Neurosurgery

Non-acute skull fracture/ non- acute traumatic brain injury

• Acute trauma
• Change in consciousness level or deteriorating neurological functions
• Head trauma with seizures

Brain tumours (intracerebral, meningioma, skull base, pituitary)

• Symptoms of signs of raised intracranial pressure
• Severe and increasing headache
• Deteriorating neurological function
• Seizures

Neurovascular disorders (aneurysm, AVMs, other)

• Symptoms of signs of raised intracranial pressure
• Severe and increasing headache
• Deteriorating neurological function
• Seizures
• Clinical suspicion or subarachnoid haemorrhage or intracerebral haemorrhage

Hydrocephalus and VP shunt

• Symptoms of signs of raised intracranial pressure
• Increasing severity of headache
• Deteriorating neurological function
• Seizures
• Swelling pain or redness along shunt tract
• Abdominal pain or swelling
• Clinical suspicion of shunt infection

Trigeminal neuralgia and other cranial nerve abnormalities

• Severe intractable pain preventing adequate fluid intake

Spine

• Actual or threatened cauda equina syndrome 
  • Unilateral or bilateral radicular pain
    • And/or dermatomal reduced sensation
    • And/or myotomal weakness
    • Reduced saddle sensation (subjective or objective pin prick)
    • unexplained or unexpected loss or change of bladder or bowel function
    • Sexual disturbance
    • perineal anaesthesia
• Presentations that increase the probability of acute threatened Cauda Equina: 
  • Back Pain with: 
    • Presence of new saddle anaesthesia, bladder or bowel disturbance. 
    • Age < 50 
    • Unilateral onset progressing to bilateral leg pain 
    • Alternating leg pain 
    • Presence of new motor weakness 
• Spinal tumour with significant pain and/or neurological deficit 
• Lumbar Spine Stenosis (LSS) presenting with clinical symptoms of the following:
  • Recurring and insidiously but increasing back pain with gradual onset of unilateral or bilateral lower limb sensory disturbance and/or motor weakness
  • Incomplete bladder emptying, urinary hesitancy, incontinence, nocturia or urinary tract infections.   Bladder and/or bowel dysfunction may progress gradually over time.
• Clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs/symptoms 
• Spinal fractures demonstrated on imaging 
• Clinical suspicion spinal infections
• High risk of irreversible deficit if not assessed urgently

Peripheral nerve compression including carpal tunnel syndrome, ulnar nerve entrapment neuropathy, common peroneal and lateral cutaneous nerve of thigh compression syndromes

• Acute development of peripheral nerve compression symptoms following trauma

Other referrals to emergency not covered within conditions:

Adult

• Collapse/altered level of consciousness/new neurological deficit
• Suspected subarachnoid haemorrhage or other intracranial haemorrhage
• Headache with concerning features:
  
  • sudden onset/thunderclap headache
  • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
  • first severe headache age over 50 years
  • severe headache associated with recent head trauma
• Symptomatic benign or malignant space-occupying lesion
• Suspected or proven blocked or infected VP shunt
• Acute hydrocephalus
• Head injuries/trauma including extensive scalp laceration or suspected traumatic brain injury
• Trigeminal neuralgia – severe uncontrollable pain

Paediatric

• Benign or malignant space occupying lesion associated with midline shift, hydrocephalus, neurological or endocrine deficit
• Acute hydrocephalus
• Suspected or proven blocked or infected VP shunt
• Vascular disorders – suspected subarachnoid haemorrhage or other intracranial haemorrhage e.g. Thunderclap headache, collapse/altered level of consciousness, headache with vomiting, new neurological deficit
• Cranial trauma – extradural, subdural haematoma, large cerebral contusion, concussion injuries, diffuse axonal injury, skull fractures, CSF fistula/leakage spinal trauma or other spinal conditions with severe or rapidly progressive deficit e.g. Loss of sensation, muscular weakness or cauda equina syndrome
• Generalised seizures, prolonged focal seizures and persistent neurological deficits