Ninewells Hospital Neurosurgical Department Guidelines for Neurosurgical Referrals The following conditions are not routinely seen: • Patients who are being treated for the same condition by Orthopaedic Surgeons • Patients with back pain without lower limb pain, or neck pain without arm pain, with unremarkable imaging are not seen in the Neurosurgery Department • Please see headings below – click appropriate hyperlink to take you to referral directions Direct from A&E/AMU/GP Urgent Routine • Subarachnoid Haemorrhage post CT/CTA/positive LP • Suspected Cauda Equina Syndrome following complete examination +/- imaging if triaged • Severe Head and/or Spinal Trauma • Blocked Shunt with clinical signs, symptoms and imaging suggestive of hydrocephalus • Most malignant intracranial tumours (high grade glioma, metastasis) • Degenerative spinal disorders with significant deficit – severe myelopathy • Severe trigeminal neuralgia, not responding to oral medication • Most benign intracranial tumours with minimal or stable deficits • Most peripheral nerve disorders • Degenerative spinal disorders with minimal or no deficit • Epilepsy/Movement disorders/Chronic neuropathic pain • Radiculopathy with muscle wasting • Minor and stable head injury with minor contusional injury on CT scan • Stable cervical, thoracic or lumbar spine fractures (i.e no neurological deficits or sensory loss) BRAIN TUMOURS Newly diagnosed primary neoplasms Meningiomas Skull base tumours Pituitary tumours Secondary neoplasms BRAIN: Haemorrhage Subarachnoid Haemorrhage (Aneurysmal) Pre-pontine Haemorrhage (perimesencephalic bleed/non aneurysmal bleed) Arteriovenous Malformations (AVMs) MCA infarct Other vascular disorders
Transcript
Ninewells Hospital Neurosurgical Department
Guidelines for Neurosurgical Referrals
The following conditions are not routinely seen: • Patients who are being treated for the same condition by Orthopaedic Surgeons
• Patients with back pain without lower limb pain, or neck pain without arm pain, with
unremarkable imaging are not seen in the Neurosurgery Department
• Please see headings below – click appropriate hyperlink to take you to referral directions
Direct from A&E/AMU/GP Urgent Routine
• Subarachnoid Haemorrhage post CT/CTA/positive LP
• Suspected Cauda Equina
Syndrome following complete examination +/- imaging if triaged
• Severe Head and/or Spinal
Trauma • Blocked Shunt with clinical
signs, symptoms and imaging suggestive of hydrocephalus
• Most malignant intracranial tumours (high grade glioma, metastasis)
• Degenerative spinal
disorders with significant deficit – severe myelopathy
• Severe trigeminal neuralgia,
not responding to oral medication
• Most benign intracranial
tumours with minimal or stable deficits
• Most peripheral nerve
disorders
• Degenerative spinal disorders with minimal or no deficit
• Epilepsy/Movement
disorders/Chronic neuropathic pain
• Radiculopathy with muscle
wasting • Minor and stable head injury
with minor contusional injury on CT scan
• Stable cervical, thoracic or
lumbar spine fractures (i.e no neurological deficits or sensory loss)
NECK Cervical Spinal Injury/stable fractures – stable without neurological compromise
NECK Cervical Spinal Injury/unstable fractures withou t
neurological compromise Hyperflexion injury (with or without C spine fractu re) – acute sensory and motor function compromise Cervical subluxation injury with or without neurological compromise
NECK PAIN Mechanical without arm pain or neurological defi cit or sensory changes
NECK PAIN with associated referred arm pain (radiculopathy ) with
and without neurological deficit NECK PAIN Secondary to malignant disease
Secondary to infection causing cord or nerve root compression
NECK PAIN with associated neurological deficit, sensory cha nges
