NATIONAL SPINAL REVIEW - TOP TEN RECOMMENDATIONS

The “Top Ten” recommendations are those that the Taskforce felt most strongly and urgently need to be implemented by current and future commissioners and providers of spinal services.

1. NETWORKS: All commissioners of spinal services should ensure that comprehensive spinal networks are established to facilitate integrated care pathways. Clinical commissioning groups and specialist commissioning must interface along these pathways. The networks for general spinal work (including primary care) must be co-ordinated with the individual and sometimes differing networks for trauma and cancer. 

2. GOVERNANCE: All providers of spinal services (including the private/third sector) irrespective of whether commissioned at CCG or specialised commissioning level should be subject to the same clinical governance arrangements. All providers should contribute to a National Spinal Registry ( or other communicating database ) The NHSLA ( and any related organisations) should publish an annual audit of any adverse consequences of the management of spinal conditions.

3. NON- SPECIFIC SPINAL PAIN: Commissioners should ensure a properly constructed Combined Physical and Psychological programme is commissioned (Fig 4.1 box 3). This is the most serious gap in current services and should be urgently addressed. The type of programme recommended by NICE is available in their guideline CG88.

4. RADICULAR PAIN: If radicular symptoms predominate at any stage, management as defined in section 4.2 is recommended. Commissioners should ensure that appropriate levels of service provision and pathways are in place to enable timely sound clinical decision making. NICE should ensure that a Quality Standard for the management of lumbar radicular pain is produced to complement the recently published NICE Guidance concerning the management of low back pain.

5. CAUDA EQUINA SYNDROME AND SPINAL INFECTION: Commissioners should ensure that specific service provision and pathways are in place for these conditions and should establish that there is a nominated regional centre which holds a register of these cases.

6. SPINAL (EXTRADURAL) METASTASES: Commissioners should review provision of services to manage MSCC, in line with the measures detailed in the NICE Guidance and Acute Oncology Measures. In particular this should include geographical coordination of availability of appropriate imaging (MRI and CT), and on call Spinal Surgeons and Oncologists. National Cancer Peer Review audits to enhance service evolution for this emergent patient population should be supported.

7. PRIMARY EXTRADURAL SPINAL TUMOURS OF OSSEO-LIGAMENTOUS AND NEUROLOGICAL ORIGIN: This service should be commissioned by the National Commissioning Board in line with extant NICE guidance for primary bone tumours. It should be noted that this is currently under review by the Clinical Reference Group advising the NHS Commissioning Board on specialised commissioning for spinal services.

8. SPINAL TRAUMA: trauma centres and units should ensure that spinal column injury without neurological deficit is included in the rehabilitation pathway being established under the major trauma networks.

9. IMAGING: Commissioners should ensure that providers are connected to the Image Exchange Portal (IEP). They should ensure that agreed protocols exist to efficiently ensure the delivery and /or receipt of imaging and radiology reports relevant to both the elective and emergency transfer of patients.

10. ADMINISTRATION: Commissioners should fund the establishment of clinical spinal emergency coordinators.