Dr Angela Timms Laurel House Surgery Tamworth, Staffordshire

1. 1 Introduction and Aim
This aim of this audit was to research our current practice in adhering to
guidance in accordance with the NICE guideline: Metastatic Spinal Cord
Compression in Adults (CG75 November 2008).
The audit standard was that all cases of suspected spinal metastasis (SM)
should be referred and have received an MRI whole spine within 7 days of
presentation (The other key recommendation of the guideline
recommends that in suspected spinal cord compression MSCC/cauda
equina syndrome the MRI should be arranged as an emergency within 24
hours. The assumption was made that most clinicians across all specialties
would recognise and act on these suspected cases in the time suggested,
so was this was not the standard I chose to investigate).
In England and Wales, it has been estimated that there are around 4000
cases of MSCC per year. By that rationale, the same group of patients, and
perhaps a much higher number, are at risk of spinal metastasis(SM)
without cord compression.
It has also been estimated that around 50% of these cases will have a
current or previous history of malignancy of the Breast, Lung, Prostate or
Myeloma.
This audit will focus on these main 4 primary malignancies, however it
should be noted that SM and MSCC should be considered in all patients
with a history of current or previous cancer with signs and symptoms that
are suggestive.
3 Results
83 patient contacts
77 patients fulfilled the criteria (6 excluded as sciatica, abdominal pain, SIJ pain).
35 of the 77 were examined
26 were referred for an MRI
i. 0 of these were for a whole spine MRI
ii. 16 had an MRI
iii. 11 had an XR
iv. 2 had a NMR Bone Scan
v. 2 had a DEXA
4 Discussion
The results show very poor awareness of the recommendation for whole spine MRI within 1 week for
suspected SM.
Not only does it appear that as GP’s we are not aware of the need for whole spine MRI and the necessary
speed for referral for this investigation, we are also referring inappropriately for other investigations.
The potential reasons for the delay in MRI could be:
1. Lack of awareness of the guideline recommendations i.e. Doctors educational need (DEN).
2. Lack of information on the referral for MRI, i.e. is previous cancer history documented on the referral
which could aid the radiologist to triage.
3. Accessibility and ease and (? cost) of other investigations may lead to inappropriate referral for XR,
Bone Scan.
On consulting the Royal College of Radiologists web based guidelines ‘i-refer’, it was noted that MRI is the
only investigation that is sensitive and specific for a skeletal spinal metastasis.
The guidance states that XR is very non-specific and non-sensitive for skeletal metastasis, and NMR Bone
Scan is sensitive but not specific and will need further evaluation with and MRI id the results are
suggestive of skeletal metastasis.
2 Method
The audit was based on searches on EMIS, the practice records computer
system at Laurel House Surgery.
Laurel House Surgery is based in Tamworth, a large market town in
Staffordshire. The practice has around 13,000 registered patients with an
average age of 39.
Searches were initially based on the read codes ‘Metastatic Spinal Cord
Compression’ and ‘Spinal Metastasis’ and Cancer of the Lung, Breast,
Prostate or Myeloma from the present back to November 2008. This
revealed only 1 patient, so search terms were expanded to include ‘MRI
Spine’ and ‘Back Pain’ for the same time period in the same group of
patients .This revealed 20 and 56 patients respectively.
A potential total of 77 patient had been identified, although at the time
of the searches it was noted that some cases will be excluded based on
not fulfilling the criteria for the audit or having alternative
diagnosis/reasons for the MRI/back pain.
The individual patient records were then analysed for details in the
history and examination, reasoning and choice of investigation, and
positive findings were noted that would meet the criteria for Spinal
Metastasis (NICE2008), these criteria are:
a) Pain in the thoracic or cervical spine
b) Progressive Lumbar spinal pain
c) Severe or unremitting lumbar spinal pain
d) Spinal pain worsened by straining, coughing or sneezing
e) Localised spinal tenderness
f) Nocturnal spinal pain that interrupts sleep
Using anonymised data, the following results were compiled:
a) Total number of patient contacts
b) Total number of patient contacts that fulfilled criteria for SM (NICE
2008) within the history
c) How many of these patients were examined
d) Of those examined , how many fulfilled criteria (NICE 2008) for MRI
within 1 week
e) Of those that met this criteria , how many were referred for
I. Whole Spine MRI
II. MRI
III. Alternative investigation i.e. XR, CT, Bone Scan, DEXA)
f) How long did those that were referred for an MRI wait before scan
result was available.
5 Conclusion
We do not appear as a practice to follow NICE 2008-MSCC in cases of SM.
I suspect that as our practice comprises skilled and dedicated professionals, that we are not unique in these
findings. I aim to present this audit to the medical team at our next protected learning time.
This audit could then be redone in a designated future time period to reassess and complete the cycle of
change and hopefully to show quality improvement, and to promote good practice.
A General Practice Based Audit on Speed of Referral for MRI Spine in Suspected Spinal Metastasis
Dr Angela Timms MRCGP
6 Credits
Author: Dr. Angela Timms General Practitioner MBBS MRCGP Laurel House Surgery, Tamworth, Staffordshire. (No conflicts of interest or affiliations)
Contributors: Mrs W.Roe Practice Manager (data searches) Dr Glennie General Practitioner (data searches and discussion) Mr P.Bannister (technical support)
References: NICE Metastatic Spinal Cord Compression in Adults CG75 Nov.2008
i-refer guidelines RCR website.
0
10
20
30
40
50
60
70
80
No.PatientContacts
Fulfilled criteria in history for MRI
Received examination of spine
Fulfilled examination criteria an MRI whole spine
Triggered referral for investigation
Triggered referral MRI spine
Triggered referal for MRI whole spine
0 10 20 30 40 50 60 70 80 90 100 110 120
1 7 21 56 112
1 7 7 7 7 7 11 14 28 28 42 56 56 56 84 112
Q1 =7 Median = 21 Q3 = 56
Fig 2 – Distribution in days for speed of referral for MRI spine in presentation of suspected spinal
metastasis (SM)
Fig 3 – Data set (days)
Fig 1 – Adherence to NICE Metastasis Spinal Cord Compression with patients who present with
symptoms and/or signs of spiral metastasis (SM)