MRI Referral Flow Chart Sciatica
Plain film lumbar spine XR is not indicated as it does not contribute to the management of leg pain
Yes
No
Does pain radiate below the knee and a genuine
straight leg raise (SLR) sign is present?
(SLR test results in severe aggravation symptoms
or LBP, not just hamstring tightness)
No
Does patient have motor deficit e.g. foot drop.
NB absent ankle jerk is not motor deficit
Yes
MRI not indicated
No
Has the patient has symptoms for more than 4
weeks?
No
Your patient may have unexpected pathology
and paediatric referral is indicated
Yes
Refer for urgent MRI and urgent surgical clinic
review
On MRI request form, write ‘urgent’ and the name
of the consultant your patient has been referred to
Yes
MRI not indicated. Continue with conservative
management, as symptoms may improve
spontaneously
Refer for routine MRI. Surgical discussion at
referrer’s discretion.
MRI request forms should state the side and
dermatomal location of symptoms / signs so that
informed correlation with imaging findings can be
made. E.g. right side sciatica, L5 dermatomal
pain/numbness. No motor signs ? R L5 nerve root
entrapment
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Forward to criteria for Acceptance GP Referrals MRI
Is patient younger than 16 years
Criteria for Acceptance of Direct GP
Referrals for Lumbar Spine MRI
Routine referral
Sciatica
•
Patients over 16 with sciatica, defined
as pain radiating below the knee,
showing no improvement within 4 weeks
of onset, with sensory deficit or genuine
positive straight leg raise.
Spinal Claudication
•
Patients with symptoms suggesting
spinal claudication (stenosis). (Pain,
weakness or numbness in one or both
legs, present on walking, eased by
sitting or bending forward, lower limb
circulation normal)
Urgent Referral
•
Patients with sciatica and a developing
motor deficit should be referred
simultaneously for an urgent MRI scan
and a surgical opinion. This should be
specified on the MRI referral form so that
it will be expedited and result made
available for the clinic appointment.
• NB an absent ankle reflex in isolation is
not a motor deficit
Clinical conditions excluded from pathway
• Suspected acute cauda equina
syndrome should be managed as
emergency
• Patients with Mechanical LBP should
not be routinely referred as most do
not require or benefit from MRI
scanning
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MRI Criteria Knee
(Barry Oliver Consultant Radiologist, Graeme Foubister Petros Boscainos and Richard Buckley Consultant Orthopaedic
Surgeons)
•
•
MRI not indicated
MRI indicated
Patients under 15 or over 60
Locked knee
•
A knee XR must have been obtained
within 6 months of MRI request
•
Suspected meniscal tear
–
–
–
•
•
(OA is very common in obese people – MRI in knees with OA
often shows meniscal damage that is not treatable by
arthroscopy)
Any previous meniscal surgery
–
•
•
(post-operative menisci simulate meniscal tears on MRI –
direct orthopaedic clinic referral is appropriate in such
patients)
Active knee inflammatory arthritis, unless symptoms
relate to a recent injury
Anterior knee pain
–
•
(such patients are orthopaedic emergencies and should be
dealt with by secondary care)
Any osteoarthritis (OA) on an x-ray
Obese patients with any clinical or radiographic
evidence of OA
–
–
(not to be confused with locking, this is momentary stiffness
following a period of immobility – typically in obese people with
patellofemoral OA)
Knee dislocation or other severe acute injury
–
•
•
previous injury with
Pseudolocking
–
•
symptoms are continuous, not momentary or intermittent
a locked knee lacks at least 15 degrees of extension and
cannot flex to 90 degrees
(such patients need urgent orthopaedic referral with a view
to arthroscopy – MRI is unnecessary and delays treatment)
(usually due to patellofemoral OA, chondromalacia patellae or
tendon problem which may benefit from physiotherapy)
Or
–
•
medial joint line tenderness and pain
worsened by external rotation at 90
degrees knee flexion
lateral joint line tenderness and pain
worsened by internal rotation at 90
degrees knee flexion
Instability
–
–
previous injury
subsequently, knee gives way during
rotation or pivoting
Forward to MRI knee flowchart
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Flowchart For Knee MRI Direct Access
Is the patient aged 15-60 years?
No patient > 60 will be accepted for
knee MRI
YES
Is the knee locked?
Is this a severe acute injury?
NO
Consider Children's Orthopaedic or Paediatric
clinic referral for children.
OA is very common in those over 60 years –
consider trial of symptomatic treatment.
YES
Urgent orthopaedic referral is indicated.
MRI may delay treatment
NO
A knee XR must have been obtained
within 6 months of MRI request
Is there: Any evidence of OA on x-ray?
Pseudolocking?
Predominantly anterior knee pain?
NO
YES
OA is likely cause of symptoms.
Consider symptomatic treatment or
physiotherapy.
YES
Rheumatology clinic referral may be more
appropriate in the absence of a relevant injury.
Is there an active inflammatory
arthritis and no recent injury?
NO
Has there been previous meniscal
surgery?
NO
Do clinical features indicate:
instability or meniscal tear
YES
YES
Consider Orthopaedic referral.
MRI referral may be beneficial to this patient
NO
Consider symptomatic treatment or physiotherapy
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