HNY Policy and Pathway Repository - Humber

This is a TRIAGE service. All referrals to HEY NEUROSURGERY services are directed to this TRIAGE service for clinical review prior to appointment. If appointment is appropriate on review, the hospital will inform patients of appointment details by letter.

PATIENTS WITH RED FLAG SYMPTOMS OR SIGNS NEED URGENT DISCUSSION with the on call neurosurgery team via the referapatient system (www.referapatient.org.uk) or to be referred to the nearest Emergency Department. A referral to neurosurgery has to be accompanied with appropriate diagnostic imaging.

This includes cases with possible Cancer, Spinal Cord Compression, Spinal Infection or cauda equina syndrome.

• Raised temperature (associated with neurological findings or back/neck pain)
• Obvious deformity of spine (new or recent)
• Presentation younger than age 20 (Consider a referral to Paediatric Neurosurgery in Leeds or Sheffield is patient is under 16)
• Onset of symptoms following significant trauma (e.g. RTA; fall from a height)
• Past medical history of cancer
• Patients who are using systemic steroids
• History of HIV and/or drug abuse
• Patients who are systemically unwell
• Patients with unexplained weight loss
• Patients with inflammatory disorders such as ankylosing spondylitis
• New onset of bowel/bladder disturbances not related to pain / including saddle anaesthesia

 

There are several ways of communicating with Neurosurgery (Advice and Guidance, Referral via ERS, Referral via referapatient.org)

• Advice and guidance, is for generic advice for a variety of conditions when it is not clear if a referral is needed.
• Referapatient is reserved for patients with an acute neurological deterioration that require input in less than 8 hours
• ERS referral is reserved for all elective cases

Prior to any communication or referral, we highly recommend that you read the additional resources at the end of this document.

Do Not Refer

Please DO NOT refer a case if patient

• Would not accept surgery if offered
• Is not fit for surgery
• Has non-specific neck, back, arm, shoulder or leg pain or 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 in the context of spinal degenerative disease (reference to NICE guidelines)
• Has an MRI showing disc bulges or lateral recess stenosis without presenting with Sciatica, Claudication, Brachialgia or Myelopathy

Neurosurgery will accept direct referrals from GPs for the following conditions

• Cervical/Thoracic myelopathy
• 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 below

Community Spinal MRI Referral form on ARDENS

 

Referrals

Outpatient Clinics

All referrals will be directed to the general neurosurgery service (Routine) where they will be triaged and then upgraded to Urgent if required. The patient will be informed by HUTH of any change to their appointment. Each Neurosurgeon has one general Neurosurgical clinic a week in the Surgical Outpatients Department on the 1st Floor at Hull Royal Infirmary, Castle Hill Hospital and East Riding Community Hospital Beverley. General neurosurgery outreach clinics are also conducted at, Scunthorpe General Hospital and York Hospital. Consultants conduct these clinics in rotation.

Information To Include 

Referral letters should include a clinical history and a summary of signs to enable us to stratify and screen referrals. If patients have been scanned in other hospitals under GP access / arrangements, the scans / CD will need to accompany the referral. Referrals following an assessment in Primary Care Triage Centre or on the recommendation of another clinician will still require a comprehensive referral letter.

Section 1: Referral (or advice & guidance) for an non-urgent incidental finding of intracranial tumour / vascular abnormality / skull base tumour

An incidental finding of intracranial pathology is not uncommon. It may represent something for which no further action is needed though rarely may represent something serious. We recommend that a referral to an appropriate MDT with as much clinical information as possible is made from primary care. Advice will be provided and a clinic outpatient appointment will be booked if considered appropriate. For a suspected abnormality please consider appropriate imaging prior to an MDT referral (CT-Angiogram when a vascular abnormality is suspected, MRI brain with contrast when a lesion is either suspected or identified) and pituitary function tests (prolactin,cortisol, GH, TFT) for suspected pituitary lesions and/or referrals for visual assessment.

MDT for Neurovascular cases:  hyp-tr.RadiologyMDT@nhs.net

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

Section 2: Referral (or advice & guidance) for the management of predominantly back or neck pain.

This is for patients who do not present with any neurological deficit or radicular pain. Overall, conservative management for patients with back pain has been proven to be a better option as endorsed by the NICE guidelines for the management of back pain (NG59 published November 2016). Although there are no clear guidelines for neck pain the same principles will apply from existing guidance for back pain. Associated symptoms such as subtle sensory disturbances or paraesthesia may often be associated with chronic degenerative changes and are unlikely to be improved with surgery. In such cases the risks of surgery often outweigh the benefits and conservative management is advocated. When symptoms persist despite non-surgical management there is still little role for surgery as explained in current NICE guidance. Certain patients may still be appropriate for referral but a clear explanation of the rationale for referral and how this falls outside the recommendations from NICE.

‘If there is an underlying pathology documented by an MRI (or other modality) that can potentially change the diagnosis of non-specific back pain to specific back pain (e.g. deformity/pars defect/infection/cancer), then a thorough history and examination should take place, with clinical judgement on referral.’

Section 3: Referral (or advice & guidance) with an aim to offer injections to the patient

When a patient is keen to explore spinal injections as a treatment option (either because of comorbidities, personal choice or circumstances, fear of risks with surgery, age etc.), referral should be directed to the Pain Service as the Neurosurgical team are not commissioned to provide this service. We are only commissioned to request diagnostic injections as part of surgical planning (e.g. when it is not clear to the operating surgeon which levels should be targeted surgically following review of an MRI and clinical examination). Spinal injections as a therapeutic intervention are routinely delivered by local pain teams.

