What Happens During a Neurosurgical Consultation?

For many people, attending a Neurosurgical consultation can feel intimidating. Patients are often anxious about their symptoms, worried about what their scan might show, or fearful that surgery may be recommended immediately. In reality, most Neurosurgical consultations are simply about understanding your diagnosis more clearly, and discussing management options in a calm, structured and professional way.

A Neurosurgical consultation generally begins with a short social and general medical history, followed by a more detailed discussion about your symptoms. This includes when your symptoms started, if there were any provocative events like a fall or other traumatic episode, how your symptoms have progressed over time, what treatments you have already been offered and tried, and how the condition is affecting your daily life including work or study, social activities, mobility, and sleep. Often relatively small details can provide important clues regarding the underlying diagnosis, and your Neurosurgeon will often ask special direct questions to try and understand your condition better – I often tell patients that my role is a bit like a detective, trying to figure the whole process out! Your previous medical history, your regular prescribed medications including pain relief, any drug allergies, whether or not you smoke cigarettes, and any other health conditions and/or previous surgery are also important, particularly if brain or spine surgery may potentially be considered as part of your treatment.

A neurological examination is then performed. Depending on your condition this may involve assessment of strength, sensation, reflexes, balance, gait, coordination, or cranial nerve function. Typically a physical examination for brain conditions involves examining the cranial nerves, balance, coordination and higher cognitive function, for cervical spine conditions it involves examining the neck, upper limbs and balance, and for lumbar spine conditions it involves examining the lower back and the legs. I normally ask patients to remove their shoes to examine them, however no other clothing needs to be removed, and no embarrassing body parts need to be exposed.

One of the most important aspects of the consultation is reviewing specialist imaging or the brain or the spine. MRI and CT scans frequently form a major part of Neurosurgical assessment, and I find it extremely helpful to review a patient’s scans together with them and to explain my findings to them in understandable language. It is important to remember that scan findings do not always correlate perfectly with symptoms. Many people have abnormalities visible on their imaging that are incidental or unrelated to their actual problem. Part of the role of a Neurosurgeon is determining which imaging findings are clinically relevant and which may simply reflect normal age-related or otherwise incidental changes. Finally, your Neurosurgeon will consider all the available information from your history, physical examination and medical imaging to come up with a considered diagnosis which best explains your presentation and which will ultimately guide management strategies.

After this assessment, management options are discussed and must incorporate individual patient factors and patient preferences. These management options may include:

• Observation alone with no direct intervention;

• Physiotherapy, particularly for balance or strength training;

• Pain management strategies, including oral medications;

• Further investigations to help with the diagnosis if it is not yet clear;

• Targeted cortisone injections, such as an epidural steroid injection or a nerve root block;

• And surgery.

The first consultation with a Neurosurgeon typically takes around half an hour, and follow up appointments can be performed in around 15 minutes. For some patients who live a long way away your appointment might be able to take place via telehealth with a video link, and the only major disadvantage of this is the inability of your surgeon to perform a physical examination. Other follow up appointments can often take place by telephone, and after an initial consultation I frequently offer patients telephone call follow up appointments particularly if it is just to discuss the findings of a new scan, or their response to an intervention that I have suggested, such as a cortisone injection. Finally, the details of your consultation will be summarised in a letter which will be sent to your referring doctor which is typically your General Practitioner, and copies of letters are also sent to any other health professional caring for you, such as other medical specialists, physiotherapists, or chiropractors for example.

Many patients are surprised to learn that surgery is often not required or recommended, and that a significant proportion of patients referred to Neurosurgeons are managed non-operatively or “conservatively”. If surgery is recommended, the consultation includes a discussion regarding the goals and expectations of surgery, the expected recovery period including how long you are not allowed to drive for and when you might expect to be able to return to work, alternatives to performing surgery, and the potential risks or complications associated with the recommended surgical procedure. Patients are encouraged to ask questions and involve family members if they wish, and if surgery is recommended more often than not your surgeon will encourage you to think about this option very carefully before committing to it, and they may offer you a follow up appointment to give you more time to consider your options and absorb all relevant information before making a final decision.

One of the most important aspects of a consultation is ensuring patients understand their condition and feel comfortable with the proposed management plan. Decisions regarding Neurosurgical treatment are often complex and individualised, and a large part of my time is spent counselling patients and their families about management options and strategies and ensuring that the chosen treatment is most appropriate for each individual. Patients should never feel embarrassed about asking questions, seeking clarification, or obtaining a second opinion, and I encourage patients and their families to ask as many questions as they like. Good communication and understanding are extremely important parts of medical care, and the best clinical outcomes are generally realised when a patient’s expectations are made very clear to ensure that they are realistic and achievable.

Finally, it is worth remembering that being referred to a Neurosurgeon does not necessarily mean something catastrophic is happening. Many Neurosurgical conditions are common, manageable, and frequently improve with appropriate treatment and guidance.