Clinical information for a spinal surgery request
Information on what you need to provide for a review.
Requests
Spinal surgery requests need to contain a:
- worker's clinical symptoms, including neurological findings
- diagnosis
- clinical rational and detailed description of the surgery
- relevant history and change in the condition over time
We need copies of relevant radiology reports and a list of Medicare Benefit Schedule (MBS) items the surgeon intends to invoice. Please provide an explanation if clinical symptoms and radiology reports do not correlate. Most of this information will be covered when surgeons include their letters to the worker's GP. Please see examples further below.
Timeframe and avoiding processing delays
Delays in reviewing spinal surgery requests can occur when insufficient clinical information is received.
The following additional information will assist a decision being made sooner:
- management options discussed or already taken
- the worker's understanding and expectations of surgery
- psychological and chronic pain comorbidities
- surgeon's rehabilitation and recovery expectations
- confirmation that a face-to-face assessment has occurred
Where the provided information is insufficient to make a decision on the request for surgery:
- further details from the treating spinal surgeon may be requested
- WorkSafe's Surgery Advisory Panel (SAP) may refer the worker to a Multi-disciplinary Independent Medical Examination for further assessment
Surgeon letter examples
- Initial letter to GP
Dear GP,
Thank you for referring Mr Citizen back to see me with recurring pain in his left leg.
As you know, I performed a L4/5 discectomy around 10 years ago. He had good relief from his leg pain and was able to return to his job as a storeman.
He has had some episodic back pain and niggles down his left leg since. These have been manageable and self-limiting. However in a recent episode, his pain has become increasingly worse. He has had to take days off, despite regular analgesia and returning to physiotherapy.
Mr Citizen's leg pain is similar to what it was previously. It radiates down the side of the thigh, side of the calf, and across the top of his foot. This is typical for L5, and this pain is worse than his back pain.
Straight leg raising precipitates the left leg pain at 45 degrees and he has grade 4/5 weakness of his EHL.
He also describes some subjective numbness around his foot.
The MRI that you ordered, shows some disc collapse and facet protrusion on the left, displacing the L5 nerve root. This is consistent with the pain he is experiencing.
We briefly discussed surgery but Mr Citizen wants to give it bit more time, so I have ordered him a nerve root injection, and told him to persevere with his physiotherapy.
I will see him after this treatment.
- Subsequent letter to GP
Dear GP,
I saw Mr Citizen again today after his left L5 nerve root injection some 4 weeks ago. This injection afforded him some pain relief of both his leg and back for 2 weeks.
Unfortunately though, he is now worse than ever. He has been unable to return to work part- time with light duties.
I have offered him a L4/5 decompression and fusion. I have told him that this has a high success rate for helping his leg pain. This is the more troublesome pain but hopefully it will help some of his back pain as well. Mr Citizen understands this and the complications of the procedure. He is going to think about it and will contact the office if he wants to go ahead.
- Letter to WorkSafe following failure of initial measures
Dear WorkSafe Agent,
Re: Mr Citizen, claim number 12345678910
Please see previous letters to Mr Citizen's GP.
Mr Citizen rang the office today and wants to proceed with the surgery.
The requested Medicare Benefits Schedule item numbers are 51011, 51021, 51031, and 51041 for an L4/5 instrumented posterior interbody and posterolateral fusion.
Thank you for expediting your review of this request.