c/o NHS Barnsley
Hillder House
49-51 Gawber Road
Barnsley, S75 2PY
Tel: (01226) 433 674
Fax: (01226) 433 797
www.yhscg.nhs.uk
Our Ref: KC/MG
Please ask for: Kim Cox
28 October 2009
To: Members of the West Yorkshire Neurosciences Commissioning Group
Dear Colleague
Re: Referral Guidelines to Neurosurgery
A paper was presented to the February 2009 SCG Board meeting which detailed
problems associated with access to neurosurgical services in Yorkshire and the
Humber. The paper focussed on two approaches to addressing the problem;
reducing inappropriate referrals and increasing capacity.
To facilitate the reduction of inappropriate referrals the paper included referral
guidelines to neurosurgery for patients with simple lumbar or cervical discogenic or
degenerative spinal disease. The Board agreed to adopt the guidelines, which had
been agreed between the three neurosurgical centres in Yorkshire and the Humber.
The Specialised Commissioning Team (SCT) is working with providers to ensure the
guidelines are incorporated into Directories of Services. As part of the
implementation of the guidelines, the West Yorkshire Neurosciences Commissioning
Group agreed to work with the SCT to ensure local GPs are aware of the guidelines.
It was agreed that commissioners would work with their GPs in the most appropriate
way to implement the guidelines and that this would be supported by a series of
statements indicating why the guidelines had been produced and what they were
designed to achieve.
These statements are given below. I would be grateful if you would now undertake
the necessary work with your GPs to ensure the guidelines are implemented.



There is an identifiable and ongoing increase in referrals to neurosurgical
services across the patch, but particularly to the Leeds service
Referrals for spinal problems constitute a significant proportion of the work
being sent.
Only a relatively small percentage of the patients seen are appropriate for and
will go on to have a surgical procedure (currently 20% or less), hence 80% of
patients would be more appropriately managed by someone other than a
neurosurgeon
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


Neurosurgical colleagues consider that if referrers adhere to a clear set of
referral guidelines for patients with spinal discogenic or degenerative disease
patients are much more likely to be managed by the appropriate services
Referral guidelines have been produced and agreed and are attached.
Advice is included on the management of patients who are not appropriate for
referral to a neurosurgeon.
I would be grateful if you would inform me of the action you have taken to implement
these guidelines by the end of November.
Should you have any questions please do not hesitate to contact me.
Yours faithfully
Kim Cox
Kim Cox
Cc
Abigail Tebbs
Peter Barnaby
Vicki Woodhead
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Referral Guidelines to Neurosurgery
Discogenic/Degenerative Spinal Disease
for
Patients
with
Simple
Lumbar
or
Cervical
Who Should be Referred?
1. Acute severe radicular arm or leg pain, not showing any improvement with conservative measures (such
as physiotherapy) by six weeks following onset. Note that some improvement is likely to imply
eventual resolution without requirement for surgery. Pain will be in a nerve root distribution.
Neurological symptoms (paraesthesia, numbness and/or muscular weakness) will be in a nerve root
distribution
and
normally
exacerbated
by
cough
and/or
movement.
Progressive neurological symptoms and/or severe radicular pain are indications for urgent referral.
2. Refractive longer term radicular pain (i.e. greater than three months) significantly interfering with
lifestyle, disturbing sleep, or causing extended periods off work.
3. Significant spinal claudication, (i.e., radiating leg pain/paraesthesia/numbness coming on with walking
and distance-limiting). Pain progression is normally from buttocks to the periphery. Relief is gained by
rest and bending forwards. Neurological symptoms (paraesthesia, numbness and/or muscular weakness)
also resolve with rest. Peripheral pulses are normal.
Urgent Referrals to the Neurosurgery On-call Team
1. Cauda Equina Syndrome. Symptoms include bilateral radiating leg pain with sphincter disturbance and
reduced perianal sensation and perineal numbness. Also progressive motor weakness affecting more
than one nerve root and/or gait disturbances. Referral must include the findings from perineal
examination.
2. Severe motor weakness accompanying an acute onset lumbosacral radicular pain syndrome, i.e.,
inability to plantar flex (S1) or inability to dorsiflex (‘foot drop’, L5).
3. Patients with signs of myelopathy. All patients should be referred, whether asymptomatic or not, with
positive long tract signs (see below) or when an MRI has been done and where, even in the absence of
long tract signs, there is cord signal change at a stenotic spinal level. Symptoms include numb, clumsy
hands,
jumping,
stiff
legs,
falls,
poor
balance
and
urinary
frequency.
Referrals to be Marked Urgent
1. Patients with neurological symptoms who fall into one or more of the following categories:
 Presentation younger than age 20
 Onset of symptoms following violent trauma (e.g. RTA; fall from a height)
 Constant, progressive non-mechanical pain
 Thoracic pain
 Past medical history of carcinoma
 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
Who Shouldn’t be Referred?
1. Patients with referred pain. For the purposes of differential diagnosis, referred arm, leg or neck pain is
more generalised in distribution and does not follow a specific nerve root distribution. Pain does not
generally spread below the elbow or knee.
2. Patients with degenerative neck or back pain generally have no surgically remedial cause and so should
not be referred. Patients should be managed with analgesia, advice and physiotherapy.
3. Patients with non-specific neurological symptoms/somatisation disorder. Such patients should be
referred to a neurologist or to the pain clinic.
4. Where radicular pain is significantly improving or resolved.
5. Where there is residual dermatomal numbness following a previous radicular pain episode.
6. Where the patient does not want any surgery (other than patients who are considered to be
myelopathic).