Section 4: Osteoporotic Fractures / Fragility fractures

Osteoporotic fractures in the absence of deformity with a new neurological deficit are not the remit of Neurosurgery. To further investigate an up to date (less than 3 months old) MRI with STIR is advised with the aim:

- Diagnose the acuteness of the fracture (old and healed or new)

- Differentiate between an insufficiency fracture or a pathological (secondary to an unknown metastatic disease - Any red flags?)

If the patient is felt suitable for vertebroplasty, a referral form to the Vertebroplasty MDT should be completed and returned to hyp.tr.RadiologyMDT@nhs.net

Patients not suitable for vertebroplasty will require bed rest and mobilisation as pain allows together with appropriate analgesia until the fractures self-heal. There is an existing agreement for these patients to be managed by Medicine-Endocrine/Geriatric/Pain team if secondary care involvement is deemed necessary. If a brace is recommended then the clinical team requesting the brace should follow up the patient.

Please consider a referral to the Metabolic Bone team for advice regarding on-going osteoporosis management.

Section 5: Referral (or advice & guidance) for the management of patients presenting with sciatica as the predominant symptom.

In such cases surgery can be considered. It is not needed for most of the cases, but it is an option that can be discussed with the patient. We would ask the referrer to confirm in the referral documentation the following:

1. Patient wants to consider surgery, rather than physiotherapy or Injections. If they opt for the latter, please make the appropriate referral to physio or the pain team.

2. Patient understands that surgery can be offered to improve their leg symptoms rather than back pain (please see NG59 for current guidance for the management of back pain).

3. Patient is willing to accept risks associated with spinal surgery such as:

Infection, Haemorrhage, Major Vascular Injury, Life at risk, Nerve damage (paralysis of legs, bowel, bladder – sexual dysfunction), durotomy (that may require another operation up to an insertion of a permanent Lumbar-peritoneal shunt), perineural fibrosis, positional neuropathy, deep venous thrombosis, pulmonary embolism, No improvement or worsening of symptoms, Disc reoccurrence or incomplete disc removal, positional neuropathy, anaesthetic risks, unexpected risks.

Note: We do not have the expectation that primary care physicians to consent patients. We want to make sure that patients have a good understanding that surgery comes with risks

4. Details of the MRI scan demonstrating pathology that is congruent with the patient’s symptomatology. There are situations where an MRI reports findings that do not fit with the patient’s presentation (please see section 7 below).

If these criteria are met a referral to Neurosurgery is appropriate. Waiting times being as they are for routine outpatient appointments, many patients are referred to the spinal clinic and wait for months to be seen, only to tell us that they don’t want surgery and that they would prefer injections to treat their problem. This is a waste of the patient’s time, causes unnecessary delays for patients that are suitable candidates for surgery and is a poor use of a limited speciality resources.

Section 6: Referral (or advice & guidance) for the management of patients presenting with brachialgia as the predominant symptom.

In such cases surgery can be considered. It is rarely needed, but it is an option to consider. We would ask for the referrer to confirm in the referral documentation the following:

1. Patient wants to consider surgery, rather than physiotherapy or Injections. If they opt for the latter please make the appropriate referral to physio or the pain team

2. Patient understands that surgery can be offered for brachialgia symptoms rather than patient’s axial neck pain (please see NG59 for the principles of managing neck pain).

3. Patient is willing to accept risks associated with spinal surgery such as:

Infection, Haemorrhage, Major Vascular Injury, Life at risk, Nerve damage (paralysis of arms/legs, bowel, bladder – sexual dysfunction), durotomy (that may require another operation up to an insertion of a permanent Lumbar-peritoneal shunt), swallowing disturbances, hoarseness, stroke, perineural fibrosis, positional neuropathy, deep venous thrombosis, pulmonary embolism, No improvement or worsening of symptoms, Disc reoccurrence or incomplete disc removal, positional neuropathy, anaesthetic risks, unexpected risks.

4. Details of the MRI scan demonstrating pathology that is congruent with the patient’s symptomatology. There are situations where an MRI reports findings that do not fit with the patient’s presentation (please see section 7 below).

If these criteria are met a referral to Neurosurgery is appropriate. Waiting times being as they are for routine outpatient appointments, many patients are referred to the spinal clinic and wait for months to be seen, only to tell us that they don’t want surgery and that they would prefer injections to treat their problem. This is a waste of the patient’s time, causes unnecessary delays for patients that are suitable candidates for surgery and is a poor use of a limited speciality resources.

Section 7: Referral (or advice & guidance) based on MRI report

Many referrals are made to Neurosurgery on the basis of MRI reports rather than the patient’s symptoms. Radiology reports include the term ‘Specialist referral is advised’ which can be misleading. It is important that patients understand that MRI will pick up expected wear and tear and it is the duty of the radiologist to report it. There is wide variability between reporting radiologists in the language used. The following studies demonstrate the variability of MRI reports and the correlation with clinical symptoms.

• In a recent study, the same patient was sent to 10 different hospitals for the same MRI scan. None of the scan reports were identical, and only 1 in 3 findings were present on all of the reports. This highlights the variability of scan reporting.
• From a randomized trial MRI reports standalone without the appropriate clinical reporting have been found to have a detrimental effect on the patient and the expectations from a consultation. 
• 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
• There is good evidence to suggest that unwarranted MRI scans are detrimental to patient wellbeing and lead to poorer outcomes

Section 8: Referral for Normal Pressure Hydrocephalus (NPH)

Management / Diagnosis of NPH is done by our neurology colleagues. Please do not refer a patient of undiagnosed NPH. These cases need referral to our neurology colleagues who will investigate further with a clinical assessment, and if appropriate a Lumbar puncture and refer to us once the diagnosis has been established and once the benefit of, for example a lumbar puncture are deemed positive by the team.