaging guidelines for spinal presentations see, ‘clinical management advice and resources - clinical resources’.

Most category 2 and 3 patients referred for a surgical opinion do not require surgery; evidence demonstrates that non-surgical management is effective for the majority of spinal conditions.

To preserve surgical outpatient capacity for high acuity cases several alternate service models have been adopted, including assessment clinics provided by advanced practice physiotherapists and spinal virtual clinics (SVC).

Appropriate category 2 and 3 patients may be assessed and managed by an advanced practice physiotherapist; outcomes may include provision of non-surgical management options for primary care, further imaging/spinal interventions where indicated and referral for definitive surgical opinion.

Most category 3 patients will not be offered a formal appointment (where patients are unlikely to benefit from a lengthy wait for spinal outpatient consultation); instead these patients may be managed by the SVC, with written advice/recommendation for ongoing management in primary care provided to referring clinician following formal review of referral and spinal imaging.

Simple spinal fractures (traumatic or insufficiency) will be managed through a separate SVC; General Practitioner’s advice on surveillance imaging and remote assessment will guide care in the community.

The service also delivers a suite of telehealth services (phone/video) for both metropolitan and regional/remotely located patients when deemed appropriate.

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient 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

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.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • 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 pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.