Radiography — Referral for an MRI Lumbar Spine in a Patient with Red-Flag Low Back Pain
A GP refers a 58-year-old man with red-flag low back pain, constitutional symptoms, and a history of renal cell carcinoma for urgent MRI lumbar spine to exclude spinal metastasis. The proficient challenge is presenting the red-flag cluster and the oncological history that justifies urgent imaging while cutting the extensive social and symptom history.
Letter type
Referral
Write to
Radiologist
Target length
200–230 words
The case notes
Patient: Mr Derek Collins, 58 years old; former smoker; history: right nephrectomy 4 years ago for pT2 renal cell carcinoma (clear cell type); surveillance CT clear at 3 years
Presenting complaint: Low back pain for 6 weeks; severity NRS 7/10 at rest; worse at night; not relieved by NSAIDs; disturbing sleep; no trauma or lifting injury; no prior back pain history
Neurological: Bilateral leg heaviness and paraesthesia reported; no bladder or bowel dysfunction to date; power grossly intact bilaterally; reflexes present but reduced at right ankle
Constitutional symptoms: Night sweats for 3 weeks; unintentional weight loss 5 kg over 6 weeks; fatigue
Examination: Vertebral tenderness at L3–L4 on palpation; no step deformity; SLRT negative bilaterally
Investigations: FBC: Hb 104 g/L (normocytic anaemia); CRP 42 (elevated); calcium 2.58 (mildly elevated); ALP 156 (above upper limit); PSA not indicated (no prostate history)
Oncological context: Renal cell carcinoma has a known predilection for skeletal metastasis including spinal; surveillance CT was 12 months ago; CT is less sensitive than MRI for early vertebral marrow involvement
Requested investigation: Urgent MRI whole spine without and with gadolinium contrast — to exclude spinal metastasis; sagittal STIR sequence specifically requested for marrow oedema
Task: Write an urgent referral letter to the radiology department requesting the MRI, justifying the urgency based on the clinical findings.
Writing task
Write an urgent referral letter to the radiology department requesting the MRI, justifying the urgency based on the clinical findings.
What to include, what to cut
The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.
Include
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The oncological context: nephrectomy 4 years ago for renal cell carcinoma (clear cell), surveillance CT clear 12 months ago — and that RCC has a predilection for skeletal metastasis
This is the key risk stratification information. Without the RCC history, this is a red-flag back pain referral. With it, it is an urgent oncological emergency until proven otherwise. The radiologist uses this to determine the scan protocol and reporting priority.
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The red-flag cluster: rest pain, night pain, night sweats, unintentional 5 kg weight loss, vertebral tenderness at L3–L4, and bilateral leg paraesthesia
Four or more red flags for malignant spinal cord compression require urgent imaging. The radiologist must see the cluster, not just one symptom.
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The specific MRI sequence requested: whole spine without and with gadolinium, STIR for marrow oedema
A non-specific MRI request without the sequence information may be imaged as a standard lumbar spine — which would miss early vertebral marrow infiltration visible only on STIR or post-contrast sequences.
Leave out
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The social history and smoking history
Former smoker history and social details do not change the MRI protocol or the reporting priority for a suspected spinal metastasis from a known renal cell carcinoma.
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The NSAID failure and the sleep impact
Rest pain and night pain are the diagnostic red flags — state them as clinical signs, not symptom descriptions. 'Night pain unresponsive to NSAIDs' in one clause; the sleep narrative is not needed.
Criterion in focus · Purpose
An urgent oncological imaging referral must justify its urgency in the opening paragraph — not after a four-paragraph clinical history. 'I am writing to request an urgent MRI whole spine in Mr Collins, a 58-year-old man with a history of renal cell carcinoma and a 6-week history of red-flag back pain with constitutional symptoms suspicious for spinal metastasis.' This opening tells the radiologist immediately what they are dealing with and why they should prioritise it. A letter that builds to the urgency is too slow for an oncological emergency.
Now write the letter — and find out what is blocking your Grade B
Write a 200–230 words referral letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.