To whom should a patient with lordosis, spondylosis, degenerative disc disease, stenosis, and bulging disc on lumbar and cervical Magnetic Resonance Imaging (MRI) be referred for evaluation and management?

Referral Recommendations for Multilevel Degenerative Spine Disease

Refer patients with lordosis, spondylosis, degenerative disc disease, stenosis, and bulging discs on lumbar and cervical MRI to a spine surgeon (neurosurgeon or orthopedic spine surgeon) if they have persistent radicular symptoms after 6 weeks of conservative management, progressive neurological deficits, or severe functional impairment warranting consideration of surgical intervention. 1

Initial Triage: Who Needs Specialist Referral vs. Conservative Management

Immediate Spine Surgeon Referral (Do Not Wait)

• Progressive or severe neurological deficits including motor weakness, sensory loss, or reflex abnormalities require urgent spine surgery evaluation 1, 2
• Suspected cauda equina syndrome with bowel/bladder dysfunction, saddle anesthesia, or bilateral lower extremity weakness demands emergency neurosurgical consultation 1, 2
• Cervical myelopathy with gait instability, hand clumsiness, or hyperreflexia indicating spinal cord compression requires prompt neurosurgical or orthopedic spine evaluation 3

Spine Surgeon Referral After Conservative Trial

• Persistent radicular symptoms for ≥6 weeks despite appropriate conservative management (physical therapy, NSAIDs, activity modification) in patients who are surgical candidates or candidates for epidural steroid injection 1, 3
• Cervical radiculopathy with arm pain, numbness, or weakness in a dermatomal distribution that has failed conservative treatment for 6 weeks 3
• Lumbar radiculopathy with leg pain, sciatica, or neurogenic claudication limiting function after 6 weeks of conservative care 1

Physical Medicine & Rehabilitation (Physiatry) Referral

• Patients with chronic axial pain without radiculopathy or red flags benefit from physiatry evaluation for comprehensive non-surgical management including targeted injections, rehabilitation programs, and pain management strategies 4
• Multilevel degenerative changes in asymptomatic or minimally symptomatic patients should be managed conservatively by physiatrists, as degenerative findings on MRI correlate poorly with symptoms 3, 5

Pain Management Specialist Referral

• Patients with chronic pain refractory to conservative measures but who are not surgical candidates due to medical comorbidities or patient preference should be referred to interventional pain management 4
• Consider this pathway when imaging findings do not correlate with clinical presentation, as up to 20-28% of asymptomatic individuals have disc herniations on MRI 1

Critical Clinical Pearls

Avoid Common Referral Pitfalls

• Do not refer based on imaging alone - degenerative changes including spondylosis, disc bulges, and mild stenosis are normal age-related findings in asymptomatic patients over 30 years old 3, 5
• Lordosis changes are not surgical indications - loss of cervical or lumbar lordosis is a common finding in degenerative disease and does not independently warrant surgical referral 6
• Bulging discs are not herniations - disc bulges are circumferential and rarely cause nerve compression requiring surgery, unlike focal herniations or extrusions 5

Documentation Requirements for Referral

• Specify dermatomal distribution of radicular symptoms and correlation with MRI findings at specific levels 1, 2
• Document failed conservative treatments including duration, specific therapies attempted, and patient compliance 1, 2
• Note functional limitations and how symptoms impact activities of daily living and quality of life 2
• Include neurological examination findings with specific motor, sensory, and reflex testing results 1, 2

When Imaging Precedes Referral

• MRI findings of intramedullary cord signal changes in cervical spine indicate poor prognosis and warrant neurosurgical evaluation even without severe symptoms 3
• Multilevel stenosis with canal narrowing and neural foraminal compromise correlates with surgical complexity and should be clearly communicated to the spine surgeon 3, 5

Special Considerations

Post-Surgical Patients

• Patients with prior spine surgery presenting with new or recurrent symptoms require spine surgeon re-evaluation, as MRI with contrast is needed to differentiate scar tissue from recurrent pathology 2
• Adjacent segment disease developing after prior fusion is common and requires specialized spine surgery assessment 3, 2

Conservative Management Duration

• The natural history shows most acute radiculopathy improves within 4-6 weeks without intervention, justifying the conservative trial period before specialist referral 1
• However, do not delay referral beyond 6 weeks if symptoms persist and patient is a surgical candidate, as prolonged nerve compression may lead to irreversible damage 1