The Value of Interhospital Transfer and Emergency MRI for Suspected Cauda Equina Syndrome: A 2-Year Retrospective Study

Abstract

INTRODUCTION The timing of surgery in cauda equina syndrome due to prolapsed intervertebral disc remains controversial. Assessment of these patients requires magnetic resonance imaging (MRI), which is of limited availability outside normal working hours in the UK. PATIENTS AND METHODS We reviewed radiological results in all patients undergoing emergency MRI within our unit for suspected cauda equina syndrome over a 2-year period, and all subjects undergoing emergency lumbar discectomy for cauda equina syndrome within the same period. Outcome measures were: proportion of positive findings in symptomatic patients and proportion of patients referred with diagnostic MRI scans undergoing emergency surgery. We also assessed outcomes of patients having surgery for cauda equina syndrome in terms of improvement of pain, sensory and sphincter disturbance. RESULTS A total of 76 patients were transferred for assessment and ‘on-call’ MRI; 27 were subsequently operated upon. Only 5 proceeded to emergency discectomy that night (prior to next scheduled list). This may be due to delays in timing – from referral to acceptance, to arrival in the department, to diagnostic scan and to theatre. With the second group of patients, 43 had emergency discectomy for cauda equina syndrome during the study period. Of these, 6 patients had an out-of-hours MRI at our hospital for assessment (one patient living locally). Most surgically treated patients experienced improvement in their pain syndrome, with approximately two-thirds experiencing improvement in sensory and sphincter disturbance. CONCLUSIONS These data support a policy of advising MRI scan for cauda equina syndrome at the earliest opportunity within the next 24 h in the referring hospital, rather than emergency transfer for diagnostic imaging which has a relatively low yield in terms of patients operated on as an emergency.

Cauda equina syndrome: a review of the current clinical and medico-legal position

“…Crocker et al [8,9,46], have addressed this issue along with that of the lack of out-of-hours MRI facilities in a large number of non-regional centres in UK which accept emergency admissions. In fact they found that of 82 patients referred with suspected CES and undergoing emergency MRI, the diagnosis was confirmed in 27 (33%), but only 5 patients required emergency surgery, 15 were on the next available daytime operation list and 6 had their surgery after more than 24 h. Clearly emergency MRI and surgery were probably of great importance for those five individuals who might otherwise have suffered disabling long term neurological compromise, but evidently these costly facilities were not essential for the other 77 patients.…”

“…Thirdly, delays may occur in the hospital [39] with junior doctors and nurses not recognising the syndrome presented to them. Finally, the non-availability of out-of-hours MRI and specialist spinal surgical facilities may singly or collectively cause further delay [8] which may be critical to the eventual outcome, especially if there is evidence of progressing neurological deficit during this time. If any of those imperfections are found to be negligent then substantial damages may be awarded.…”

Complaints of micturition, defecation and sexual function in cauda equina syndrome due to lumbar disk herniation: a systematic review

“…2). Selection procedure and subsequent citation tracking resulted in 16 reports on 15 different studies that met all criteria [5,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. One study was reported in two publications [19,20].…”

Cauda equina syndrome: the importance of complete multidisciplinary team management

“…Owing to the high morbidity caused by CES, it is vital that patients suspected to have this condition are investigated and treated appropriately and efficiently 1 7 14 15. However, this report will explain the treatment of CES that goes far beyond the operating room, and requires true multidisciplinary team (MDT) input.…”

“…Patients may present late after not noticing subtle symptoms or signs, while doctors may also not be privy to these 1. These delays may be compounded by a lack of MRI out of hours in certain hospitals 7. This has resulted in many patients with CES having a delayed diagnosis, thus experiencing permanent dysfunction of their bowel, bladder or sexual function 1 4 8–11.…”