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Neurosurgery


If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

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

 

The following are not routinely provided in a public Neurosurgery service.

Adult

  • Fusion for back pain due to degenerative disease without correlating clinical symptoms or signs of neural compression
    • chronic pain is defined as any pain lasting more than 6 months. Back and neck chronic pain – degenerative changes nil acute neurology (please refer to Spine CPC)
  • Non-specific headache without concerning features or not requiring surgical intervention should be referred to neurology.

 Spine

  • Fusion for back pain due to degenerative disease without correlating clinical symptoms or signs of neural compression
    • chronic pain is defined as any pain lasting more than 6 months. Back and neck chronic pain – degenerative changes nil acute neurology (please refer to Spinal CPC)
  • Non-specific headache without red flags concerning features or not requiring surgical intervention should be referred to neurology.

 Paediatric

  • Positional plagiocephaly/moulding – refer paediatric plastic and reconstructive surgery