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Queens Hospital | Neurosurgery | Last update 3rd December 2018
Please read and follow our referral pathway guidelines. This will prevent repetition and variability, and ensure concise and rapid responses.
Select pathway
Select pathway above before continuing
Regional Referrals from outside BHRUT
All referrals should be via referapatient®.
Sending scans:
The transfer of scans for review can take some time. We therefore recommend contacting your PACS transfer team/radiographers to send any relevant imaging at the earliest opportunity via the Image Exchange Portal (IEP). For urgent cases request 'Blue Light Transfer' through IEP.
Metastatic Spinal Cord Compression (MSCC)
In general the local MSCC co-ordinator should be contacted first but in case of difficulty a direct referral to Neurosurgery can be made.
The MSCC Co-ordinators for the Essex Hospitals are as follows:
Basildon
Broomfield
Colchester
Princess Alexandra
Southend
If the patient has a known malignancy and is under the care of an oncology team, they should always be contacted directly as a matter of urgency.
Referrals from within BHRUT
All referrals should be via referapatient®.
Any spinal referral should be in line with the agreed BHRUT Acute Spinal Pathway
Metastatic Spinal Cord Compression (MSCC)
Within BHRUT the Neurosurgical SpR (x6177) acts as the MSCC Co-ordinator and should be contacted if MSCC is diagnosed
If the patient has a known malignancy and is under the care of an oncology team, they should always be contacted directly as a matter of urgency
BHRUT Acute Spinal Pathway
Trauma
1 Cervical , thoracic or lumbar spine injury (back to Acute Spinal Pathway)
ED order CT for C0 to T4, X Ray for other levels if clinically indicated, Patients must have primary and secondary survey performed and acted upon by trauma team. See Appendix i for who needs radiological investigation.
IF [1a.] Neurology present (back to Acute Spinal Pathway)
Positive MRI or CT - Discuss with neurosurgery on call (dect 6177), if age & co-morbidity appropriate (see Appendix ii) admit to Neurosurgery.
Negative MRI / CT - Neurology opinion / admit under Neurology if neurological cause suspected.
IF [1b.] No Neurology and Bony Injury (back to Acute Spinal Pathway)
Admit under neurosurgery if age and co-morbidity appropriate 16-65, 65-75 with no co-morbidities.
Over 75 admit under medicine and discuss with neurosurgery (see Appendix ii).
If non-surgical / stable with or without a simple brace (simple refers to soft/hard collar and/or anti-flexion brace) refer (Rapid Spinal Assessment Service via neurosurgery reg on call 6177 (RSAS). If further imaging required admit under RSAS but Neurosurgery to review within 24 hours of imaging becoming available.
This group of patients may be suitable for the rapid assessment spine pathway with early input from senior physiotherapy and pain team
If Operative or Unstable admit to Neurosurgery
IF [1c.] No Bony Injury and No Neurology
ED discharge if able to . If unfit for discharge because of pain admit to orthopaedics for pain management.
5 Pelvic Fracture, Sacral Fracture and Polytrauma (back to Acute Spinal Pathway)
These should be solely managed by Orthopaedic team.
Back Pain without trauma
2 Back Pain without trauma (back to Acute Spinal Pathway)
ED to arrange MRI if indicated (see Appendix iii)
Emergency doctors have access and arrange MRI scans urgently without approval of neurosurgery on call. If Cauda Equine is suspected, please complete the appropriate radiology forms and contact Radiologist on call.
(Conditions such as renal colic, vascular dissection etc must be excluded)
IF [2a.] Neurology including urinary or bowel disturbance (back to Acute Spinal Pathway)
Discuss with Neurosurgeons. If MRI shows surgical target then admit to Neurosurgery.
If MRI negative, discharge home with outpatient Neurosurgery (if indicated), refer to Neurology (if unusual neurological symptoms and signs) or admit under Orthopaedics for pain management if unable to discharge home.
IF [2b.] No neurology present (back to Acute Spinal Pathway)
This group of patients should be discharged home with adequate analgesia and an early follow up in community spinal assessment service (available to GPs) and MRI scan as virtual ward. If unable to be discharged home discuss with Orthopaedics for admission for pain control.
3 Fragility Fracture (back to Acute Spinal Pathway)
This is a rehabilitation problem. Usually elderly patients with other medical issues. Admit under medicine for the elderly and discuss with Neurosurgery if instability is suspected for further imagining. In younger age group (below 65) admit under RASS and rule out pathological cause. If able to mobilise with anti-flexion brace then aim for home and outpatient Neurosurgery. If unable to mobilise for pain refer to Neurosurgery (Mr KM David or Mr B Arvin) for consideration of kyphoplasty.
4i Metastatic Disease Primary KNOWN (back to Acute Spinal Pathway)
These need to be discussed with the MSCC co-ordinator 6177 and admitted under Neurosurgery or Oncology depending on the proposed treatment.
4ii Metastatic Disease Primary UNKNOWN (back to Acute Spinal Pathway)
Admit to Oncology for work up. Discuss with Neurosurgery if instability is suspected.
Appendices
APPENDIX i (back)
Need for radiological investigation?
The National Emergency X-Radiography Utilization Study (NEXUS)
• Alert no language barrier not intoxicated
• No midline posterior tenderness
• No focal neurological deficit
• No distracting painful condition
• NB Excluded: Penetrating trauma age<16, “bad” injuries such as fall from a considerable height, thrown of a horse, fatality of someone in the same accident, resolved neurology, returning patient.
• If above is negative there is no need for radiological investigations.
APPENDIX ii (back)
Age
Suggestion: adult 16- 65 years old
For patients 65-75 gray area depends of physiological status
>75 years old suggest medicine for elderly to admit and refer ortho/neurosurgery as appropriate.
Co-morbidities
If patient medically unfit for imaging and/or surgery (recent MI, on-going sepsis, sever COPD, blood abnormality, on warfarin (? Asprin ? clopidogrel ) etc.. discuss case with neurosurgery.
If surgery indicated in spite of high risk admit to Neurosurgery otherwise admit to Medicine for initial work-up.
Use Charlson Co-morbidity index as a reference.
Patients 65-75 scoring equal or above 6 should be referred to medical team in the first instance
APPENDIX iii (back)
Need for MRI scan:
The current practice is that only the Neurosurgical middle grade or Consultant can request an MRI scan of acute spine conditions. This adds delays and confusion to the patient pathway. To avoid this we suggest the following 2 groups of patients should have access to immediate MRI scan arranged by ED.
This has been agreed by Radiology for requests during daytime (09:00-21:00)
1- Suspected Cauda Equina patients based on initial assessment.
2- Patients with spinal trauma and neurological deficit unexplained by x-ray or CT.
GP Information
In general neurosurgery does not take emergency referrals directly from GPs and patients would normally be referred to the local A+E (possibly in discussion with appropriate teams such as General Medicine or Orthopaedics)
Please ring the On-call Neurosurgical SpR for:
- general advice or
- regarding patients discharged within the last 28 days
Paediatric Referrals
The Department of Neurosurgery at Great Ormond Street Hospital manages all patients under the age of 16 years. Referrals can be made via the on-call neurosurgical SpR at GOS.