Evaluation of nationwide referral pathways, investigation and treatment of suspected cauda equina syndrome in the United Kingdom

Abstract

Purpose: Cauda equina syndrome (CES) is a spinal emergency with clinical symptoms and signs that have low diagnostic accuracy. National guidelines in the United Kingdom (UK) state that all patients should undergo an MRI prior to referral to specialist spinal units and surgery should be performed at the earliest opportunity. We aimed to evaluate the current practice of investigating and treating suspected CES in the UK. Materials and Methods: A retrospective, multicentre observational study of the investigation and management of patients with suspected CES was conducted across the UK, including all patients referred to a spinal unit over 6 months between 1st October 2016 and 31st March 2017. Results: A total of 28 UK spinal units submitted data on 4441 referrals. Over half of referrals were made without any previous imaging (n ¼ 2572, 57.9%). Of all referrals, 695 underwent surgical decompression (15.6%). The majority of referrals were made out-of-hours (n ¼ 2229/3517, 63.4%). Patient location and pre-referral imaging were not associated with time intervals from symptom onset or presentation to decompression. Patients investigated outside of the spinal unit experienced longer time intervals from referral to undergoing the MRI scan. Conclusions: This is the largest known study of the investigation and management of suspected CES. We found that the majority of referrals were made without adequate investigations. Most patients were referred out-of-hours and many were transferred for an MRI without subsequently requiring surgery. Adherence to guidelines would reduce the number of referrals to spinal services by 72% and reduce the number of patient transfers by 79%.

‘Scan-negative’ cauda equina syndrome: what to do when there is no neurosurgical cause

“…'Scan-negative’ cauda equina syndrome is relatively common: a recent study involving 28 of the 30 UK neurosurgery centres found 4441 referrals for possible cauda equina syndrome over a 6-month period 11. A systematic review of cauda equina syndrome incidence and three scan-negative cauda equina syndrome studies found 69%–84% of patients referred as possible cauda equina syndrome had negative or non-explanatory scans, with no other neurological cause found 1.…”

133 Neurosurgery Education in The Medical School Curriculum: A Scoping Review

“…Given the limited access to neurosurgical expertise in most countries, generalists are expected to care for an expanding volume of both pre-operative, post-operative and non-operative neurosurgical patients; for example, a recent study of traumatic brain injury patients in the UK revealed that only 17% of patients referred to the neurosurgical center were transferred for specialist management. [26][27][28] This can be particularly true in LMICs where neurosurgical provision is scarce. 4,5 Estimates show that the poorest third of the world's population receive only 3•5% of all major surgeries undertaken worldwide.…”

The Neurology and Neurosurgery Interest Group (NANSIG)—ten years of cultivating interest in clinical neurosciences

“…In the past 4 years, NANSIG has established itself as a platform for members to collaborate and contribute to high-quality multi-centre research; some of which has informed national specialty reports [ 16 , 21 ]. To date, NANSIG has been involved in seven (three complete, four ongoing) national research, audit and quality improvement projects, with several in the process of being developed (Table 1 ).…”

“…of conference presentations No. of publications ENTICE [ 16 ] Retrospective study assessing adherence of cauda equina syndrome referrals to published national guidelines. Supported by the BNTRC 2016 2017 86 56 28 4441 2 1 STUN [ 14 ] Cross-sectional study of undergraduate neuroanatomy teaching in the UK and Ireland 2019 2020 11 6 24 N/A 1 1 ELISAR-GB Prospective evaluation of intraoperative surgical adjuncts used in the resection of glioblastoma tumours 2019 Ongoing 84 46 28 291 2 - SPICE-19 [ 5 , 8 , 34 ] Prospective observational study of mental health and well-being of medical students and foundation doctors during the COVID-19 pandemic 2020 2020 35 34 32 2075 10 4 CRANIAL [ 9 , 10 , 24 ] Prospective observational cohort study of cerebrospinal fluid rhinorrhoea rates after endonasal intervention to the skull base 2020 Ongoing 148 34 30 869 …”