Neurosurgery+Referrals

NEUROSURGERY Referrals:

 * All patients managed by CCHP should be referred to CCHP by completing a prior auth form for referral or procedure. CCHP manages care for all CCHP members, and for Basic Health Care and Health Care Initiative patients. Essentially all patients who do not have PO, MO, TO, or TZ are managed by CCHP.
 * PO (no coverage) patients needing referral should sent to Financial Counseling to see what if any coverage they might qualify for.
 * MO (straight Medicare) can generally be referred to the private sector.
 * TZ (Medi-Cal pending) have no coverage outside of our system. Urgent referrals should be coordinated thru Utilization Management.
 * TO patients generally are limited to UCSF or UCD. John Muir now has a Medi-Cal contract.

To refer a patient to the California Center for Pituitary Disorders at UCSF, call 1-866-559-5543. To refer a patient to the UCSF Spine Center, call (415) 353-2739 or 1-866-81-SPINE. If you have difficulty reaching a staff member or faculty physician, contact the clinic manager, Cheryl Palmer, at (415) 353-4969. UCSF Neurosurgery Referrals

The list of diagnoses that need urgent or emergent attention include, but is not limited to, spinal cord compression, intracranial hemorrhages, epidural abscesses, and intracranial mass with neurologic findings. Patients sent to our emergency room **should not be admitted** as our hospital is not equipped to handle such emergencies and the patient needs a higher level of care. Diagnosing cord compression of sudden onset is regarded as a medical/surgical emergency. In general, the longer the time before intervention to remove the compression causing nerve damage, the greater the damage caused to the nerves. However, diagnosing spinal cord compression can be difficult, especially in the patient with chronic back pain. A thorough neurologic exam is paramount testing for weakness, sensory findings, and reflexes. Special attention should be considered in the patient with a history of cancer, spinal trauma, severe disc herniation, or spinal stenosis.
 * Urgent/Emergent Neurosurgery cases: **
 * Radiologic confirmation:** If you are worried that your patient may be developing something that requires emergent neurosurgery, **order a STAT MRI and call the radiologist on call**. Ordering the MRI as "urgent" is NOT sufficient. Ordering the MRI as STAT without having an actual conversation with a radiologist is also NOT sufficient.
 * Referral**: Since we no longer have a neurosurgeon in our system, this can be challenging. Patient’s with Basic Health Insurance need to get an authorization, which can take days, but often, many weeks or months to get approval. Referring patients with Medi-Cal is even more difficult. If you do not think the patient can wait for such authorization, and the problem is more emergent, please **send the patient to an ED that has neurosurgical services** (e.g. John Muir). Provide patient with appropriate imaging if available. Please call the ED to provide a ‘warm’ hand-off.
 * Diagnosis:** The following is a brief review of diagnosing spinal cord compression with cauda equina which is one of the more common neurosurgical emergencies:
 * Pain** is usually the first symptom and, on average, often precedes other neurologic symptoms of spinal cord compression by seven weeks. Affected patients usually notice a severe local back pain which progressively increases in intensity. Pain is often worse with lying down. Over time, the pain may develop a radicular quality.
 * Weakness** is present in 60 to 85 percent of patients with spinal cord compression at the time of diagnosis. With cauda equina lesions, the weakness is associated with depressed deep tendon reflexes in the legs. The progression of motor findings prior to diagnosis typically consists of increasing weakness followed sequentially by loss of gait function and paralysis. **Sensory findings** are less common than motor findings but are still present in a majority of patients at diagnosis. Patients frequently report ascending numbness and paresthesias if questioned and examined carefully. **Bladder and bowel dysfunction** is generally a late finding. Detrusor weakness may cause urinary retention. They may also present with decreased rectal tone and bowel incontinence as well as sexual dysfunction or saddle anesthesia.