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Send the referral
Fax (07) 3236 9555, or have the patient bring it. The rooms are at Watkins Medical Centre, Level 10, 225 Wickham Terrace, Spring Hill QLD 4000.
Cervical spine referrals
Information for general practitioners and specialists referring patients with neck and arm symptoms. How to send a referral, what makes a cervical referral useful, which imaging answers which question, and the presentations that warrant escalation rather than a routine appointment.
Fax (07) 3236 9555
Referrals and correspondence. Rooms direct on (07) 3870 3708.
12 months
GP referral validity for an initial specialist consultation. Specialist referrals, three months.
Next business day
The practice states that its office will contact patients within the next business day after an online enquiry.
Mon to Fri
Reception 8:30am to 4:30pm. Urgent concerns are better phoned through than emailed.
HOW TO REFER
Getting a patient in
Nothing unusual: a current referral, the imaging, and enough clinical detail to work out whether the finding explains the symptoms.
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Or have the patient enquire
Patients can send an enquiry through the website and the office will contact them within the next business day. They do not need the referral in hand to make contact.
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Referral validity
A referral from a general practitioner is valid for twelve months; one from a specialist is valid for three months. Medicare rebates require a valid Medicare card and a current referral.
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What the patient should bring
Past and recent X-rays, scans and laboratory results, their Medicare and health fund cards, and a list of current medications. Images rather than reports alone.
The mechanics, including a checklist of what to put in the letter, are set out on refer a patient.
WHAT HELPS
Six things that make a cervical referral useful
Cervical decisions turn on whether the imaging finding explains the symptoms. Most of what settles that comes from the referral rather than from the scan.
The distribution, not just the diagnosis
Where the pain, numbness and weakness actually are. C6 and C7 account for the large majority of cervical radiculopathy, and a clear dermatomal and myotomal description often predicts the level better than the report does.
Duration and trajectory
More than 85 per cent of acute cervical radiculopathy improves without specific treatment, most within eight to twelve weeks. Whether the patient is six weeks or six months in, and whether they are improving, changes the conversation entirely.
Objective weakness, if present
Graded power rather than a report of weakness. Progressive motor loss is one of the few findings that changes the urgency of a cervical referral on its own.
Any cord signs
Hyperreflexia, Hoffmann's, clonus, gait disturbance, bilateral hand clumsiness, Lhermitte's. These shift a routine referral into a different category, and they are found on examination rather than on the scan.
What has already been tried
Which non-surgical measures, for how long, and with what effect. Whether conservative care has had a fair go is frequently the crux of the decision.
The images, not only the report
Degenerative findings are near-universal on cervical MRI in asymptomatic people. The assessment is a reading of the images against the examination, which cannot be done from a written summary.
ESCALATE RATHER THAN QUEUE
The presentations that should not sit on a routine list
Most cervical referrals are routine. A small number are not, and the difference is usually found on examination rather than on imaging.
Suspected myelopathy
Bilateral hand clumsiness, gait disturbance, hyperreflexia, Hoffmann's or clonus. Function lost to degenerative cervical myelopathy does not reliably return, which is why it is assessed on a different timescale from radiculopathy.
Progressive motor deficit
Documented weakness that is worsening between reviews, as distinct from pain that is not settling.
Sphincter disturbance or leg symptoms
New bladder or bowel change, or spreading lower limb numbness, in a patient with cervical pathology. This is an emergency department presentation, not a referral.
Systemic red flags
Fever, night pain, unexplained weight loss, a history of malignancy, immunosuppression, or significant trauma. Different differential, different pathway.
Phoning is better than faxing for these
The practice notes that it cannot guarantee a timely response to urgent matters sent through the website enquiry form, and asks that urgent concerns be phoned through on (07) 3870 3708 during business hours. A patient with acute cord compression, rapidly progressive weakness or sphincter disturbance should be directed to an emergency department rather than an outpatient appointment.
The red flags, the mJOA severity bands and the natural history evidence behind them are set out in full on urgent referrals and myelopathy red flags.
The examination decides the urgency, not the scan
What separates a routine referral from an urgent one is almost always a physical finding rather than an imaging one. Reflexes, gait and hand function say more about timing than the report does.
IMAGING
Which investigation answers which question
General guidance rather than a protocol. What matters most is that whatever is obtained comes with the patient as images, not only as a report.
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MRI
The investigation of choice for both radiculopathy and suspected myelopathy. It shows disc material, the nerve roots, the cord and the space available to it, with no radiation.
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CT
Better for bone. Useful where osteophyte, ossification or bony foraminal narrowing is the likely culprit, where MRI is contraindicated, or for surgical planning.
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Plain films, including flexion and extension
Alignment, listhesis and instability, which cross-sectional imaging in a neutral position will not show. Relevant when a motion-preserving option is being considered.
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Nerve conduction studies and EMG
Where the differential includes a peripheral entrapment or a plexopathy rather than a root lesion, or where the imaging and the clinical picture do not agree.
Bear in mind the base rate: in an MRI study of 1,211 asymptomatic volunteers, 87.6 per cent had disc bulging and 5.3 per cent had spinal cord compression. A positive scan in a patient whose symptoms do not match it is a common and unhelpful result, which is why the clinical description in the referral carries so much weight.
NATURAL HISTORY
Two findings that set the timing
Radiculopathy and myelopathy behave in opposite directions over time, which is why the same degree of imaging change carries very different urgency depending on the examination.
More than 85%
Acute cervical radiculopathy improves without specific treatment
Most of it within eight to twelve weeks, with 83 per cent regaining satisfactory function by three years. A patient six weeks into a first episode of C7 radiculopathy with intact power is on a favourable trajectory, and the referral question is usually about pain control and review rather than surgery.
StatPearls, Cervical Radiculopathy
56% by 10 years
Untreated cervical myelopathy deteriorates
Around 21 per cent had deteriorated by two years, close to 28 per cent by three years and around 56 per cent by ten years. Decompression halts progression for most people, and international guidelines report clear improvements in function after surgery, with earlier treatment giving the better odds of recovery rather than simply arrest.
AO Spine RECODE-DCM and AO Spine guideline
NEXT
Referrer pages
Refer a patient
How to send a referral, what to include in the letter, referral validity, and what to tell the patient to bring.
How to refer ›Urgent referrals and red flags
Cord signs, the mJOA severity bands, the natural history evidence, and the presentations that belong in an emergency department.
Red flags ›Contact and location
Phone, fax, consulting hours, the rooms in Spring Hill and the hospitals where surgery takes place.
Contact the rooms ›About this information
The contact details, referral validity and enquiry response statements on this page are as published by the practice. The clinical guidance is general information for referring practitioners, drawn from the sources below, and is not a protocol or a substitute for your own clinical judgement. More about Dr Tollesson.
References
Cervical Radiculopathy, StatPearls, National Library of Medicine, for the level frequencies and the natural history of acute cervical radiculopathy.
Degenerative Cervical Myelopathy: Development and Natural History, AO Spine RECODE-DCM, for the progression figures in untreated myelopathy.
A Clinical Practice Guideline for the Management of Degenerative Cervical Myelopathy, AO Spine and the Cervical Spine Research Society, for the mJOA severity bands and treatment recommendations.
Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine, 2015, for the prevalence of imaging findings in people without symptoms.
Referrals by fax to (07) 3236 9555. Urgent concerns by phone.
Rooms direct on (07) 3870 3708, Monday to Friday, 8:30am to 4:30pm. Patients can also send an enquiry through the website and will be contacted within the next business day.