Long tract signs (also known as upper motor neuron or pyramidal signs)
1. Should be done/commented on for all patients with cervicovertebral or cervical radicular pain as a
screen for an underlying myelopathy.
2. Signs to look for include: hyper-reflexia, Babinski, clonus, crossed-adductor reflexes, Hoffman’s, and
loss of fine finger movements.
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On Making a Referral…
1. Arrange an MRI scan of the relevant spinal area to be available by the time of appointment (or if not
possible, give in the referral letter sufficient information for such an investigation to be pre-ordered,
e.g., pattern of pain radiation, any contraindications to MRI such as pacemaker). If scans have been
performed prior to first out patient appointment, the images (preferably on CD) should accompany the
referral letter. The scan report should, if possible, accompany the images but should not be a substitute
for them.
2. Note that if a patient has had previous spinal surgery and an MRI is requested, the details of the surgery
should be provided on the request, and in particular the request should be marked as requiring
contrast/gadolinium.
3. Prescribe a trial of gabapentin if radicular symptoms and/or trial of amitryptilene 25mg ~ 6pm daily for
sleep disturbing vertebral pain, in addition to standard analgesics (i.e., compound analgesic and strong
anti-inflammatory such as diclofenac 50mg TDS). Tell patients about Transcutaneous Electrical Nerve
Stimulation.
Management of those Patients who should not be Referred
Patients with either acute or chronic neck or back pain and no neurological signs and symptoms rarely have a
surgically remedial problem. Such patients need a clear and informative explanation of why neurosurgical
intervention will not be of benefit. They are then best managed in primary care through a combination of advice,
appropriate medication and access to physiotherapy and chronic pain specialists.
Referrers who have concerns regarding individual patients are encouraged to contact the neurosurgical
department for advice prior to referral.
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SPINAL PATIENTS
Referrers who have concerns regarding individual patients are encouraged to contact the neurosurgical department for advice prior to referral
CAUDA
EQUINA
ACUTE / SEVERE
RADICULAR PAIN
eg. Sciatica, brachalgia
PROGRESSIVE
NEUROLOGICAL
SYMPTOMS
eg. Foot drop
REFRACTORY
TO OPIATES
INCREASE
ANALGESIA
LOCAL A+E DEPT FOR
EMERGENCY SCAN
CHRONIC / REFRACTORY
RADICULAR PAIN
< 6 WEEKS
INCREASE
ANALGESIA
ORGANISE
MRI *
SPINAL
CLAUDICATION
> 6 WEEKS
PATIENT IS FIT
FOR SURGERY
AND WILLING
TO CONSIDER
AN OPERATION
INCREASE
ANALGESIA
ORGANISE
MRI *
ORGANISE
MRI *
ORGANISE
MRI *
RED
FLAGS
NO RED
FLAGS
FAXED
REFERRAL
FLEXION /
EXTENSION
X RAYS
NORMAL
ABNORMAL
ANALGESIA
+ PHSYIO
SCAN
POSITIVE
EMERGENCY
ON CALL REFERRAL
BACK / NECK
PAIN
MYELOPATHY
FAXED
REFERRAL
PRIMARY
CARE REVIEW
OUTPATIENT
REFERRAL
OUTPATIENT
REFERRAL
OUTPATIENT
REFERRAL
CHRONIC PAIN
SPECIALIST
REFERRAL
OUTPATIENT
REFERRAL
*Arrange an MRI scan of the relevant spinal area to be available by the time of appointment (or if not possible, give in the referral letter sufficient information for such an investigation to be pre-ordered, e.g., pattern of pain radiation,
any contraindications to MRI such as pacemaker). If scans have been performed prior to first out patient appointment, the images (preferably on CD) should accompany the referral letter. Note that if a patient has had previous spinal
surgery and an MRI is requested, the details of the surgery should be provided on the request, and in particular the request should be marked as requiring contrast/gadolinium.
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NOTES ON SPINAL REFERRALS
RED FLAGS










SPINAL CLAUDICATION
Presentation younger than age 20
Onset of symptoms following violent trauma (e.g. RTA;
fall from a height)
Thoracic pain
Past medical history of carcinoma
Patients who are using systemic steroids
History of HIV and/or drug abuse
Patients who are systemically unwell
Patients with unexplained weight loss
Persistent severe restriction of lumbar flexion
Patients with inflammatory disorders such as ankylosing
spondylitis
Radiating leg pain, paraesthesia or numbness coming on with walking and
distance-limiting.
Pain progression is normally from buttocks to the periphery.
Relief is gained by rest and bending forwards.
Neurological symptoms (paraesthesia, numbness and/or muscular
weakness) also resolve with rest.
Peripheral pulses are normal.
CAUDA EQUINA SYNDROME





MYELOPATHY (cord compression)
Symptoms include numb, clumsy hands; jumping, stiff legs; falls, poor
balance and urinary frequency.
Bilateral radiating leg pain
Sphincter disturbance
Reduced perianal sensation
Perineal numbness
Progressive motor weakness affecting more than one
nerve root and/or gait disturbances
Examine for long tract signs (also known as upper motor neuron or
pyramidal signs)
Signs to look for include: hyper-reflexia, Babinski, clonus, crossedadductor reflexes, Hoffman’s, and loss of fine finger movements.
Referral must include the findings from perineal examination
RECOMMENDED ANALGESIC REGIME
Prescribe a trial of gabapentin if radicular symptoms and/or trial of amitryptilene 25mg ~ 6pm daily for sleep disturbing
vertebral pain, in addition to standard analgesics (i.e., compound analgesic and strong anti-inflammatory such as diclofenac
50mg TDS). Tell patients about Transcutaneous Electrical Nerve Stimulation
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