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Table 1 Coding Terms with definitions and examples from lumbar spine CT referrals

From: Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data

Category code Definition Examples of Referral form text
 Red Flag condition This refers to serious spinal pathologies (e.g. cancer, fracture, cauda equina syndrome or infection) where immediate imaging would be appropriate. “41 year old male multiple back surgeries now complains of increasing pain, difficulty urinating. He does say that he has had urinating difficulties more often and has been ongoing for several months. Diagnosis: Rule out cauda equina”
“Back pain. Fall 1 week ago.? Fracture L1. Pain out of proportion. Diagnosis: back pain”
Potentially appropriate
 Radicular Syndromes or Leg-dominant pain This refers to the conditions of spinal stenosis, radiculopathy or radicular pain (described as “radiation to legs”, numbness, or shooting pain). “Lower back with radiation to legs and numbness and tingling in her feet, shooting pain in toes. Diagnosis: Low back pain”
“numbness left leg, mechanical low back pain”
“Patient with radicular back into the gluteal region. Patient with x-ray L spine with OA. Diagnosis: Rule out nerve root compression.”
 Non-specific Low Back Pain This refers to any referral that did not describe symptoms that suggested a red flag condition or radicular syndromes. “Persistent low back pain. Degenerative disc disease with L3–4 narrowing. Diagnosis:? Discogenic low back pain”
“Increasing back pain. Diagnosis: OA”