Back and/or Neck Pain (Neurosurgery)

ADULT

  • 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 or signs of raised intracranial pressure
    • Severe and increasing headache
    • Deteriorating neurological function i.e. increasing headache and/or nausea vomiting, decrease in conscious level, seizure, development of focal neurological signs
    • Seizures
    • Suspected glucocorticoid deficiency

    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

    Back and/or Neck Pain

    • Cauda equina syndrome
    • High energy spinal trauma
    • Suspected epidural abscess or discitis

    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 Neurosurgical Conditions

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

    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
    • Determine the potential for underlying sinister pathology
    • Many Category 2 and most Category 3 patients referred for a surgical opinion will not require surgery. Evidence demonstrates that active non-surgical management is as effective for a number of spinal conditions.
    • Appropriate category 2 and 3 patients will initially be assessed / reassessed and case managed by an expert musculoskeletal physiotherapist. Outcomes may include provision of appropriate non-surgical management plans, discussion or appointment with a spinal surgeon or discharge.
    • Consider referral to persistent pain management early as necessary

    Medical management

    • Caution should be used in prescribing opiates for spinal pain which should be prescribed in line with current guidelines
    • Anti-inflammatory and analgesia may be considered
    • Advice, education and reassurance
      • Heat, activity modification, normal activity
    • Physiotherapy and exercise

    Clinical resources

    Patient resources

Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)

    Request for advice / eConsult

  • Where diagnosis of the following Minimum referral consult conditions is equivocal, eConsult is available to provide timely advice in regard to diagnosis, investigations, or management OR 
  • May be provided on receipt of a referral if eConsult is deemed to better meet the needs of the patient.

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  • Significant spinal nerve root compression or spinal cord compression with evolving neurological signs/symptoms
    • Severe sciatica with new onset reflex & muscle power deficit e.g. Foot drop
    • Severe neck & arm pain with new neurological deficit
  • New onset or radiologically proven Cervical Degenerative Myelopathy with symptoms of spinal cord dysfunction
  • Spinal tumours (benign or malignant)
  • Stable spinal fractures without evolving neurological deficit
Category 2
(appointment within 90 calendar days)
  • Acute cervical & lumbar disc prolapse with moderate to severe radicular symptoms and stable neurological signs
  • Significant neurogenic claudication/limitation of walking distance with stenosis on imaging
Category 3
(appointment within 365 calendar days)
  • Moderate neurogenic claudication/limitation of walking distance with stenosis on imaging.
  • Anterolisthesis/spondylolisthesis
  • Severe scoliosis (>50 degrees)
  • Coccydynia refractory to 6 months of conservative management including injection

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Non-Surgical Pathways

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

  • Presence and duration of neurological signs and symptoms
  • Presence or absence of concerning features
    • age (at onset) < 16 or > 50 with new onset pain
    • motor deficit e.g. foot weakness
    • recent significant trauma
    • weight loss (unexplained)
    • previous history malignancy (however long ago)
    • history of IV drug use
    • previous longstanding steroid use
    • recent serious illness
    • recent significant infection
  • Mechanism of injury
  • Functional status
  • Management to date (including previous spinal surgery and non-operative management)
  • General medical history
  • Oswestry Disability Index (ODI) for back pain / Neck Disability Index (NDI) for neck pain
  • Pain Diagram
  • CT / MRI for suspected nerve pathology – if unsure consider eConsult
  • Nerve conduction studies if appropriate

3. Additional referral information Useful for processing the referral

  • FBC, ELFT, ESR, CRP results, rheumatoid serology, Calcium and phosphate, electrophoresis, immunoglobin's, PSA (IF RELEVANT to their presentation)
  • Other relevant reports from any providers in a public or private sector related to the presenting problem

NB: Imaging of the spine is not recommended in most patients with an acute presentation or with a stable chronic presentation unless there is the indication of sinister or serious pathology (concerning features). If there are no signs of sinister or serious pathology imaging may be indicated after a trial of conservative therapy. (Diagnostic Imaging Pathway)

  • For any lumbar spondylolisthesis plain lateral standing films in flexion and extension are helpful in addition to the CT/MRI

4. Request

  • 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.)

  • 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.

    • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate 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: 23 January 2023

© State of Queensland (Queensland Health) 2023

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