and existing myelopathy
CLINICAL GUIDELINE FOR THE MANAGEMENT OF ACUTE LOW BACK PAIN BACK PAIN Mechanical lower lumbar back pain/chronic lower
lumbar back pain without neurological deficit or neuropathic pain
BACK PAIN Cauda Equina Syndrome (complete or incomplete) BACK PAIN Secondary to neoplastic disease or infection BACK PAIN With sciatica with/without neurological deficit BACK Lumbar or Thoracic Spinal Injury/unstable fractu res
with or without neurological compromise Peripheral Nerves Carpal Tunnel Syndrome Suspected ulna nerve compression Peripheral Nerves Occipital neuralgia
• Hormone levels including Prolactin (PRL < 4000iU) and early morning cortisol if suspected pituitary tumour
• Ninewells Neurosurgery approach to the management of CNS cancer includes access to: Neuro-oncology for MDT team discussion, assessment and treatment planning
• Neurology and Epilepsy Clinic or Epilepsy Specialist Nurse for seizure management
• Neuro-psychology
• Pain Management Service
• Neuro-rehabilitation
• Palliative Care Service
• Endocrinology Service
• Refer on call – page 3110 if patient neurologically stable and GCS 14 or above, the patient should be referred between the hours of 08:00 and 20:00
• If prolactinoma is confirmed
(ie Prolactin level >4000iU) refer to Endocrinology team
• Referral to Neurology if
patient presents with seizure
• Consider commencing on full dose Dexamethasone (8mg BD – 08.00 and Noon or 14.00hrs) and proton pump inhibitor treatment dose, such as Omeprazole 20-40mg daily.
• Note significant PMH, previous neoplasms and risk factors
• Presenting history and deficits
• CT scan brain
• CT staging – Chest/Abdo/Pelvis
• Ninewells Neurosurgery approach to the management of CNS cancer includes access to: Neuro-oncology for MDT team discussion, assessment and treatment planning
• Neurology and Epilepsy Clinic or Epilepsy Specialist Nurse for seizure management
• Neuro-psychology
• Pain management service
• Neuro-rehabilitation • Palliative care service
• Endocrinology service
• Refer on call – 3110 if patient neurologically stable and GCS 14 or above, the patient could be referred between the hours of 08:00 and 20:00
• Referral to Neurology if patient presents with seizure
• Consider commencing on
full dose Dexamethasone (8mg BD – 08.00 and Noon or 14.00hrs) and proton pump inhibitor treatment dose, such as Omeprazole 20-40mg daily
• Presenting history and clinical evaluation – GCS, pupils, neurological deficit
• Family history
• CT Brain
• CTA
• Lumbar puncture - + xanthochromia and red cells (ideally 3 consequetive CSF tube samples, protected from light)
• MRI/MRA
• Ninewells Neurosurgery approach to the management of aneurysmal haemorrhage will include discussion with the Neurovascular Interventionist Teams at Edinburgh or Glasgow once aneurysm confirmed. Highly likey to be transferred as an emergency at the earliest bed availabiltiy
• Medical and nursing management of patients with positive aneurismal haemorrhage:
• Immediate referral to on call – 3110 for SAH/ Pre-pontine haemorrhage
• Stop antiplatelet/ anticoagulant meds – reversal may be required
• Cervical or intracranial arterial or venous dissection – Neurology referral
• MCA infarct – Stroke referral • Patient’s over the age of 60
years may be considered for decompressive cranietomy
• DSA
2 hourly Neuro obs – GCS and vital signs BP/HR – monitor for signs of raised ICP – hydrocephalus/ rebleed
• 3lt minimum fluid intake – IV access
• Catheterisation in patients with lower GCS
• Analagesia (IV paracetamol, oral or IM Codeine Phosphate if tolerated Antiemetic (ondansetron oral/IV). Avoid opiod analgesia
• Strict bedrest to 30
degrees maximum, (commode toileting) until after treatment of aneurysm.
