NHS North Derbyshire and NHS Hardwick CCG PLCV Referral Form Back pain: injections and elective surgery THIS FORM MUST BE COMPLETED IN FULL AND SUBMITTED WITH THE APPROPRIATE CLINICAL INFORMATION Patient details Referring GP details Surname Referring GP Forename(s) Practice name Address Practice address Post code Post code Date of birth Telephone number NHS Number GP practice code Part A - PLCV Criteria/declaration for back pain: injections and elective surgery ALL MUST Discectomy for Lumbar Disc Prolapse (criteria 1,2 and 3 must be met and one APPLY: of criteria 4) The patient is 18 years or older The patient has had magnetic resonance imaging, showing disc herniation (protrusion, extrusion, or sequestered fragment) at a level and side corresponding to the clinical symptoms Symptoms persist despite some non-operative treatment for at least 6 to 8 weeks (e.g. analgesia, physical therapy etc). The patient has a corresponding neurological deficit (asymmetrical depressed reflex, AT LEAST decreased sensation in a dermatomal distribution, or wekness in a myotomal ONE MUST distribution, altered bowel or bladder function) APPLY: OR The patient has radicular pain (below the knee for lower lumbar herniations, into the anterior thigh for upper lumbar herniations) consistent with the level of spinal involvement OR There is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise– positive between 30° and 70° or positive femoral tension sign)
NHS North Derbyshire and NHS Hardwick CCG PLCV Referral Form Back pain: injections and elective surgery THIS FORM MUST BE COMPLETED IN FULL AND SUBMITTED WITH THE APPROPRIATE CLINICAL INFORMATION Patient details Referring GP details Surname Referring GP Forename(s) Practice name Address Post code Practice address Post code Date of birth Telephone number NHS Number GP practice code Part A - PLCV Criteria/declaration for back pain: injections and elective surgery Discectomy for Lumbar Disc Prolapse (criteria 1,2 and 3 must be met and one of criteria 4) ALL MUST APPLY: The patient is 18 years or older The patient has had magnetic resonance imaging, showing disc herniation (protrusion, extrusion, or sequestered fragment) at a level and side corresponding to the clinical symptoms Symptoms persist despite some non-operative treatment for at least 6 to 8 weeks (e.g. analgesia, physical therapy etc). The patient has a corresponding neurological deficit (asymmetrical depressed reflex, decreased sensation in a dermatomal distribution, or wekness in a myotomal distribution, altered bowel or bladder function) OR The patient has radicular pain (below the knee for lower lumbar herniations, into the anterior thigh for upper lumbar herniations) consistent with the level of spinal involvement OR There is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise– positive between 30° and 70° or positive femoral tension sign) AT LEAST ONE MUST APPLY:
Back_pain_injections_and_elective_surgeryv2_7.10.15.docx