September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

1. September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

2. Referral Pathways through the Spine Service

3. Referral from 2° care Specialist Nurse Conservative Management Physiotherapy DISCHARGE GP Referral Triage Further investigation Osteopathy Surgical Management Injection Therapy Request to GP to refer to Pain Management Watchful waiting

4. GP Referrals • CSSS takes referrals from Trent region as it is the regional centre for excellence in spinal surgery. • Spinal cord injuries referred to Sheffield. • Patients arrive at CSSS once they have been triaged in the community. 1°/GP Referral

5. Triage Process • Initially paper triage • ‘Chronics’ triaged by ESP’s • Surgical/pathologies triaged by surgeons • ± 80% referrals non-surgical GP referral Triage

6. Further Investigation • Imaging – MRI, CT, X-ray, DEXA • Bloods • Neurology - NCS GP Referral Triage Further investigation

7. Surgical Management • Specific neurological findings • Imaging identifies pathology • CES or ICES • Deformity GP Referral Triage Further investigation Surgical Management

8. Conservative Management • No pathology on imaging. • No clear/concerning neurological findings. • No surgical target. • Examination reveals findings which support conservative management. Conservative Management 1°/GP Referral Triage Further investigation

9. Discharge Considerations • No surgical target. • No pathology. • ‘Normal’ neurology. • No findings on examination which would support conservative management. • Where reassurance is required. • Where GP management is appropriate. • Inappropriate referral – with advice for appropriate referral/specialism. GP Referral Triage DISCHARGE

10. Surgical vs. Conservative Management Where either a surgical or conservative management approach has been advised, that decision can be reversed at any point if: • The condition improves or deteriorates. • New evidence comes to light to warrant a change in management. • The chosen option fails to deliver the anticipated outcome. • A new pathology emerges. • The patient changes their mind. Conservative Management DISCHARGE GP Referral Triage Further investigation Surgical Management

11. Referral from 2 Care Referral from 2° care • From sports medicine, oncology, rheumatology, orthopaedics, etc, where a spinal opinion is required. • Into MDT meeting. Conservative Management DISCHARGE GP Referral Triage Further investigation Surgical Management

12. Watchful Waiting Referral from 2° care • Watchful waiting – where no specific intervention is indicated but patient needs to be monitored if there is concern that the condition could deteriorate, e.g. DDD, scoliosis, ? Myelopathy. Conservative Management DISCHARGE GP Referral Triage Further investigation Surgical Management Watchful waiting

13. Pain Management Referral from 2° care • Unable to refer directly to pain management from 2 care, therefore need to refer patient back to GP with request to make a referral to pain management. Conservative Management DISCHARGE GP Referral Triage Further investigation Surgical Management Request to GP to refer to Pain Management Watchful waiting

14. Specialist Nurse Referral from 2° care Specialist Nurse • Include: • Oncology nurse • Scoliosis nurse • Osteoporosis nurse • Post-op nurse Conservative Management DISCHARGE GP Referral Triage Further investigation Surgical Management Request to GP to refer to Pain Management Watchful waiting

15. Injection Therapy Referral from 2° care Specialist Nurse • Injection therapies – therapeutic and diagnostic intervention. • Includes FJI, NRB, SIJI, CE. • Where deemed to be an effective management technique, request made for PM to take over. Conservative Management DISCHARGE GP Referral Triage Further investigation Surgical Management Injection Therapy Request to GP to refer to Pain Management Watchful waiting

16. Physiotherapy • Post op rehab • Post trauma rehab • Muscle imbalance • Weak core • Neuromuscular conditions Referral from 2° care Specialist Nurse Conservative Management Physiotherapy DISCHARGE GP Referral Triage Further investigation Surgical Management Injection Therapy Request to GP to refer to Pain Management Watchful waiting

17. Osteopathy Referral from 2° care Specialist Nurse • Where mechanical dysfunction is suspected. • Where assessment identifies ‘osteopathic restrictions’. • Where ST components are identified. • Where other interventions have failed – surgical/conservative. Conservative Management Physiotherapy DISCHARGE GP Referral Triage Further investigation Osteopathy Surgical Management Injection Therapy Request to GP to refer to Pain Management Watchful waiting

18. Referral Pathways through the Spine Service Referral from 2° care Specialist Nurse Conservative Management Physiotherapy DISCHARGE GP Referral Triage Further investigation Osteopathy Surgical Management Injection Therapy Request to GP to refer to Pain Management Watchful waiting