• Transfer of patients should
be bed to bed, with nurse escort, not Porter on chair
• 4hrly Nimodipine 60mg
• TED socks/Consider commencing laxatives
but it must be stressed that the outcomes are poor
BRAIN Incidental Aneurysms or other miscellaneous vascular conditions Evaluation Management Referral Guidelines
• Presenting history and clinical evaluation – GCS, pupils, neurological deficit/ cranial nerve signs
• Family history
• CT Brain
• CTA
• MRI/MRA
• DSA
• Ninewells Neurosurgery approach to the management of incidental findings of aneurysm will depend on patient’s age, symptoms and presentation.
• Management of
hypertension • Consideration of elective
coiling/clipping if aneurysm is considered a high rupture risk (risk of haemorrhage is significantly lower in elderly patients)
• There is usually no urgency for incidental aneurysm findings unless symptoms are causing neurological signs such as visual deficits or other cranial nerve function deficits
• Routine referral or discussion with on-call within in normal working hours
• Presenting history, trauma history and clinical evaluation – GCS, pupils, neurological deficit/ cranial nerve examination
• Considerations for mechanism and time of injury, such as speed of impact/height of fall
• Key factors for CSDH – acute agitation and deterioration of GCS in early stages post trauma
• Key factors for CSDH – gradual and progressive changes in neurological functioning – developing unilateral weakness, unsteady gait, dysphasia etc trauma history is usually that of weeks, even months prior
• Consider patient co-morbidities, current functional and medical status, pharmacology – warfarin/aspirin/clopidogrel
• CT Brain • INR
• ASDH: Ninewells Neurosurgery approach to the management of Acute subdural haematoma will depend upon the circumstances of injury/patient’s GCS status/ medical health/ pharmacology etc
• Acute deterioration, minimal co-morbidities, normally functioning independently with no antiplatelet/ anticoags are good indicators for a good recovery following surgery Consideration should be given to warfarin reversal if surgery is deemed urgent
• CSDH Very elderly patients (over 80’s) with multiple co-morbidities, reduced functional ability and multi pharmacology do not usually benefit from surgical intervention
• Where the patient is stable with no immediate threat to further deterioration in GCS – patients can be referred during normal working hours 08:00 – 20:00.
• In acute/life threatening situation contact on call 3110
BRAIN Acute intracerebral haematoma (in isolation) Please refer to the acute stroke team, especially if age > 70 yrs, as we very rarely operate on any intracerebral haematoma <3cm in diameter, unless it is in the cerebellum with evidence of hydrocephalus or if associated with an intraventricular haemorrhage. If GCS 14 or above, overnight referrals should instead be made at 8am the following day. BRAIN Head Injury – with CT evidence of contusions/skull
– acute/Blocked Shunt Evaluation Management Referral Guideline s
• Usually presenting acutely with reduced conscious level. Clinical evaluation, should include previous history of shunt insertion current GCS status, Cranial nerve examination, full neurological examination.
• Key points: pupil reaction, down gaze palsy, length of time for reduced GCS – gradual or sudden onset. Visual problems, double/blurred vision and fundoscopy.
• PMH – current medication
• Urgent CT scan – hydrocephalus – size of ventricles
• Shunt series X-rays – abdomen, chest, head to look for shunt blockage, break or disconnection
• Ninewells Neurosurgery will approach diagnosis management of blocked shunt or acute hydrocephalus as urgent
• Consider preparation for urgent surgical intervention – bloods, ECG, etc where warranted
• Presenting history, type of trauma, triage of patient and clinical evaluation – GCS, pupils, neurological deficit/ cranial nerve signs, presence of neck/c-spine discomfort. Consideration to involvement of head injury also
• C-spine immobilisation, flat bed rest, log rolling until injury ruled as stable.
• Secondary survey
• X-ray of C spine – ensure adequate views for accurate assessment – C1-C7 (consider swimmers and open mouth views)
• CT C-spine
• Ninewells Neurosurgery approach to the management stable cervical spinal injury will depend on CT/X-ray findings, patient age and co-morbidities.
