REMEDY : BNSSG referral pathways

Radiology Guidelines for Primary Care

Checked: 19-09-2018 by Rob.Adams Next Review: 19-09-2019

Overview

Access to the most appropriate diagnostics from primary care should be encouraged where this facilitates the patient being cared for in primary care. This guidance has been compiled by the BNSSG planned care diagnostics team alongside primary and secondary care MSK clinicians. We welcome any feedback regarding the guidance, via the Remedy Feedback button (above right)

Guidance indicates the recommended appropriate diagnostic testing for back, shoulder, knees, small joint, soft tissue "swellings", brain and sinus.  The intention is to provide advice and guidance in order to help GPs reduce the occurrence of unnecessary or inappropriate direct access referral for imaging.

You can also access national guidelines produced by the Royal College of Radiologists on iRefer. Click on the link and then if  you are on an N3 connection you should be able to click on the green box - log in automatically -  to take you to the guidelines without needing a password.

 

 

Lumbar Spine

  • Plain film is unlikely to be helpful unless you are concerned about an osteoporotic vertebral fracture. In patients over 75 a low trauma vertebral fracture is sufficient to make a diagnosis of osteoporosis. For more information see BNSSG Osteoporotic vertebral fracture care pathway in Rheumatology section on Remedy
  • For severe sciatica with distal dermatomal distribution, lasting more than 6 weeks, consider referral to the local spinal interface service. If there are progressive neurological signs (motor weakness) refer urgently and book an MRI concurrently. For true foot drop refer to Neuro-surgery via the emergency department
  • Refer to the emergency department if there are concerns regarding cauda equina/ conus medularris syndrome (saddle anaesthesia, sphincter disturbance, acute urinary retention or incontinence associated with reduced bladder sensation, acute faecal incontinence, severe or progressive motor loss)
  • Book MRI directly for suspected spinal malignancy or spinal infection

Cervical Spine

  • Plain film is rarely useful. Degeneration of the neck is common from middle age and pain symptoms often improve with time. Consider referral to MSK services if neurological signs (motor weakness) or severe pain that is persistent and continues to disrupt daily activities

 

Shoulders

  • Plain film may be helpful in distinguishing frozen shoulder and osteoarthritis, and can demonstrate calcific tendinitis (please see the Shoulder Problems section of Remedy for guidance on the diagnosis of shoulder problems in primary care)
  • Shoulder injection may be given without imaging control. Ultrasound is indicated where there is a diagnostic dilemma or failure to respond to first line treatment and where care is likely to be maintained in primary care. If you are considering a scan you should request a plain film at the same time
  • MRI shoulder is usually for pre-operative planning and is not indicated from primary care unless discussed with a radiologist

Hips

  • Plain film is less useful in the management of osteoarthritic hip pain unless there are clinical reasons to contemplate surgery. Arthritis is common in patients over 45. Please check there has been no previous similar imaging within the last 2 years. Plain film may demonstrate features associated with femoroacetabular impingement and dysplasia
  • Consider referral to the emergency department if severe hip pain and sudden inability to weight bear +/- history of fall, sudden severe significant deterioration of chronic hip pain, sudden change in true leg length, suspected avascular necrosis or sepsis

Knees

  • Plain film is less useful in the management of osteoarthritic knee pain unless there are clinical reasons to contemplate surgery. Arthritis is common in patients over 45. Please check there has been no previous similar imaging within the last 2 years
  • MRI knee to rule out ligamentous or meniscal damage where urgent referral not indicated. Use plain film to rule out osteoarthritis as primary cause of symptoms in older patients. MRI does not add value in the investigation of the osteoarthritic knee. Surgery is unlikely to be contemplated unless there is significant osteoarthritis or true locking that fails to improve after 3 months of conservative management
  • Ultrasound is only of value in assessment of quadriceps inflammation or tears and to assess the infra-patellar tendon
  • Imaging of a Baker’s cyst is unnecessary

Previous Joint Replacement

  • Plain film may demonstrate loosening of the prosthesis. Pain after metal-on-metal joint replacement requires investigation & referral to MSK services

Heel, Achilles and Foot

  • Most cases can be diagnosed and managed using the clinical history and examination including plantar fasciitis, achilles tendinitis (including hagland’s deformity and heal spurring), and metatarsalgia (morton’s neuroma). Plain films of ankle and foot are required for those patients requiring surgical review

Soft tissue swellings

  • Ultrasound is the investigation of choice. Referral should only be performed in situations of a diagnostic dilemma and should have a clear rationale documented in the referral. Avoid imaging of characteristic lipomas and ganglia.
  • Consider 2 week wait sarcoma referral for:
    • suspicious soft tissue mass >5cm diameter
    • Any deep, hard, fixed mass
    • Any enlarging or painful soft tissue mass

Brain

  • CT scan is the initial investigation of choice.
  • Requests for MRI should be discussed with radiology – guidelines to be developed
  • Brain imaging for patients with headache: see the Headache section of Remedy for advice on 'Who should be investigated for brain tumour in primary care'
  • Also see the Brain and CNS suspect cancer section for advice on appropriate 2WW referral.

Sinus

  • Imaging rarely adds value.
  • MRI and CT not available to primary care and is for pre operative planning procedures.