MRI Referral Guidelines

MRI scanning is a powerful diagnostic tool and frequently helps to select the most appropriate treatment option and plan management in patients with musculoskeletal disorders.

The list below represents abridged guidelines on situations where MRI may or may not be specifically indicated and is based on the royal college of radiologists publication “Making the best use of a department of clinical radiology” (5th edition).

These guidelines represent the opinion of experienced specialist radiologists and help to outline a number of clinical presentations and situations where MRI scanning may be of value and others where the investigation may not be indicated.

In circumstances where there is clinical doubt, or symptoms are severe, unremitting or progressive, urgent assessment by an appropriate specialist clinician should be considered.

These guidelines have been discussed with Dr Curzon Consultant Radiologist and Dr Clifford, chief of service for radiology

Referrers responsibility

Referrals for MRI will only be accepted on an appropriate request form. The contraindications section of this form should be filled in; failure to do this will cause a delay or possibly refusal to scan your patient.

The referrer must be familiar with the duties and responsibilities of a referrer who must be conversant with the exposure and safety implications that may relate to their patient during the MR examination. Ultimately, the responsibility for the patient’s health and well-being will rest with them. Referring clinicians must confirm that there are no contraindications to MR for their patient before referral.

Ensure the patient is identifiable from the request form. Name, date of birth, address and NHS number must all be present.

Ensure clinical details conform to those in the referral guidelines. If they do not, or there is insufficient information for the practitioner then the examination may not be performed.

There must be the referrer’s signature and name written legibly in block capitals so that the referrer can be identified.

Area and symptoms Indicated or not
Lumbar spine
Sciatica less than 6 weeks with no adverse features(no red flag symptoms or signs) MRI not usually indicated
RCGP guidelines indicate that conservative management is appropriate in sciatica with out adverse features, MRI reserved for sciatica which does not resolve within the 6 week period.
Sciatica  failed conservative management MRI indicated (1)
Clinical radiological correlation is important, as a significant of disc herniations demonstrated on MRI are asymptomatic
Low back pain with adverse symptoms or signs MRI spine indicated (2)
Sphincter or gait disturbance
Saddle anaesthesia
Severe progressive motor loss
Widespread neurological deficit
Previous carcinoma
Systemically unwell weight loss
HIV, IV drug abuse
Steroids
Structural deformity
Acute Cauda Equina MRI indicated
(Urgent referral via A+E or Neurosurgery routeSphincter or gait disturbanceSaddle anaesthesia)
Mid line chronic low back pain—without progression Not usually indicated (2a)
In the absence of focal or neurological signs, asymptomatic chronic degenerative changes are a common finding. A trial of non interventional treatment (exercise, physiotherapy, chiropractor treatment may be appropriate)
Chronic facet joint symptoms and signs – but without radiation down leg MRI Not Usually Indicated (2b)
Non-invasive treatment is often effective.MRI should be reserved for cases unresponsive to conservative management or with atypical symptoms.
Thoracic spine
Isolated chronic back pain – Without adverse features or radiation MRI Not Usually Indicated.
MRI very rarely identifies treatable lesions in the absence of focal features. Imaging is rarely useful in the absence of neurological signs or pointers of metastases or infection
Thoracic pain with radicular radiation – long tract signs or persistent symptoms. MRI Thoracic Spine Indicated (3)
In adults thoracic radicular pain may be an early sign of impending cord compression. Acute thoracic pain in elderly patients may require more urgent referral for imaging to assess for vertebral collapse. Plain radiographs are often adequate with MRI reserved for complex cases.
Cervical spine
Neck pain with brachalgia and/or neurological signs MRI Cervical spine Indicated (4)
In patients where pain affects lifestyle, is unresponsive to conservative treatment or there are adverse features (eg long tract signs) MRI is most useful where there are single root symptoms and signs, and least useful where symptoms and signs are referable to multiple dermatomes.
Acute neck pain MRI not Usually Indicated
Severe or adverse features only. Most neck pain resolves on conservative treatment. Degenerative changes are invariably seen on MRI beginning early middle age and are often unrelated to symptoms.
Chronic neck pain MRI Not Usually Indicated
Degenerative changes are invariably seen on MRI beginning early middle age and are often unrelated to symptoms.
Hip
Hip pain MRI Pelvis Not Usually Indicated (5)
X-ray or MRI only if symptoms and signs persist or there is a complex history.
Hip pain with suspected avascular necrosis MRI Hip Indicated  (6)
Knee
Acute knee pain – Following trauma or accident, in previously non-symptomatic joint. MRI Knee Indicated (7)
Especially under the age of 50 and without signs of osteoarthritis
Long-standing knee pain – (18-50 Year Old) MRI Knee Indicated (8)
Particularly for suspected ligament or meniscal injury.
Long-standing knee pain – (Over 50 years Old) MRI Knee Indicated (9) – (Following X-Ray)In patients over 50 a plain film should be performed before requesting MRI as this can highlight joint degeneration.
Ankle and Foot
Ankle and foot symptoms Specialist referral
MRI should be used selectively and normally only requested by a specialist clinician.
Shoulder
Non localised shoulder pain MRI not usually indicated
Shoulder impingement syndrome, shoulder instability, rotator cuff tear Specialist referral
Ultrasound is the investigation of choice in the first instance. MRI may be useful as an additional investigation where further information is required
Elbow
Elbow symptoms Specialist referral
Usually reserved for when surgical intervention is being considered.
Wrist
Wrist symptoms Specialist referral
Usually reserved for when surgical intervention considered.
Brain
Headache MRI Brain Indicated (10)
Although MRI should be used selectively and normally only requested by a specialist clinician

Exclusions

  • Pacemakers or other categorised safety related contraindications.
  • Cochlear implants
  • Confirmed metallic foreign body in orbit of eye.
  • Neuro stimulator

The following are a list of implants that will need to be determined as MRI safe prior to the MRI examination. The provider will obtain and cross check the make and model number against a MRI safety register. Where the implant is determined to be safe the patient episode will continue, however where the implant is determined to be unsafe the request will be rejected on grounds of safety.

Also listed are circumstances where extra precautions and patient awareness will be addressed with the patient prior to the examination, and which may lead to deferral of the examination.

Cautionary

  • Cerebral aneurysm clip in the brain
  • Heart valve Replacement.
  • Intra-vascular stents, filters and coils
  • Ocular implants
  • Shrapnel injuries
  • Penile implants
  • Any other unknown implant until it has been determined as MRI safe