• Management considerations include consideration for c-spine imobilisation – collar (soft/beaded/Miami J)
• Patients are usually followed up on ward 23B as out-patients for repeat X-rays as necessary
• MRI to rule out spinal cord changes or nerve root compression may be required
• Minor C-spine injuries/stable fractures only requiring collar, with stable GCS and no neurological signs, should be referred between hours of 08:00 and 20:00
• Recommendation would be to make a referral to TORT (orthotics) fax referral on their blue form (link to form below) for appropriate collar as instructed by Neurosurgery on call. TORT fax number is: 496322 or referral via email at: [email protected] orthotic referral form
• The on-call Reg/ANP for neurosurgery will give instruction for date and time for ward review.
NECK Cervical Spinal Injury/unstable fractures without
Hyperflexion injury (with or without C spine fracture) – acute sensory and motor function compromise Cervical subluxation injury with or without neurological compromise
Evaluation Management Referral Guidelines
• Presenting history, type of trauma, triage of patient and clinical evaluation – GCS, pupils, neurological deficit/ cranial nerve signs, presence of neck/c-spine discomfort. Consideration to involvement of head injury also
• C-spine immobilisation, flat bed rest, log rolling until injury ruled as stable
• Catheterisation
• Secondary survey
• CT C-spine
• MRI C-spine
• Ninewells Neurosurgery approach to the management unstable cervical spinal injury will depend on CT/X-ray findings, patient age and co-morbidities.
• Management considerations include consideration for c-spine immobilisation – Miami J)/ traction/ referral to spinal injury unit in Glasgow.
• Should be considered major
trauma event where there is motor and/or sensory loss.
• Admission to ITU for high level injury and signs of spinal shock
• Urgent referral 3110
• May require urgent MRI with a STIR sequence if there are neurological signs and symptoms which patient could have if still in MTU or A&E
NECK PAIN Mechanical without arm pain or neurological deficit or
• Presenting history and clinical evaluation, neurological deficit, noting key points such as: Presence and duration of symptoms and signs, including evidence of lower limb spasticity General medical condition/ systems review PMH – current medication, previous surgery history
• Plain x-ray
• CT scan • MRI
• Ninewells Neurosurgery approach to the management of neck pain includes: Activity modification/ education Analgesia/NSAIDS Physiotherapy
• Patients with no referred arm pain or neurological deficit and unremarkable imaging are not seen by neurosurgery
NECK PAIN with associated referred arm pain (radiculopathy) with or
without neurological deficit Evaluation Management Referral Guidelines
• Presenting history and clinical evaluation, neurological deficit, noting key points such as: Presence and duration of symptoms and signs, including evidence of lower limb spasticity General medical condition/ systems review PMH – current medication, previous surgery history
• Plain x-ray
• CT scan
• MRI
• Ninewells Neurosurgery approach to the management of neck with radiculopathy will include access to MRI to determine for nerve root compression
• Medical management includes analgesic pathway for neuropathic pain
• Referral is usually routine via SCI Gateway for clinic review.
• Referral to 3110 on call neurosurgery where there are signs of new myelopathy
NECK PAIN Secondary to malignant disease
Secondary to infection Evaluation Management Referral Guidelines
• Presenting history and clinical evaluation, neurological deficit, severity of pain
• PMH – current medication, previous surgery history
• CT scan • MRI
• Ninewells Neurosurgery approach to the management of secondary neoplasm/infection in the cervical spine will depend upon stability of C spine and will decisions will rest with the consultant
• Consideration of ID/ Oncology input will also be required in these cases.
