Cranial malformations - chiari
PAEDIATRIC
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Emergency
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
- 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
- Unilateral or bilateral radicular pain
- 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
- Back Pain with:
- 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
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Other useful information for referring practitioners Not and exhaustive list
Minimum Referral Criteria
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Category 1
(appointment within 30 calendar days)- Chiari malformation confirmed on imaging with hydrocephalus/ syringomyelia
- Chiari malformation with neurological signs
- A child currently in out of home care (OOHC), or at risk of entering or leaving OOHC, where they have previously been on a waiting list for this problem and were removed without receiving a service.
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Category 2
(appointment within 90 calendar days)- Chiari malformation without neurological signs
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Category 3
(appointment within 365 calendar days)- No category 3 criteria
Please insert the below information and minimum referral criteria into referral
1. Reason for request Indicate on the referral
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
2. Essential referral information Referral will be returned without this
- General referral information
- Clinical neurological assessment
- Confirmation of OOHC (where appropriate)
- MRI result
3. Additional referral information Useful for processing the referral
- Previous problems with general anaesthesia and/or significant parental concern about anaesthesia
4. Request
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General referral information
Patient's Demographic Details
- Full name (including aliases)
- Date of birth
- Residential and postal address
- Telephone contact number/s – home, mobile and alternative
- Medicare number (where eligible)
- Name of the parent or caregiver (if appropriate)
- Preferred language and interpreter requirements
- Identifies as Aboriginal and/or Torres Strait Islander
Referring Practitioner Details
- Full name
- Full address
- Contact details – telephone, fax, email
- Provider number
- Date of referral
- Signature
Relevant clinical information about the condition
- Presenting symptoms (evolution and duration)
- Physical findings
- Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
- Body mass index (BMI)
- Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
- Current medications and dosages
- Drug allergies
- Alcohol, tobacco and other drugs use
Reason for request
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
Clinical modifiers
- Impact on employment
- Impact on education
- Impact on home
- Impact on activities of daily living
- Impact on ability to care for others
- Impact on personal frailty or safety
- Identifies as Aboriginal and/or Torres Strait Islander
Other relevant information
- Willingness to have surgery (where surgery is a likely intervention)
- Choice to be treated as a public or private patient
- Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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Notes
- Please note that where appropriate and available, the referral may be streamed to an associated public allied health and/or nursing service. This may include initial assessment and management by associated public allied health and/or nursing, which may either expedite or negate the need to see the public medical specialist.
- A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
- Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
Last updated: 13 June 2023
