Neurosurgery (Brain & Spine)

Definition/Description

Neurosurgery is the surgical specialty focused on the diagnosis and treatment of disorders affecting the entire nervous system, including the brain, spinal cord, peripheral nerves, and cerebrovascular system, covering conditions from tumours and trauma to vascular issues, pain, and congenital defects, often involving advanced technology and multidisciplinary teams for complex care.

Brain Disorders: Tumours, aneurysms, traumatic brain injury (TBI), - for hydrocephalus, epilepsy, infections and stroke see Neurology
Spinal Disorders: Degenerative conditions, spinal cord compression, disc herniation, trauma, congenital issues (like spina bifida)
Peripheral Nerve Disorders: Nerve damage, compression, and related pain.
Vascular Issues: Cerebral aneurysms, arteriovenous malformations (AVMs).

Neurosurgeons conduct clinics at Hull Royal Infirmary, Castle Hill Hospital and East Riding Community Hospital in Beverley. General Neurosurgery outreach clinics are also conducted at Scunthorpe General Hospital and York Hospital. Consultants conduct these clinics in rotation.

This page relates to requirements and referral to Neurosurgery for Brain and Spinal issues, and the information is for Primary care referrals only.

Red Flag Symptoms

Red Flag Symptoms Requiring Urgent Neurosurgical Assessment - please consider referral to Accident and Emergency department

Headaches: Sudden-onset and persistent
Signs of Raised Intracranial Pressure: Vomiting, severe headache or, drowsiness.
Acute Neurological Deficit: Rapidly progressive weakness, particularly if unilateral.
Seizures: New, unexplained seizures in adults.
Cognitive/Mental Changes: New, unexplained, or progressive changes in memory, personality, or behaviour.

Visual Disturbances: Sudden loss of vision, double vision (diplopia), or blurred vision.

Guidelines on Management

Neck and Back Pain

Most cases of low back pain are non-specific and have no identifiable cause. Less commonly, back pain can be the presenting complaint of an underlying pathology. Acute back pain usually resolves within a week or so, but can recur and become chronic in some patients, when it becomes a chronic long-term condition, managed in primary care with advice, education physiotherapy and analgesia.

Analgesia will help with background inflammatory pain but will not help much with pain from body weight loading or movement – this is where physiotherapy (core stability) can help. Patients may also find use of Transcutaneous Electrical Nerve Stimulation (TENS) machines for pain management.

Most patients can be managed in Primary care supported by Community Pain Clinics or an MSK services (see additional information for links) If back pain persists and community interventions have not assisted, consider contact with Neurosurgery via A&G. Patient could also be referred to the Secondary Care Pain team for spinal injections.

Please refer patients with chronic back pain to MSK/Physio prior to referral for MRI or Neurosurgery to ensure that the physiology is the lead causation factor. A referral for MRI for back pain without MSK/Physio assessment will not be accepted in secondary care (NICE NG59, November 2016)

If there is a positive or incidental mass lesion/tumour found on an MRI of the spine then you can refer with clinical history and examination. The email for MDT for Spinal cases: hyp-tr.huthspinalmdt@nhs.net. This is NOT for degenerative spinal disease and not for urgent/emergency referrals

For Headaches and Migraine see headache Management or Neurosurgery for initial guidance and management.

In relation to referrals to Neurosurgery this is more in relation to patients with acute symptoms or cancers as detailed below.

Brain and central nervous system cancers (NG12)

adults
- consider an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) (to be performed within 2 weeks) to assess for brain or central nervous system cancer in adults with progressive, sub-acute loss of central neurological function
children and young people
- consider a very urgent referral (for an appointment within 48 hours) for suspected brain or central nervous system cancer in children and young people with newly central neurological dysfunction

Refer urgent patients (not exhaustive) to MRI scan with:

symptoms related to the Central nervous System (CNS) in whom a brain tumour is suspected, including:
- progressive neurological deficit
- new-onset seizures
- headaches
- mental changes
- cranial nerve palsy including visual changes.
- unilateral sensorineural deafness
headaches of recent onset accompanied by features suggestive of raised intracranial pressure, for example:
- vomiting
- drowsiness
- posture-related headache
- pulse-synchronous tinnitus
- or by other focal or non-focal neurological symptoms, for example blackout, change in personality or memory
a new, qualitatively different, sudden onset, unexplained headache that becomes progressively severe
suspected recent-onset seizures (refer to neurologist)

Refer urgently patients previously diagnosed with any cancer who develop any of the following symptoms:

recent-onset seizure
progressive neurological deficit
persistent headaches
new mental or cognitive changes
new neurological signs.

