Please send form to:
Email: kch-tr.spinemdt@nhs.net
Post: Spine MDM, Neurosurgery, King’s College Hospital, Denmark Hill, LONDON, SE5 9RS
Phone: 020 3299 5178 / 1225
Please note we no longer accept faxes
Neurosurgery Spinal MDT Referral Form
Are Back Pain “Red Flags” of Cauda Equina Syndrome present?
Red flag cases require urgent assessment and should be immediately referred to A&E or
discussed with Neurosurgery on-call via telephone. This form is for non-emergency referrals
only. Please do not refer red flag cases to the MDT unless advised to do so by on-call or A&E.
Lambeth & Southwark residents should be referred to the MCAT Service via the referral form
available on the KCH website: http://www.kch.nhs.uk/gps/referral-forms
Referrals are first reviewed and triaged by our spinal MDM panel. If surgery is not recommended
we do not offer an outpatient appointment. With this in mind, please provide a detailed outline of
patient symptoms and a clinical history of what has been tried already such as physiotherapy or
pain management. Please be clear on what symptoms you are asking the surgery team to treat.
We require an MRI less than 6 months old to review a patient and will need details of the
location where those images were performed in order to obtain the images. If the MRI was
performed overseas or privately we will need a CD copy of the imaging sent with the referral.
We do not accept referrals where the patient has isolated neck or axial back pain without nerve
compression. The MDM exists to identify patients with signs and symptoms of nerve root or
spinal cord compression which may be amenable to surgical intervention.
If the mandatory fields on this form are not completed the referral will be returned without being
reviewed by the clinical team.
*Referrer:
*Title:
Department:
*Date of Referral:
*NHS Number
*Referrer
Address
*Patient Name
E-mail address
*Date of birth
Fax number
*Tel. number
*GP Name
*Patient
Address
*GP Tel. number
*GP address
* Denotes mandatory field. Referral forms will be returned without clinical review if mandatory fields are not completed.
Date of last review: November 2015. Next review due: May 2017
05/02/2016
1
*History of presenting complaint: Duration and details of symptoms (eg: weeks/months/years
history, back/leg/arm pain, right/left side, pins and needles/numbness, paraesthesia etc.)
*Neuro Examination Findings (Power, sensation, reflexes, SLR):
*MRI Spine
Yes
No
*Where performed:
Date:
NB must be less than 6 months old or referral
will be returned (tertiary referrals only)
X-ray
Spine
Please attach report if available
Yes
No
NB: If performed overseas or
privately we require a CD copy of
MRI to accompany the referral.
Where performed:
Date:
Please attach report if available
Other:
*Previous conservative treatments
Physiotherapy
Pain clinic
Osteopathy
Epidural
Other (please state):
Outcomes:
*Previous surgical procedure (if any):
*Past medical history:
*Current medication: (Including information on anti-coagulant medication)
*Is the patient fit for general anaesthetic?
Yes
No
*Is the patient willing to consider surgery?
Yes
No
* Denotes mandatory field. Referral forms will be returned without clinical review if mandatory fields are not completed.
Date of last review: November 2015. Next review due: May 2017
05/02/2016
2
Any additional information:
Please check all sections have been completed before sending. Any referrals that are not
complete or do not fit the required criteria will be returned. Thank you for your co-operation.
* Denotes mandatory field. Referral forms will be returned without clinical review if mandatory fields are not completed.
Date of last review: November 2015. Next review due: May 2017
05/02/2016
3