• Referral to on call – 3110 for advice on ongoing management such as acute/chronic pain referral
• Would only consider urgent
referral where there is a risk of C spine instability or rapidly progressive myelopathy
NECK PAIN: with associated neurological deficit, sensory changes and
existing myelopathy Cervical myelopathy is due to spinal cord compression, rather than nerve root compression. It presents with stiffness of hands, dropping things, spasticity, stiff gait +/- poor balance and falls. Examination reveals hyper-reflexia, upgoing plantars, ankle clonus, positive Hoffman's test and difficulty with fine movements of the hands and fingers but usually normal sensation and strength (apart from hand grip), stocking/glove altered sensorium.
clinical evaluation, neurological deficit, noting key points such as: Presence and duration of symptoms and signs, including evidence of lower limb spasticity
• General medical condition/systems review
• PMH – current medication, previous surgery history
• Plain x-ray
• CT scan
• MRI
approach to the management of neck with myelopathy will include review of current imaging specifically MRI to determine for cervical cord signal changes
• Physiotherapy pathway if surgery risks outweigh benefits
• Would consider urgent
admission in acute deterioration
• If patient’s condition long
standing, refer during normal working hours
CLINICAL GUIDELINES FOR THE MANAGEMENT OF ACUTE LOW BACK PAIN
These brief clinical guidelines and their supporting base of research evidence are intended to assist in the management of acute back pain. It presents a synthesis of up to date international evidence and makes recommendations on case management. Please note that first line treatment for back pain and unilateral sciatica (without red flags) is analgesia and physiotherapy organised from primary care. Musculoskeletal (MSK) Helpline Recommendations and evidence relate primarily to the first six weeks of an episode, when management decisions may be required in a changing clinical picture. However, the guidelines may also be useful in the sub-acute period. . These guidelines are intended for use as a guide only by the whole range of health professionals who advise people with acute low back pain, particularly simple backache. Diagnostic Triage: is the differential diagnosis between:
• Simple backache (non-specific low back pain) - over 95% of cases • Nerve root pain – under 5% of cases • Possible serious spinal pathology – under 2% of cases
CAUDA EQUINA SYNDROME – Immediate referral followin g examination and demonstration of:
• Bilateral nerve pain (leg pain radiating past the knees) • Loss of bladder/bowel control, presence of bladder retention, acute erectile
dysfuntion • Perianal/perineal anaestheia, absence of anal tone on examination • Progressive lower limb weakness, absence of lower limb reflexes
BILATERAL LEG PAIN LOSS OF BLADDER OR BOWEL CONTROL LOSS OF PERIANAL/PERINEAL SENSATION PROGRESSIVE WEAKNESS LOSS OF BLADDER FILLING SENSATION
CONSIDER CAUDA EQUINA SYNDROME
WILL REQUIRE URGENT NEUROLOGICAL AND PHYSICAL EXAMINATION AND ASSESSMENT TO INCLUDE PIN PRICK SENSORY EXAMINATION OF SADDLE AREA AND DIGITAL RECATAL EXAMINATION, ABDOMINAL BLADDER EXAMINATION AND REFLEXES (see assessment tool on page 19)
URGENT REFERRAL TO ON CALL NEUROSURGERY
IF EXAMINATION DEMONSTRATES LOSS OF
PERIANAL/PERINEAL SENSATION AND ANAL
TONE ABSENCE OF ANKLE REFLEXES, BLADDER
RETENTION
UNILATERAL LEG PAIN RADIATING BELOW KNEE LEG WEAKNESS ACUTE FOOT DROP LOSS OF REFLEXES
WILL REQUIRE URGENT LOWER LIMB NEUROLOGICAL EXAMINATION AND ASK PATIENT ABOUT BLADDER AND BOWEL CONTROL, SENSATION CHANGES OF SADDLE AREA AND BLADDER RETENTION
PROMPT REFERRAL TO NEUROSURGICAL ON-
CALL TO ALLOW EXPEDITING LUMBAR MRI
See physiotherapy SOP for foot drop accessible here
Red flags for possible serious spinal pathology (co nsider prompt referral)
• Unilateral pain radiating below knee and weakness including acute foot drop or loss of reflex
• Features of systematic illness (history of carcinoma, steroid use, HIV, compromised immunity, unexplained weight loss, fever, night sweats, recent foreign travel) or raised CRP/ESR/WCC without other obvious signs).
