Spinal Myeloma Service Referral

This form may be used to refer all Myeloma patients but may not be looked at over the weekend or out of hours.

Therefore patients with Abnormal Neurology should still be referred using this form but *must also be discussed with the on-call spinal surgical team.

Patients with Normal Neurology should be referred using this form and do not need to be discussed.

All cases will be triaged and seen as soon as possible in line with current cancer guidelines.
Where necessary a member of our myeloma team will contact you for advice.

Imaging:
All myeloma patients will need comprehensive spinal imaging.
Prior to referral, please arrange:

  1. MRI whole spine with Sagittal T1 + STIR sequences
  2. CT of any abnormal bony anatomy with sagittal and coronal reconstructions

Please send all imaging via IEP to the Royal National Orthopaedic Hospital.
We are unable to provide an opinion without appropriate imaging.

These forms are only for tertiary referrals from other hospitals. We will not accept referrals from GPs using the online referral form below.

If you are a GP referring to the RNOH please use the NHS e-referral system, e-RS.

Demographics:

Patient details:

Referring Team:

Diagnosis:
*Myeloma Subtype is required
*Light Chain Type is required
Tumor Markers:
*FISH Type is required
Radiological and Clinical:
Radiological evidence of neural compression:
Symptoms of altered neurology:
Imaging Completed:
*Date of MRI is required
*Date of CT is required
*Date of Skeletal Survey is required
Chemotherapy / Radiotherapy / Cancer Treatment:
*Date Chemotherapy commenced is required
Medical History:

Many of the patients referred to us will require surgery. In order to keep travel and appointments to a minimum; please complete the following medical history form so that we are able to pre-assess our patients for surgery when they come to outpatient clinic.

Cardiovascular:

Prev Cardiac Intervention:

*ECG Result is required
*Echo Result is required
*BNP Result is required

If any signs of cardiac failure or on cardio-toxic chemotherapy, please request ECG, ECHO and BNP and send results to spinal.myeloma@rnoh.nhs.uk.

Respiratory:
Haematological:
Renal:
Other:
Infection Screening & Skin Integrity:
Drug History:
Other Comments:

Please use this space for any other comments or to tell us about any other medical co-morbidities the patient may have and not covered above

Thank you for your referral. Our myeloma coordinator will confirm all imaging has been received and will contact the referrer / designated contact to arrange clinic appointments.

If your patient develops abnormal neurology, the case must be discussed with the on-call spinal surgical team at the Royal National Orthopaedic Hospital.

Please click the button below to submit your form. You will receive an automated email confirming successful submission to the Referrer’s Email address.

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Myeloma