Salisbury Foundation Trust Radiology Department Referral Guidelines for Primary Care: Musculoskeletal Imaging

Transcription

1 Salisbury Foundation Trust Radiology Department Referral Guidelines for Primary Care: Musculoskeletal Imaging These guidelines have been issued in conjunction with the Royal College of Radiology referral guidelines, irefer: Making the Best Use of Clinical Radiology, version 8 (2017) and with NICE guidelines. This document is available on ICID, via the Trust website. Requests made outside these guidelines will be returned by mail or . Non-specific requests, such as?joint/ligament/tendon/muscle, will also be returned. Please provide detailed clinical information including your history and examination findings with a clear clinical question. It is possible that an imaging examination requested is changed to an alternative examination or that an additional examination is performed. Patients who attend the walk-in GP service with referrals not clinically indicated according to these guidelines will be sent away and asked to contact their referring GP practice. Please note that this document is not exhaustive and if you need further advice regarding referral for imaging investigations, then please contact the Duty Radiologist who is available on extension 4873 via the hospital switchboard ( ) 9 am 5 pm, Monday to Friday. Referrals for complex imaging can be accepted in accordance with specific instructions from a Radiologist in an imaging report, or following discussion with the Duty Radiologist. Please note that requests for imaging to be performed locally on the basis of advice from external specialists may not be accepted. In this event any referral should include the clinic letter from the specialist. Information regarding the location of previous imaging examinations should also be included so an attempt can be made by Radiology Department administration staff to import images and reports necessary for comparison. October 2018 Dr Graham Lloyd-Jones Lead Clinician and MSK Radiologist Dr Katie Peace Clinical Lead for MRI and MSK Radiologist Dr Sam Leach MSK Radiologist 1

2 Any body part Imaging technique/referral Comments/exceptions Trauma is the first line investigation See specific body parts for additional information Osteoarthritis Imaging not generally indicated In general imaging is only indicated to exclude other diagnoses See NICE guidelines CG177 sections See specific body parts for exceptions Clinical indication regarding possible other diagnosis must be provided, for example - trauma - morning stiffness - hot swollen joint - suspected gout - suspected inflammatory arthritides (e.g. rheumatoid) - suspected septic arthritis - suspected malignancy Muscle and tendon injuries - Partial/ low grade - High grade No imaging indicated Specialist referral Consider urgent referral for suspected acute high grade injury as early repair may be indicated Image guided joint / soft tissue injections Not indicated from primary care Soft tissue lump and - Pain, tenderness, fixed, >5 cm or enlarging or Atypical clinical features (please specify) Ultrasound (US) Clinical follow up will be required for soft tissue lumps even if US does not show sinister features such as pain, enlargement, skin discolouration Patients who have unremarkable US findings should be followed up clinically and encouraged to report development of sinister features Soft tissue lump and - - Suspected lipoma - Lump <5 cm, soft, nontender, not enlarging No imaging indicated Follow up clinically Skin lesions No imaging indicated Consider referral to dermatology 2

3 Cervical Spine Imaging technique/referral Comments/exceptions Traumatic neck pain (Emergency Department referral may be appropriate see comment) If acute cervical spine fracture or ligamentous injury is suspected then the patient should be immobilised and ambulance transfer to the Emergency Department should be arranged Suspected osteoporotic collapse Suspected axial spondyloarthritis Rheumatology referral Non-specific neck pain not responding to conservative management after 12 weeks without red flags*** Referral to spinal physiotherapy or spinal surgeons Neck pain generally improves or resolves with conservative treatment Degenerative changes begin in early middle age and are often unrelated to symptoms and, therefore, s of the cervical spine are often not useful Pain - With radiculopathy Referral to spinal physiotherapy or spinal surgeons An MRI request may also be made at the time of making the specialist referral but no MRI will be accepted unless it is stated that referral has been made in the clinical details provided Please specify the side and dermatomal distribution Pain - History of malignancy or other red flags *** Urgent referral to spinal surgeons An MRI request may also be made at the time of making the specialist referral but no MRI will be accepted unless it is stated that referral has been made in the clinical details provided Pain - Suspected cord compression Immediate referral to the on call orthopaedic team who will arrange imaging *** see appendix 3

4 Thoracic Spine Imaging technique/referral Comments/exceptions Traumatic back pain Emergency Department referral may be appropriate Suspected osteoporotic collapse Suspected axial spondyloarthritis Rheumatology referral Non-specific thoracic spine pain without trauma No imaging indicated Degenerative changes are invariably present from middle age onwards. Imaging of the thoracic spine is rarely useful in the absence of red flags *** Pain - Persistent / difficult to manage Referral to spinal physiotherapy or spinal surgeons Pain with - History of malignancy or other red flags *** Urgent referral to spinal surgeons An MRI request may also be made at the time of making the specialist referral but no MRI will be accepted unless it is stated that referral has been made in the clinical details provided Pain with - Suspected cord compression *** see appendix Immediate referral to the on call orthopaedic team who will arrange imaging 4

