Information for referring physicians

FOR REFERRING PHYSICIANS

What comes back to you is a structural diagnosis and the testing that established it, not a letter confirming your patient was seen.

The problem this practice is organized around

Cervical pain is a differential, not a diagnosis, and imaging does not resolve it. Degenerative findings are close to universal after middle age and correlate poorly with the segment actually generating symptoms. So the question that decides management — which structure — is answered by examination and controlled diagnostic block, not by a report.

Facet involvement accounts for a substantial and age-dependent share of chronic neck pain, and single diagnostic blocks carry a false-positive rate high enough that a confirmatory block is part of the protocol rather than an optional refinement. A multispecialty international working group has published consensus guidance on exactly this. We follow it, and the block findings appear in the note whether they support the working diagnosis or overturn it.

What actually gets tested

• Cervical medial branch blocks, with confirmation, before any radiofrequency ablation is discussed. How the block is performed and read.
• Electrodiagnostic studies on site — EMG and nerve conduction, which is what separates a C6 radiculopathy from a median neuropathy at the wrist, and identifies the patients who have both. What the study measures.
• Provocation discography, in the narrow group where a disc is the plausible generator and the decision turns on it. When it is appropriate.
• Vestibular testing where dizziness accompanies neck symptoms and the origin is genuinely unclear. What VNG shows.

The referrals where this changes your management most

• Arm symptoms with an equivocal picture. Cervical radiculopathy, carpal or cubital tunnel, thoracic outlet, or more than one at once. Physical tests alone perform modestly here, and the double-crush pattern is missed precisely because the first plausible answer stops the search. Double crush, carpal tunnel or neck.
• Shoulder pain that has not responded to shoulder treatment. C5–6 refers convincingly into the deltoid and lateral arm. Sorting shoulder from neck.
• Axial neck pain with a normal MRI. The commonest reason a patient has been told there is nothing wrong. Why the scan is normal.
• Persistent pain after fusion. Adjacent segment, hardware, or a pain generator that was never the operated level. After a fusion.
• Headache with a cervical pattern, particularly where migraine treatment has partially failed. Cervicogenic headache.

What we ask you to send urgently rather than refer

Progressive myelopathic signs, a rapidly evolving motor deficit, and suspected giant cell arteritis with visual symptoms are not outpatient referrals. Send those where they need to go and call us afterward. The findings that qualify.

What you receive back

• A note that states the working diagnosis, the structure implicated, and how that was established.
• What was excluded, and on what basis — usually the more useful half.
• The electrodiagnostic report where a study was done, with the clinical correlation rather than the raw numbers alone.
• A plan with its decision points named, so you know what happens if the first step does not work.

What we will not do with your patient

We do not route directly to a surgeon as an opening move. The diagnosis gets refined first, and a good number of patients referred for a surgical opinion turn out to have a testable, treatable pain generator that no operation would have addressed. The exception is the urgent presentation above, which goes urgently.

We also do not treat a level that a block did not confirm. If the testing is negative, the note says so and the plan changes. That is the only way the notes are worth anything to you the next time.

Patients already on opioid therapy

Referring a patient on chronic opioid therapy does not complicate the referral. A substantial part of the work here is establishing a structural diagnosis so that interventional treatment can carry the load a medication has been carrying, and supporting a taper without dropping the patient into withdrawal while it happens.

The reduction follows the diagnosis. It is not a condition of being seen, and it is not a target imposed on your patient before anyone has worked out what is generating the pain.

Practical

• Send imaging on disc or with portal access rather than the report alone, and prior electrodiagnostic studies if there are any.
• A line on what has been tried and what each thing did — partial responses are the detail that most often changes the plan.
• If the problem began with a collision or at work, say so; the documentation differs. After a collision, injured at work.
• Call the office directly for anything time-sensitive rather than waiting on a faxed reply.