• History of progressive weakness or anaesthesia, with point tenderness on palpation of spine
• Constant unremitting pain • Sudden onset back pain • Sudden loss of power or sensation – spinal level
Nerve Root Pain
• Specialist referral is not usually required within the first 6 weeks provided symptoms are stable.
• Unilateral leg pain worse than low back pain • Pain radiates to the foot or toes • Numbness and paraesthesia in the same direction • SLR reproduces leg pain • No cause for alarm, no signs of disease • Conservative management with analgesia and physiotherapy should be enough, but
may take up to 6-12 weeks. The value of physiotherapy should not be
underestimated as first line treatment for these patients as many recover well with physiotherapy intervention.
• Full recovery is expected but recurrence is possible • It is expected that such symptoms are difficult to treat in the acute phase of
presentation. • It is expected that some acute symptoms may mimic signs of cauda equina
compression, but often this is due to acute spasm brought on by nerve irritation to the muscular structure. This can be relieved by a short course of low dose Diazepam.
Simple Backache - Specialist referral not required:
• Presentation age 20-55 years • Lumbo-sacral, buttocks and thighs • Mechanical pain • Patient is well • Nothing to worry over, back pain not serious, very common • No signs of serious damage or disease • Varying recovery – days or weeks • Non permanent weakness – recurrence is possible, but no re-injury • Hurting does not mean harm, returning to work and normal activity is essential to help
recovery, stopping activity is more harmful Drug Therapy
• Prescribe analgesia at regular intervals not PRN • Start with paracetamol, titrate to NSAIDs. Finally consider a short course of muscle
relaxant. • Avoid strong Opioids if possible.
Evidence
• Paracetamol effectively reduces low back pain and can be more effective when used with NSAIDS
• NSAIDs used alone are effective in reducing pain • Weak Opioid compounds may be effective when NSAIDs and Paracetamol used
together, are inadequate Advice on staying active
• Advise patients to stay as active as possible and continue normal daily activities • Advise patients to increase their physical activities progressively over a few days or
weeks • If patient is working, then advice to stay or work according to pain severity or as work
based activities allow, though returning to work as soon as possible is beneficial When conducting assessment, consider “yellow flags”
• Consider patients’ beliefs, behaviours that may predict poor outcomes: • A belief that back pain is harmful or potentially severely disabling • Fear avoidance behaviour and reduced activity levels • Tendency to low mood and withdrawal from social interaction • Expectation of passive treatments rather than a belief that active participation will
help
BACK PAIN Mechanical lower lumbar back pain/chronic lower lumbar back pain without neurological deficit or neuropathic pain
Evaluation Management Referral Guidelines
• Presenting history and clinical evaluation, neurological deficit, noting key points such as: Chronicity, Presence and duration of symptoms and signs, including evidence of lower limb spasticity
• General medical condition/systems review
• PMH – current medication, previous surgery history
• Key Points: • Duration of symptoms • Presence of neurological
symptoms and signs • Previous spinal surgery • General medical
condition and medication
• Patients with no referred lower limb pain or neurological deficit and unremarkable imaging are not seen in Neurosurgery Clinic.