Consider urgent referral (to scan) in patients with rapid progression of:

subacute focal neurological deficit
unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these
personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour

Please follow referral criteria as detailed below – noting the differentiation between routine, urgent and urgent following Imaging Investigation.

For Red flags or Cancer Symptoms – use appropriate Imaging referral forms as detailed on the respective pages.

Referral Criteria/Information

Do Not Refer

If your patient:

would not accept surgery if offered
is not fit for surgery
has non-specific neck, back, arm, shoulder or leg pain in a non-dermatomal pain.
Has pain related restriction of movements (this is not considered as a neurological motor deficit)
Has already been seen in a Pain Clinic or an MSK Service for neck pain or back pain and been classed as unsuitable for surgical intervention
Has severe back or neck pain only in the presence of degenerative disease
Has Osteoporotic Fractures / Fragility fractures – consider referral to - Vertebroplasty MDT
Has undiagnosed normal pressure Hydrocephalus/or on scan report– refer to Neurology for further investigation and lumbar puncture.
If an MRI shows disc bulges or lateral recess stenosis without presenting with Sciatica, Claudication, Brachialgia or Myelopathy.
- Findings described in MRI reports are very common in people with NO PAIN, such as disc degeneration (91%), disc bulges (64%), disc protrusion (32%), annular tear (38%). These findings increase with age and can be signs of a naturally maturing spine.
- Nine out of ten people with NO neck pain have disc bulges on MRI and most people in their 20s have bulging discs

Referral Criteria

Prior to any communication or referral, we highly recommend that you read the additional resources - GP Spinal Referral Guidance to Neurosurgery

Advice and Guidance is available through NHS Electronic Referrals (eRS) for generic advice for a variety of conditions when it is not clear if a referral is needed.

Neurosurgery will accept direct referrals from GPs for the following conditions

Cervical/Thoracic myelopathy
Patients presenting with Sciatica, Claudication or Brachialgia
Neurological motor deficit in a specific myotome (or myotomes) that correlates to MRI findings
Spinal canal stenosis or radiologically proven cauda equina compression.
Complicated postoperative course
Any other case that the GP may feel appropriate and it is not included in any of the guidance provided

Advice and Guidance and Referrals to Neurosurgery at Hull University Teaching Hospitals Trust is via NEUROSURGERY TRIAGE service through NHS Electonric Referrals (eRS).

Speciality	Service ID	HUTH Service Name
Neurosurgery (TRIAGE)	7992680	Neurosurgery & Spinal Triage – Hull University Teaching Hospital - RWA

All referrals to this service receive clinical review prior to appointment and upgraded to urgent if required. The hospital will inform patients of appointment details by letter/patient portal, or if necessary (urgent or short notice change) by telephone – please ensure the patients details are correct and included.

Information to include in the referral (eRS Neurosurgery TRIAGE)

Referral letter should include
- Patients’ details, NHS number and all contact details
- a clinical history
- a summary of signs and symptoms
- If patient has attended pain/MSK – include report/outcomes.

REFERRAL for non-urgent incidental finding on MRI scan:

Following any brain or spine MRI, where there are positive or incidental findings of a tumour or vascular abnormality, you can make a referral to an MDT for review. Referral emails should include a clinical history and a summary of signs and symptoms, and the scans / CD will need to accompany the referral. Details should also include the patient’s name, NHS Number, DOB and medications. A referral form template for MDT is available for GPs through the ARDENS system

Please ensure to include the form and any scans and refer to most appropriate MDT.

MDT for Spinal cases: hyp-tr.huthspinalmdt@nhs.net – tumour only, but if acute neurological deficit or red flags – see above

MDT for Neurovascular cases: hyp-tr.RadiologyMDT@nhs.net - (please refer for a CT-Angiogram when a vascular abnormality is found)

MDT for Neuro-Oncology cases hull.neurooncology@nhs.net

MDT for Skull Base pathology: hull.neurooncology@nhs.net

MDT for Pituitary/Sella lesions: hyp-tr.hcvpituitary@nhs.net and please provide prolactin, cortisol, igf-1 levels, TFT with the referral.

For URGENT/ EMERGENCY REFERRALS use Referapatient – Online referral portal FOR ONCALL patients with an acute neurological deterioration that require input in less than 8 hours as well as for Spinal Cord Compression, Spinal Infection or confirmed radiological cases of cauda equina syndrome https://www.referapatient.org/

Cross over with other ICBs/Areas

Neurosurgery is provided by Hull University Teaching Hospitals Trust for the wider Humber and North Yorkshire ICB area and extending to parts of Greater Lincolnshire