From the neurosurgical point of view, these include (See referral guidelines):
- Suspected cauda equina syndrome
- Acute foot drop
- Suspected infection
- Suspected vertebral fragility fractures (VFF Pathway opens a new window)
Suspected cauda equina syndrome
Red flags include:
- Bilateral sciatica – sudden onset bilateral radicular pain, or unilateral radicular pain, that has progressed to bilateral
- Severe or progressive bilateral neurological deficits of the legs such as major motor weakness with knee extension, ankle everson or foot dorsiflexion
- Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible
- urinary retention with overflow urinary incontinence
- Loss of sensation of rectal fullness, if untreated this may lead to
- irreversible faecal incontinence
- Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
- Laxity of the anal sphincter
- Sexual dysfunction – inability to achieve erection or to ejaculate, or loss of genital sensation.
Acute foot drop
Foot drop is a symptom of a variety of disorders and can be classified as either a central or peripheral problem. Peripheral problems can be differentiated into peripheral neuropathy or radiculopathy.
Foot drop from a spinal source causes weakness due to compression of L4 and/or L5 nerve roots causing weakness predominantly in the tibialis anterior muscle and characteristic slapping gait (high stepping gait).
- Foot drop is classified as weakness of Dorsiflexion grade 3 or less (Oxford scale).
- There is no current agreed timescale that would define an acute episode.
- For acute cases early opinion is considered essential to see if surgery is indicated.
- Consideration for Surgery is based on a number of factors including duration since onset, grade of power, age, medical fitness and patient’s preference.
Suspected infection
Such as discitis, vertebral osteomyelitis, or spinal epidural abscess.
Red flags include:
- Fever
- Tuberculosis, or recent urinary tract infection
- Diabetes
- History of IV drug use
- HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised.
