Information for GPs

Which Patients Should You Refer To a Neurosurgeon?

Neurosurgeons are able to treat a wide array of patients with problems ranging from brain tumours to degenerative spinal disorders and peripheral nerve compression. Generally, if you suspect that there is a disorder of the brain or spine which may require a surgical opinion then referral to a local neurosurgeon would be appropriate.

There is considerable overlap between the clinical conditions encountered by orthopaedic surgeons, neurosurgeons and neurologists. Generally, once these patients are assessed and investigated by any one of these specialists they can be referred on to the appropriate specialist within the OUH trust if this is required.

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Below are some guidelines on the urgency of referral of some common neurosurgical conditions

What Constitutes a Neurosurgical Emergency?

The conditions listed below are a guide, if you have any concerns about a patient then you can either talk to the Neurosurgical registrar on call at the John Radcliffe Hospital (Tel 01865 741166), or the Consultant on call available via the John Radcliffe Hospital switchboard.

1. Patients that should go to A&E in the first instance

  • Alteration in level of consciousness
  • Sudden neurological deficit with altered level of consciousness
  • Sudden onset headache with suspicion of intracranial haemorrhage
  • New cranial nerve palsy, especially painful oculomotor nerve palsy
  • Gradual onset neurological deficit such as hemiparesis
  • Symptoms of raised intracranial pressure
  • Any suggestion of CSF shunt malfunction
  • Suggestion of Cauda Equina Syndrome*

2. Patients that need an urgent referral

If in doubt about the urgency of a referral please contact the neurosurgical SpR on call at the John Radcliffe Hospital Oxford (Tel 01865 741166). Otherwise a fax is best either addressed to the Neurosurgical consultant on call, or a consultant of your choice (Fax 01865 231885).

My secretary can be contacted via the below, or the form on the contacts page

Natasha Morgan
Tel: 01865 234838
Fax: 01865 231885

Once the details are taken, or the fax received, the urgency of the case will be assessed and the patient booked into the next available clinic, or arrangements will be made for the patient to be seen urgently as an outpatient on the day assessment unit, level 2 of the West Wing at the John Radcliffe Hospital.

Cases that would be appropriate urgent referrals include:

  • New foot-drop with or without sciatica
  • New Onset severe back pain and sciatica unresponsive to conventional measures
  • New weakness or numbness in an upper limb
  • New onset severe nocturnal back pain
  • Thoracic myelopathy
  • Progressive cervical myelopathy

3. Patients that can be referred routinely

These referrals are best made by letter and / or fax, or choose and book. In some cases patients will be prioritised based upon the need to investigate / treat more urgently and be seen sooner than this.

  • Back pain unresponsive to conventional measures
  • Back pain and sciatica
  • Neurogenic claudication due to spinal stenosis
  • Neck pain unresponsive to conventional measures
  • Neck pain and cervical radiculopathy
  • Carpal tunnel syndrome / ulnar neuropathy

*Cauda Equina Syndrome

This clinical syndrome can be very difficult to diagnose. The cardinal symptoms are back pain, sciatica (often bilateral), and disturbance of the perineal or pericoccygeal sensation. In association with this may be weakness of numbness of the legs and / or feet with absent ankle reflexes, and rarely knee reflexes.

Urinary symptoms can be difficult to interpret in a patient in severe pain who has also taken analgesics causing constipation. Features that are red flag symptoms include urinary and faecal incontinence and painless distension of the bladder. If a patient complains of urinary symptoms, then often a useful question is whether they feel more comfortable after emptying their bladder ie they have intact bladder sensation.

If you have a patient in whom you suspect cauda equina syndrome but are not sure then the safest option is to refer via your local A&E where a more formal assessment can be made, and imaging organised if appropriate. The John Radcliffe Hospital A and E staff have the ability to assess patients and now arrange MRI scans. If the MRI scan shows cauda equina compression we would almost always operate the same day as presentation.