• Consider referral to Physiotherapy, Acute or Chronic Pain service, patients with mechanical lower back pain not requiring surgery should be referred to a more appropriate service, such as Rheumatology or a local physiotherapist
BACK PAIN Cauda Equina Syndrome (complete or incomplete) Evaluation Management Referral Guideline s
• Patient presents with low back pain, nerve root or mechanical back pain, with or without leg pain symptoms
• Are there ?:‘Red flag’ signs
such as dysfunction of: • Bladder - painless
retention or incontinence • Bowel incontinence • Sexual function (loss of
erection) • Paraesthesia of peri-anal
and perineal area patient cannot feel saddle area when wiping
• Severe low back pain • Bilateral leg pain • Motor weakness, sensory
loss, or pain in one, or more commonly both legs
• Loss of ankle reflexes
• Ninewells Neurosurgery adopt an emergency approach to the management of cauda equina syndrome which includes: • Emergency MRI • Emergency surgery
• Please see the following
guide in relation to back pain and red flag signs: Low Back Pain and Sciatica
• If the patient demonstrates positive signs, on call neurosurgery should be contacted immediately bleep 3110
Examination should inclu de • Motor assessment of lower
limbs • Sensory assessment of
lower limbs, to include S3, S4, S5 dermatomes (pin prick)
• All reflexes of lower limbs • Abdominal examination for
bladder distention • Rectal examination to test
anal reflex (either present or absent)
Positive findings will show • Restricted straight leg raise
due to pain and positive root tension signs
• Lack of response to pain stimulus (pin prick assessment), in dermatomes S3, S4, S5
• Absence of anal tone • Distended bladder painless
to palpate • Absence of reflexes,
primarily in ankle Back Pain secondary to neoplastic disease or infection Evaluation Management Referral Guidelines
• Presenting history and clinical evaluation, neurological deficit, noting key points such as: • Presence and duration of
symptoms and signs, including evidence of lower limb weakness, level of sensory loss (if any), bladder or bowel involvement
• General medical condition/systems review
• PMH – current medication, previous surgery history
• Initial diagnostics should include • Bloods • Plain x-ray • CT scan
• Ninewells Neurosurgery approach to the management of neoplastic/infection back pain depends on extent of disease process on investigations and patient examination in terms of motor, sensory function spinal instability risk.
• Please see the following
guide in relation to back pain and red flag signs: Low Back Pain and Sciatica
• Consideration of
stabilisation surgery is not usually an option for multiple metastatic lesions in majority of spinal bones.
• Unless acute cord compression with complete motor and sensory loss, patient can be referred within the hours of 08:00 – 17:00
• Where there is suggestion of infection such as discitis (without cord compression), patient may be considered for CT guided biopsy procedure, which is not a procedure carried out by the Neurosurgical team
• Patient will require
discussion with medical/radiology/ID team to arrange this procedure
• MRI diagnosis and blood
that represent discitis should be referred to ID team
Back Pain and sciatica with neurological deficit Evaluation Management Referral Guidelines
• Presenting history and clinical evaluation, neurological deficit, noting key points such as: • Presence and duration of
symptoms and signs, including evidence of lower limb weakness, red flag signs
• General medical condition/systems review
• PMH – current medication, previous surgery history
Key Points: • Duration of symptoms • Presence of neurological
symptoms and signs • Previous spinal surgery • General medical
condition and medication
• MRI Lumbar-Sacral spine
• Ninewells Neurosurgery approach to the management of back pain and sciatica includes: • Analgesia (see
guidelines below) Scottish Palliative Care Guidelines: Pain Management Scottish Palliative Care Guidelines: Neuropathic Pain • Physiotherapy to include
activity modification/ Education
• If symptoms persist after 6 weeks consider MRI
• Please refer to the following guide for further information in regards to back pain and sciatica:
Low Back Pain and Sciatica NHS Inform: Back Problems
• Patient should be referred
to physiotherapy prior to referral to neurosurgery
• Patient should undergo MRI prior to clinic referral for an informed approach to surgical opinion
BACK Lumbar or Thoracic Spinal Injury/unstable fractures with or without neurological compromise
Evaluation Management Referral Guidelines
• Presenting history, type of trauma, triage of patient and clinical evaluation – GCS, pupils, neurological deficit/ cranial nerve signs, presence of neck/c-spine discomfort. Consideration to involvement of head injury/neck also
• Immobilisation, flat bed rest, log rolling until injury stabilised
• Ninewells Neurosurgery approach to the management unstable cervical spinal injury will depend on CT/X-ray findings, patient age and co-morbidities
• Management considerations include consideration for surgery, referral to spinal injury unit - Glasgow
