Neurosurgery

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols 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 i.e. increasing headache or local pain at site of trauma, development of nausea, vomiting and/or decrease in conscious level, seizure, development of focal neurological signs
    • 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 i.e. increasing headache and/or nausea and vomiting, seizure, decreasing conscious level, the development of focal neurological signs
    • Seizures

    Neurovascular disorders (aneurysm, AVMs, other)

    • Symptoms of signs of raised intracranial pressure
    • Severe and increasing headache
    • Deteriorating neurological function i.e. increasing headache and/or nausea and vomiting, seizure, decreasing conscious level, the development of focal neurological signs
    • 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 i.e. increasing headache and/or nausea and vomiting, seizure, decreasing conscious level, the development of focal neurological signs, tenderness, redness and/or swelling along shunt tract
    • 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
    • Back and neck chronic pain – degenerative changes without acute neurology (please refer to Spinal CPC) (Chronic pain is defined as any pain lasting more than 6 months.)
    • Non-specific headache without red flags concerning features or not requiring surgical intervention should be referred to neurology
    • Pathology of the sacrum: refer to Orthopaedic service

    Paediatric

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

Last updated: 20 December 2021

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