Spinal Practitioner

The spinal Advanced Physiotherapist Practitioner (APP) service has been running for over 10 years. The team is an integral part of the NUH spinal service and includes clinical and admin staff.

A spinal APP is a physiotherapist who has specialised in spinal assessment, management and care.

Training includes post-graduate qualifications such as a Master’s degree and/or specialised training with the spinal surgical consultant team. APPs are accountable to the Health and Care Professions Council. APPs are required to keep up to date with evidence-based practice, role specific competencies and to demonstrate their ongoing capability, usually in a portfolio format.

The APP team work in the spinal outpatient department (elective pathway) and on the Neuro Spinal Assessment Unit (NSAU). In outpatients, APPs run clinics for adult patients with spinal degenerative conditions and adolescent scoliosis patients.

On NSAU we run an emergency service for appropriate patients from A&E or patients referred urgently from the community.

As most people with spinal problems do not need surgery, guidance in the UK recommends that you are seen by an APP for specialist assessment and further investigations if required. APPs can request MRI, XRs, injections and bloods tests.

Neuro-spinal assessment area (NSAU) is an adult neurosurgery/neurology/spinal assessment area to help improve Emergency Department (ED) flow and reduce unnecessary admissions. The unit provides specialist triage for urgent and emergency presentations. The spinal component of NSAU is led by a Spinal Physiotherapy Consultant and includes highly experienced physiotherapists with advanced knowledge and skills in the assessment, diagnosis and treatment of spinal pain. Please read the attached leaflet (ST3 booklet v3.pdf [pdf] 444KB) for more information about what to expect if you attend NSAU (previously, ST3).

From NUH page, unedited but needs changing: ST3 is our Same Day Emergency Care (SDEC unit). This Unit is designed to provide rapid access assessment and treatment planning for suspected serious spinal and neurosurgical conditions. The Unit’s remit is to assess you to decide if you need emergency surgery or other emergency intervention. You may be seen on the same day as attending the emergency department, the day after or a few days after seeing another health care professional, depending on the symptoms you have.

In these clinics we see patients with all manner of age-related conditions for consideration of spinal surgical management. Typically, patients are referred to see us by General Practitioners, Musculoskeletal (MSK) Triage services or other medical specialities following diagnostic imaging (MRI scans, X-Rays).

Patients will be seen by one of our Spinal Practitioner team who will take a detailed history, perform an in-depth examination and explain the results of any prior investigations in context. Via a shared decision making approach, the options for management will be discussed and the next steps agreed upon. This may well include further investigations, diagnostic injections, referral to other specialities or discussion for spinal surgery with our Consultant Surgeon colleagues.

The most common conditions seen include:

Back and Leg symptoms due to nerve compression (Lumbar Radicular pain / Lumbar Stenosis)

Neck and Arm symptoms due to nerve or spinal cord compression (Cervical Radicular pain / Cervical Myelopathy)

Who are Non-medical prescribers?
In our team we have several individuals who can prescribe medication that are not doctors. They have achieved a separate qualification for this and their prescribing is overseen by their professional body, which has a code of standards. This has to be within their scope of practise, which in our case is mostly pain relief and its associated medications.

What is Non-medical prescribing?
Non-medical prescribing (NMP) is the term used to describe any prescribing completed by a healthcare professional other than a doctor or dentist.

How do they become NMP’s?
Suitable practitioners complete an appropriate programme from a university. Non-medical prescribing programmes provide the knowledge, skills and training to prescribe medication safely and competently.

The Royal Pharmaceutical Society has created a Prescribing Competency Framework for all prescribers that has been designed to help student education, maintain prescribing standards and give guidance for those involved in NMP.

Why don’t we just have doctors prescribe?
Non-medical prescribing (NMP) builds on the practitioner’s ability to care and treat their patients. This ultimately enhances patient care by giving patients quicker access to treatment with medicines, helping to decrease waiting times and reducing hospital admissions. So you can get the right medication, quicker and hopefully feel better sooner.