5 Lumbar Spine Imaging technique/referral Comments/exceptions Traumatic back pain Emergency Department referral may be appropriate Suspected osteoporotic collapse Suspected axial spondyloarthritis Rheumatology referral Non-specific lower back pain Imaging is not indicated Non-specific lower back pain with or without sciatica not responding to conservative management after 12 weeks without red flags*** Referral to spinal physiotherapy or spinal surgeons No imaging of the lumbar spine is indicated in the context of non-specific lower back pain with or without sciatica See NICE guidelines NG59 sections Pain with - History of malignancy or other red flags *** Urgent referral to spinal surgeons An MRI request may also be made at the time of making the specialist referral but no MRI will be accepted unless it is stated that referral has been made in the clinical details provided Pain with - Suspected conus or cauda equina compression ***see appendix Immediate referral to the on call orthopaedic team 5

6 Shoulder Imaging technique/referral Comments/exceptions Traumatic shoulder pain Acute dislocation refer to ED Pain < 50 years of age - Impingement - Rotator cuff US only after failed conservative management (including physiotherapy and injection if appropriate), and if patient suitable for surgical repair Pain > 50 years of age - Impingement - Rotator cuff is first line investigation normal US only after failed conservative management (including physiotherapy and injection if appropriate), and if patient suitable for surgical repair abnormal specialist referral Shoulder instability / recurrent dislocation and orthopaedic referral Elbow Imaging technique/referral Comments/exceptions Traumatic elbow pain Suspected epicondylitis Imaging is not indicated prior to specialist referral Epicondylitis is usually a clinical diagnosis and US is not usually required 6

7 Wrist / Hand/ Thumb Imaging technique/referral Comments/exceptions Traumatic wrist/hand/thumb pain Please specify anatomical site of pain/tenderness e.g. radial wrist, dorsal wrist, MCP joint, distal/proximal interphalangeal joint If base of thumb pain, please specify if CMC or MCP joint Suspected inflammatory arthritis and rheumatology referral If there is a clinical suspicion of inflammatory arthropathy then and specialist referral Referral for US small joints of the hands will not be accepted Tenosynovitis US Hip Imaging technique/referral Comments/exceptions Traumatic hip pain Bursitis US is of limited benefit and does not alter management prior to specialist referral Consider referral if conservative management fails. Trochanteric bursitis is a clinical diagnosis which frequently reflects tendinopathy of the gluteus medius insertion on the greater trochanter, without a bursal fluid collection Suspected femoroacetabular impingement in patient <50 and refer to orthopaedics s can be normal so if this diagnosis is suspected in patients <50, then referral is required regardless of findings 7

8 Knee Imaging technique/referral Comments/exceptions Traumatic knee pain Post-traumatic knee pain with locking or instability + referral Urgent referral may be indicated Knee pain years first line investigation MRI only indicated if plain X- ray is entirely normal and conservative management has failed with high clinical suspicion of ligament or meniscal of the knee is required prior to planning MRI and is required for complete MRI interpretation Please provide detailed information regarding examination findings and suspected diagnosis Knee pain > 40 years first line investigation MRI not indicated prior to orthopaedic referral If suspect malignancy then urgent orthopaedic referral indicated. Suspected injury to extensor mechanism (quadriceps tendon and patella tendon) US Ultrasound can demonstrate quadriceps tendinopathy or patellar tendinopathy Suspected Osgood- Schlatter s Imaging is not routinely indicated Osgood-Schlatter s disease is a clinical diagnosis Baker s cyst can be helpful see comments A mass in the popliteal fossa is very likely to be a Baker s cyst and these generally do not require any imaging can be helpful to show osteoarthritis the most common cause of a Baker s cyst in adults Consider US if there are atypical or potentially sinister features Post surgical Knee and orthopaedic referral No request for MRI will be accepted prior to referral for patients who have had previous knee surgery of any description 8

9 Ankle Imaging technique/referral Comments/exceptions Traumatic ankle pain US has no role following ankle sprain or suspected ligamentous injury prior to specialist referral Tendinopathy / tenosynovitis US Acute tendon rupture (e.g. Achilles tendon) Urgent Specialist / Emergency Department referral Chronic Achilles tendinopathy Imaging is not indicated prior to physio / specialist referral Foot Imaging technique/referral Comments/exceptions Traumatic foot pain Tendinopathy/ tenosynovitis US Morton s neuroma / intermetatarsal bursitis US not indicated prior to specialist referral In the case of clinically suspected Morton s neuroma an can be helpful to determine presence of osteoarthritis which is the most common cause of forefoot/toe pain Plantar fasciitis No imaging indicated Consider referral if not responding to conservative management Most patients with heel pain can be managed on the basis of clinical findings without imaging 9

10 Appendix: Red Flags. The term red flags in the context of spinal pain, refers to clinical or laboratory features which may highlight serious underlying : Neurological: - Sphincter or gait disturbance - Severe/progressive motor loss - Saddle anaesthesia - Widespread neurological deficit Other: - Previous or current malignancy - Systemically unwell - Raised CRP with no other identified cause - HIV - Weight loss - IV drug abuse - Steroids - Structural deformity - Non-mechanical back pain (no relief with bed rest) - Any other feature of concern please discuss with the Duty Radiologist available on extension 4873 via the hospital switchboard ( ), 9 am 5 pm, Monday to Friday. Dr G. Lloyd-Jones Dr K. Peace Dr S. Leach Lead Clinician and MSK Radiologist Clinical Lead for MRI and MSK Radiologist MSK Radiologist October