Magnetic Resonance Imaging (MRI) Referral Guidelines Speciality of Radiology March 2011

Version: Ratified by (name of Committee): Date ratified: Date issued: Expiry date: (Document is not valid after this date) Review date: Lead Executive/Director: Name of originator/author:

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1.0 NHS Worcestershire Clinical Senate 8th March 2011 29th March 2011 Any revisions to the policy will be based on local and national evidence Minimum 3 yearly March 2014 Simon Hairsnape Dr Umesh Udeshi, Worcestershire Acute Hospitals NHS Trust Ms Chris Emerson, Head of Acute Commissioning, NHS Worcester NHS Trusts, Independent Providers, GP’s, patients NHS Trusts, Independent Providers, GP’s, patients, Public & Patient Involvement Forum

CONTRIBUTION LIST Key individuals involved in developing the document Name Dr Umesh Udeshi Dr Richard Davies

Designation Consultant Radiologist GP, Redditch & Bromsgrove GPCC

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1. Background MRI scanning is a powerful diagnostic tool and frequently helps to select the most appropriate treatment option and plan management in patients with musculoskeletal disorders. The list below represents abridged guidelines on situations where MRI may or may not be specifically indicated and is based on the Royal College of Radiologists publication ― Making the Best use of a Department of Clinical Radiology‖ (5th edition). These Guidelines represent the opinion of experienced specialist radiologists and help to outline a number of clinical presentations and situations where MRI scanning may be of value and others where the investigation may not be indicated. In circumstances where there is clinical doubt or symptoms are severe, unremitting or progressive, urgent assessment by an appropriate specialist clinician should be considered.

2. Referrers Responsibility Referrals for MRI will only be accepted on an appropriate request form. The contraindications section of this form should be filled in; failure to do this will cause a delay or possibly refusal to scan your patient. The referrer must be familiar with the duties and responsibilities of a referrer who must be conversant with the exposure and safety implications that may relate to their patient during the MR examination. Ultimately, the responsibility for the patient’s health and well being will rest with them. Referring clinicians must confirm that there are no contraindications to MRI for their patient before referral. Ensure the patient is identifiable from the request form. Name, Date of birth, address, telephone number and NHS number must all be present. An electronic ICE Order Comms request will be expected once rolled out to all practices. Ensure clinical details conform to those in the referral guidelines. If they do not, or there is insufficient information for the practitioner then the examination may not be performed. There must be the referrer’s signature and name written legibly in block capitals so that the referrer can be identified. Cases that do not meet the eligibility criteria but are determined to be exceptional should be discussed with the consultant radiologist before referrial for MRI.

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3. Clinical Indicators for MRI Referral: Area and Symptoms

Indicated or not

Lumbar Spine Sciatica less than 6 weeks with no adverse features (no red flag symptoms or signs)

MRI not usually indicated RCGP guidelines indicate that conservative management is appropriate in sciatica without adverse features, MRI reserved for sciatica which does not resolve within the 6 week period.

Sciatica failed conservative management

MRI indicated Clinico-radiological correlation is important, as a significant proportion of disc herniations demonstrated on MRI are asymptomatic

Low Back Pain with adverse symptoms or signs

MRI spine indicated. Sphincter or gait disturbance Saddle anaesthesia Severe progressive motor loss Widespread neurological deficit Previous carcinoma Systemically unwell weight loss HIV, IV drug abuse Steroids Structural deformity

Acute Cauda Equina

MRI indicated ( Urgent referral via Neurosurgery/specialist orthopaedic route) Sphincter or gait disturbance Saddle anaesthesia

Mid line chronic low back pain— without progression

Not usually indicated. In the absence of focal or neurological signs, asymptomatic chronic degenerative changes are a common finding. A trial of non interventional treatment ( exercise, physiotherapy, chiropractor treatment may be appropriate)

Chronic facet joint symptoms and signs – but without radiation down leg

MRI not usually indicated. Non-invasive treatment is often effective. MRI should be reserved for cases with atypical symptoms.