As a progressive, research-based spinal service, we provide spinal injections as per the GIRFT (Getting It Right First Time) Guidelines for lumbar radicular (nerve root) pain. Specifically, our practitioners are trained to perform nerve root blocks under X-ray guidance inclusive of L4-S1 region of the lumbar spine. As practitioners, we are an integral part of your clinical assessment, discussion of MRI imagery and treatment planning. We aim to inform the decision-making of all patients concerning the judicious use of spinal injections as both diagnostic and therapeutic tools. We are there to fully explain and discuss the indications to inject and any common risks/complications of the procedures as part of the consent process.

Following the injection, all patients are reviewed at 6-8 weeks post-procedure to discuss their current presentation, queries and assistance with ongoing clinical planning. As injecting practitioners, we undertake regular reviews with senior spinal/pain consultants to ensure clinical currency and competence and collect data to allow for service / individual review. This also enables us to share good practice between hospitals to assist in the ongoing development of practitioner-led spinal injections services across the NHS.

Young people that get referred to the spinal unit who have a spinal curvature (kyphosis, scoliosis and/or spinal pain) may see one of the Advanced Physiotherapy Practitioner (APP) team for their initial assessment and future conservative management. During this clinic appointment the APP will seek information about the history, ask questions about any previous medical intervention and perform a physical examination. Part of this assessment may also involve certain tests or diagnostic images such as an X ray or an MRI scan.

For young people with a spinal curvature there is a possibility that the curve particularly during growth will become more exaggerated. Monitoring for curve progression is achieved during a clinic follow up appointment where individuals will re- reassessed and further x rays taken at specific intervals. In some circumstances a spinal curvature may require different forms of intervention such as physiotherapy and/or bracing. This aims to halt the curve through growth. Surgical intervention is also performed in some specific cases.

The options and management for all individuals will be very specific to their presentation and is developed through a process of outcomes shared decision making and choice between the young person and their parent(s) / carer and the APP and surgeon.

How to Refer:

Outpatient Clinic
Primary Care / MSK Interface Services:
ERS referral with clinical and information regarding any diagnostic investigations

Consultant to Consultant – Clinic Referral letter

NSAU
Same day emergency care unit –
Healthcare Professional referral via Telephone QMC ext. 86217

Criteria for Referrals:
Degenerative Pathway
GP must be in the patient’s catchment area for lumbar pathologies only (link here to list of GPs in catchment area) otherwise refer to the local degenerative pathway. We are able to take Cervical + Complex from anywhere.

Patient must have recent imaging of the affected area within 1 year with a clear spinal pathology. MSK interface services can provide imaging not available to GPs.

Document timeline of symptoms and any deterioration – as much detail here as possible.

Document PMH DH and relevant SH that might impede access to surgery i.e. heavy alcohol use etc.

Patient should be happy to explore surgery as an option.

Referrals should have a presumptive diagnosis and reason for spinal surgical input / assessment / anticipated outcome.

Conditions:
Lumbar Disc pathologies with Lumbar radicular pain/radiculopathy
Lumbar Degenerative Stenosis
Lumbar Spondylolisthesis
Cervical Radicular pain/Radiculopathy due to Disc or Degenerative Stenosis
Cervical Cord Compression/Myelopathy
Tandem Stenosis

Adult Deformity Pathway
Referral to Complex Adult Deformity Surgical clinics

Paediatric Deformity Pathway
For external referrers, the pathway for back deformity and scoliosis covers both adults and paediatrics and is a regional referral pathway. Any patient with this can be referred.
Adult Spinal deformity and scoliosis
Paediatric Spinal deformity and scoliosis

Emergency Pathway SDEC unit (NSAU)
Pathways - Getting It Right First Time - GIRFT
Contact Neuro Spinal Assessment Unit (NSAU) on extension 86217

Have the patients’ recent assessment details, the timeframe this occurred in and what the emergency concern is.

The spinal practitioner will ask for details of the case and advise whether the patient is to attend NSAU that day, in the future or whether another pathway is better suited for them and what investigations are needed to facilitate this.

