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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk. Referral Pathways through the Spine Service. Referral from 2° care . Specialist Nurse. Conservative Management. Physiotherapy. DISCHARGE. GP Referral. Triage. Further investigation. Osteopathy.

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September 5th – 8th 2013

Nottingham Conference Centre, United Kingdom

www.nspine.co.uk



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


Gp referrals
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


Triage process
Triage Process

  • Initially paper triage

  • ‘Chronics’ triaged by ESP’s

  • Surgical/pathologies triaged by surgeons

  • ± 80% referrals non-surgical

GP referral

Triage


Further investigation
Further Investigation

  • Imaging – MRI, CT, X-ray, DEXA

  • Bloods

  • Neurology - NCS

GP Referral

Triage

Further investigation


Surgical management
Surgical Management

  • Specific neurological findings

  • Imaging identifies pathology

  • CES or ICES

  • Deformity

GP Referral

Triage

Further investigation

Surgical Management


Conservative management
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


Discharge considerations
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


Surgical vs conservative management
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


Referral from 2 care
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


Watchful waiting
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


Pain management
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


Specialist nurse
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


Injection therapy
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


Physiotherapy
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


Osteopathy
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


Referral pathways through the spine service1
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


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