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Thoracic Spine Isolated Chronic Back Pain Without adverse features or radiation

MRI Not Usually Indicated. MRI very rarely identifies treatable lesions in the absence of focal features. Imaging is rarely useful in the absence of neurological signs or pointers of metastases or infection

Thoracic pain with radicular radiation - long tract signs or persistent symptoms.

MRI Thoracic Spine Indicated In adults thoracic radicular pain may be an early sign of impending cord compression. Acute thoracic pain in elderly patients may require more urgent referral for imaging to assess for vertebral collapse. Plain radiographs are often adequate with MRI reserved for complex cases.

Cervical Spine Neck pain with brachalgia and/or neurological signs

MRI Cervical spine Indicated In patients where pain affects lifestyle, is unresponsive to conservative treatment or there are adverse features (eg long tract signs). MRI is most useful where there are single root symptoms and signs, and least useful where symptoms and signs referable to multiple dermatomes.

Acute Neck pain

MRI not Usually Indicated Severe or adverse features only. Most neck pain resolves on conservative treatment. Degenerative changes are invariably seen on MRI beginning early middle age and are often unrelated to symptoms.

Chronic Neck Pain

MRI Not Usually Indicated Degenerative changes are invariably seen on MRI beginning early middle age and are often unrelated to symptoms.

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Hip Hip Pain

MRI Pelvis Not Usually Indicated (5) X-ray or MRI only if symptoms and signs persist or there is a complex history. X-Ray usually 1st line investigation.

Hip pain with suspected avascular necrosis

MRI Hip Indicated X-Ray usually 1st line investigation.

Knee Acute Knee Pain – Following trauma MRI Knee Indicated or accident, in previously nonEspecially under the age of 50 and symptomatic joint. without signs of osteoarthritis X-Ray usually 1st line investigation. Long-Standing Knee Pain – (18-50 Year Old)

MRI Knee Indicated Particularly for suspected ligament or meniscal injury.

Long-Standing Knee Pain – (Over 50 years Old)

MRI Knee Indicated – (Following XRay) In patients over 50 a plain film should be performed before requesting MRI as this can highlight joint degeneration, when MRI may not be indicated.

Ankle and Foot Ankle and foot Symptoms

Specialist Referral MRI should be used selectively and normally only requested by a specialist clinician.

Shoulder Non localised shoulder pain

MRI not usually indicated

Shoulder impingement syndrome, shoulder instability, rotator cuff tear

Specialist referral. MRI may be useful. This is usually a clinical diagnosis. Imaging only indicated after initial conservative management or if invasive treatment being considered.

Elbow Elbow Symptoms

Specialist Referral Usually reserved for when surgical intervention is being considered.

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Wrist Wrist Symptoms

Specialist Referral Usually reserved for when surgical intervention considered.

Brain Headache

MRI Brain Indicated - Although MRI should be used selectively and normally only requested by a specialist clinician. Imaging in chronic headache without focal neurology is usually unrewarding.

4. Exclusions: There are a number of Contraindications to MRI. Pacemakers Implantable cardioverter-defibrillators Cochlear implants Confirmed metallic foreign body in orbit of eye Vagus nerve stimulators Neuro stimulator Cerebral aneurysm clip in the brain Capsules retained from Capsule Endoscopy

5. Cautionary The following are a list of implants that will need to be determined as MRI safe prior to the MRI examination. The provider will obtain and cross check the make and model number against a MRI safety register. Where the implant is determined to be safe the patient episode will continue, however where the implant is determined to be unsafe the request will be rejected on grounds of safety. Also listed are circumstances where extra precautions and patient awareness will be addressed with the patient prior to the examination, and which may lead to deferral of the examination. Heart valve Replacement (Please include details of make, type, details of when and where surgery performed if possible) Intra-vascular stents, filters and coils Page 6 of 7

Ocular implants Shrapnel injuries Penile implants Any other unknown implant until it has been determined as MRI safe 1st Trimester of pregnancy Recent metallic implants or clips (within 6 weeks)

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