Conditions:
?CES – as per GIRFT Pathway
Acute Footdrop
?MSCC
Severe or acutely progressive Myelopathy (Cervical / Thoracic)
?Infection

How long will my scan results take/can I have my results/where is my follow up?
Reporting depends on a case by case basis. It can take weeks to months to attain appropriate imaging, unfortunately this is out of our control and is based on the radiology vetting process.

Nerve conduction studies take up to 10 weeks.

MRI results depends on priority but can be a 6-8 month wait. Whilst we may not get formal reporting, we are trained to screen imaging for sinister/emergency pathology. Should we have any concerns, we will endeavour to expedite a report as necessary.

NSAU do not do scans/investigations – where is my scan carried out?
MRI department, CT department, Nerve conduction studies to neuro physiology.
Please see the Our services | NUH page for more information.

I have had an MRI, but my results have not been sent to the GP. What should I do?
Scan results are not automatically sent to GPs. However, if the GP has access to Notis, they can see the report there. Otherwise, GPs can request MRI results from the Specialty PA, Shamell Cable, and she will send them out.

Information booklets - link

Who can answer my questions about surgery?
If you are listed for surgery, please contact your waiting list co-ordinator for details. If seen on NSAU and you have a question re: surgery, then you can contact NSAU on the number you were given at the time of your review.

What is happening with my case being discussed in MDT?
Virtual spinal practitioner MDT via the elective pathway will receive an outcome via letter.
Patients discussed via NSAU, often in morning MDT, should receive a phone call within 24 hours of their case being discussed.
Letters are sent to patients with the outcomes.
If it is a face to face MDT – they will be reviewed face to face with the consultant/advanced practitioner.

Young people that get referred to the spinal unit (age 10-18) where there is a suspected spinal curvature and they do not have any other significant medical conditions, may see one of the Advanced Physiotherapy Practitioner (APP) team for their initial assessment and future management (if no surgical correction is indicated).

The young people that are assessed by an APP are the more straightforward curve presentations namely Adolescent Idiopathic Scoliosis (AIS). The more complex scoliosis or deformity presentations will be reviewed by a specialist spinal surgeon within the NUH spinal unit rather than an APP.

During the initial clinic appointment the APP will seek information about the history, ask questions about any previous medical intervention and perform a physical examination. Part of this assessment may also involve certain tests or diagnostic images such as an X-ray or an MRI scan.

For young people with an AIS there is a possibility that the curve, particularly during growth will become more exaggerated. Monitoring for curve progression is achieved during a clinic follow up appointment where individuals will be reassessed with further X-rays taken at specific intervals.

In some circumstances, a spinal curvature may require different forms of intervention such as physiotherapy and/or bracing. This aims to halt the curve through growth. Surgical correction of AIS is also performed in some cases. The APP’s work closely with the spinal surgeons so that if this is required or surgical discussion is needed all patients can access this pathway in the most efficient way.

The options and management for all individuals will be very specific to their presentation and is developed through a process of outcomes shared decision making and choice between the young person and their parent(s)/carer and the APP and surgeon.

Am I suitable for a review on NSAU? Who should contact NSAU?
NSAU referrals are accepted via a healthcare professional/GP. There are very specific circumstances where we want patients to contact us and they will be notified on how to do so as appropriate.

If your case is believed to be an emergency, please call 111 or contact your clinician.

What should I bring to my appointment?
A list of the medicines you take.
Your full past medical history.

I want a copy of my scan. Where can I get it?
Patients will need to go through data protection, because of data protection we are not allowed to send them out.
Data Requests & Your Privacy | NUH

I have missed my appointment, what happens now?
Please see Page 13 of the NUH Patient Access Management Policy for information regarding missed appointments.
CLCGP026-Patient-Access-Management-Policy-Version-10-Sept-22.doc (live.com)

Where can I find more information about my condition?
There are different resources to give you more information about your condition such as:

NUH Publication Library - Adult Information Leaflets | NUH
NHS health condition pages - Health A to Z - NHS (www.nhs.uk)
BASS - British Association of Spine Surgeons - Patients