If any part of this referral form is incomplete your referral may be

Northern Health Spinal Assessment and Management Service
Fax 9495 3510
This assessment form must be fully completed and sent with your referral letter
5.
Are there any signs of neurological
involvement?
Patient Name: ___________________________
Clonus
Yes
No
Plantar reflex (do toes go up?)
Yes
No
Ataxia
Yes
No
Hyperreflexia
Yes
No
Asymmetrical reflex loss
Yes
No
Urinary/bowel dysfunction
Yes
No
DOB: ________________
1.
Your referral letter needs to include the
following:
-
Reason for referral/working diagnosis
Medical history
Current Medications
Current management & response to this
Imaging and other relevant investigations
Weakness (please list weakness groups):
Attach report(s), and request patient to bring imaging to
appointment
2.
Is the patient’s body mass index (BMI) greater
than 40 kg/m2?
Yes
No
3. Please indicate the area(s) of symptoms:
Any other relevant signs/symptoms?
6.
Have conservative
treatment/management options been
trialled?
Exercise
Yes
No
Physio/Chiro/Osteo
Yes
No
Weight Loss (if applicable)
Yes
No
Other (please list):
7.
Functional Limitations
Walking duration
<100
100-150m
>500
Sitting duration?
<5min
5-15mins
>15mins
Is sleeping significantly disturbed?
8.
Yes
No
Has the patient had spinal surgery within
Victoria in the past? If so, where and when?
4. Does the patient have features of inflammatory
back pain?
Yes
No
9. Has the patient been referred to another
health service for assessment of this spinal
problem?
Yes No
If any part of this referral form is incomplete your referral may be
rejected and returned to you for further information
Explanatory Key for Assessment Form
Ask patient to describe the area of pain as accurately as possible, then shade this area on the
body chart. This helps to identify different causes of pain by identifying if pain has a more
typical dermatome or not.
Please describe cause (if any) and approximate date of onset.
progressively worsened.
Let us know if it has
The patient’s BMI assist in determining the most appropriate management. (BMI – (weight
(kg)/height (m)2).
Please ensure that the patient has both films and reports of any investigations available to bring
to their appointment.
Signs of Neurological Involvement
Clonus is a series of involuntary muscular contractions due to sudden stretching of the
muscle. Clonus is a sign of certain neurological conditions, and is particularly associated
with upper motor neuron lesions. Clonus is most common in the ankles, where it is tested by
rapidly flexing the food upward (dorsiflexion). Only sustained clonus (5 beats or more) is
considered abnormal.
The plantar reflex is examined by firmly drawing or scraping a blunt instrument along the
lateral sole of the foot and observing the movement of the toes. A normal response is a
downward (flexed) movement or no movement. If the toes move upwards this is considered
abnormal and is a sign of upper motor neuron damage.
Ataxia is a gross lack of coordination of muscle movements. This may be evident in eye
hand coordination or by gait dysfunction (wide stance, poor imbalance, short stride length).
Hyperreflexia is defined as overactive or over responsive reflexes. Examples of this can
include twitching or spastic tendencies, which are indicative of upper motor neuron disease
as well as the lessening or loss of control ordinarily exerted by higher brain centres of lower
neural pathways (disinhibition). Loss of a reflex indicates a potential lower motor neuron
damage.
Bladder and bowel dysfunction can occur as a result of cord or cauda equina damage.
Signs of incontinence and loss of control, particularly when associated just prior or soon
after the onset of neck or back pain maybe significant indicators or neurological damage.
Sensory loss and motor weakness can indicate both cord (mylopathic) or nerve root
(radicular) compression. The pattern of loss indicates the type and extent of neurological
damage. The patient may describe weakness of a muscle group (i.e. dorsiflexors of foot) or
more general nature. Similarly sensory loss may relate to a prescribed area supplied by a
particular nerve root (dermatome) or more generally.
Many types of low back/leg pain and neck/arm pain will respond to a range of
conservative measures.
In order to prevent acute pain becoming chronic, these
conservative options should be explored first unless the involvement of neurological signs is
more profound.
Functional limitations help to identify certain types of mechanical and neurological
involvement. Whilst a more extensive functional analysis is useful, these key functions will
assist in diagnosing certain types of injury.
For further information email [email protected] or call 1300 128 539
If any part of this referral form is incomplete your referral may be
rejected and returned to you for further information