Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals

Hussain, Muhammad Masood; Razak, Adam Alexander; Hassan, Syed Sibet; Choudhari, Kishor A.; Spink, George

doi:10.1080/02688697.2018.1457771

Cited by 19 publications

(8 citation statements)

References 18 publications

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“…1,47 Six studies included all patients referred with suspected CES. 4,5,7,27,29,39,45 All studies assessed populations referred to either secondary or tertiary care. Banerjee and Jalgaonkar 5 studied only children.…”

Section: Incidence Of Confirmed Ces In Patients Suspected Of Having Cesmentioning

confidence: 99%

“…The imaging type in all studies was MRI. Only 2 studies described findings on MRI defining a diagnosis of CES based on the finding of canal compromise, which was more than 50% in one study 29 and more than 75% in the other. 26 Three studies stated that cauda equina compression was determined by the reporting radiologist but did not state the criteria used.…”

Section: Incidence Of Confirmed Ces In Patients Suspected Of Having Cesmentioning

confidence: 99%

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What is the incidence of cauda equina syndrome? A systematic review

Hoeritzauer

Wood

Copley

et al. 2020

Journal of Neurosurgery: Spine

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OBJECTIVECauda equina syndrome (CES) is a surgical emergency requiring timely operative intervention to prevent symptom progression. Accurately establishing the incidence of CES is required to inform healthcare service design and delivery, including out-of-hours imaging arrangements.METHODSA systematic literature search of MEDLINE, EMBASE, and Scopus was undertaken to identify original studies stating the incidence of CES, and the estimates were combined in a meta-analysis as described in the protocol registered with PROSPERO (registration no. CRD42017065865) and reported using the PRISMA guidelines.RESULTSA total of 1281 studies were identified, and 26 studies were included in the review. Data about CES incidence were available from 3 different populations: asymptomatic community populations, patients with nontraumatic low-back pain, and patients presenting as an emergency with suspected CES. The incidence of CES was 0.3–0.5 per 100,000 per year in 2 asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working-age population. CES occurred in 0.08% of those with low-back pain presenting to primary care in 1 study, and a combined estimate of 0.27% was calculated for 4 studies of those with low-back pain presenting to secondary care. Across 18 studies of adults with suspected CES, 19% had radiological and clinical CES. Difficulties in comparison between studies resulted from the heterogeneous definitions of CES and lack of separation of more advanced CES with retention, which is unlikely to be reversible. In the studies of patients with suspected CES, the small sample size, the high number of single-center studies (18/18), the high number of studies from the United Kingdom (17/18), the retrospective nature of the studies, and the high number of abstracts rather than full texts (9/18) reduced the quality of the data.CONCLUSIONSFrom current studies, it appears that CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Determining accurate incidence figures and designing a bespoke service for investigation of patients with suspected CES would require a consensus clinical and radiological definition of CES and international multisite studies of patient pathways of investigation and management.

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Section: Incidence Of Confirmed Ces In Patients Suspected Of Having Cesmentioning

confidence: 99%

Section: Incidence Of Confirmed Ces In Patients Suspected Of Having Cesmentioning

confidence: 99%

What is the incidence of cauda equina syndrome? A systematic review

Hoeritzauer

Wood

Copley

et al. 2020

Journal of Neurosurgery: Spine

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“…Cauda equina syndrome is a rare, as well as complex, syndrome with an annual incidence of approximately 1 in 100,000 [ 6 - 7 ]. Only 0.08% of patients with backache presenting to primary care and 0.27% presenting to secondary care had cauda equina and 19% of patients with clinically suspected cauda equina had cauda equina syndrome [ 4 ].…”

Section: Discussionmentioning

confidence: 99%

Compliance With the Cauda Equina Pathway: Results of a Closed-Loop Audit

Ago¹,

Mohammed²,

Maqsood³

et al. 2021

Cureus

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IntroductionThe British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and operative intervention in patients with suspected cauda equina syndrome (CES). Due to the lack of a 24-hour MRI service and the centralisation of neurosurgery to large tertiary centres, there is a need for an evidence-based protocol for the referral of patients presenting with back pain, with red flags to specialist tertiary neurosurgical centres. MethodsThe standard operating procedure (SOP) at our local hospital outlines steps in the assessment, triage and onward referral of patients presenting with symptoms of acute CES.A closed-loop audit cycle was performed; the first cycle was between September and December 2020 and the second was between January and April 2021. Recommendations made after the first cycle were actioned prior to re-audit. ResultsThere was 100% compliance regarding discussions with neurosurgery following MRI and appropriate management following neurosurgical advice. There was a 21.1% increase in appropriate discussions with neurosurgery by the emergency department (ED), increased accurate documentation of red flags (5% anal tone and 21% perianal sensation). There was a 53% decrease in senior ED doctor referral to neurosurgery, although 100% referrals were discussed with an ED senior prior to referral, and a 20% decrease in compliance regarding neurosurgery plan documentation. ConclusionWe were able to improve our compliance with several aspects of the SOP using simple measures. We could not improve one aspect of SOP, namely, a discussion with the specialist centre being performed by a senior doctor.Since CES requires timely management and early scanning, we recommend a robust protocol at the admitting hospital. This paper presents the protocol at our hospital and the rationale behind it. We discuss what affects our compliance with the SOP and how simple interventions have helped us improve.

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“…This did not seem to suggest lack of concern for the person with suspected CES, but worry that despite their efforts to be vigilant, they may still encounter associated litigation. This reflects the rise in litigation rates over recent years which has been suggested as a contributing factor to the change in the accepted management of suspected CES (Germon et al, 2015; Todd & Dickson, 2016; Hussain, Razak, Hassan, Choudhari, & Spink, 2018). Although concern regarding litigation has been well documented in medical literature as an influential factor in clinical decision‐making, there has previously been a lack of in‐depth qualitative enquiry on the topic to highlight its effect on clinicians' wellbeing (Cheng et al, 2014; Minkoff, 2012; O'Dowd, 2015; Sekhar & Vyas, 2013).…”

Section: Discussionmentioning

confidence: 99%

Physiotherapists' experiences of managing persons with suspected cauda equina syndrome: Overcoming the challenges

Paling¹,

Hebron

2020

Musculoskeletal Care

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Introduction Cauda equina syndrome (CES) is rare, but its symptoms are not and musculoskeletal physiotherapists frequently encounter persons with suspected CES. Given that delayed diagnosis of CES can result in devastating consequences for affected persons and costly litigation for healthcare organisations, it is imperative that persons presenting with suspected CES are well managed. However, this may present a challenge to physiotherapists. Therefore, the aim of this study is to explore physiotherapists' experiences of managing persons with suspected CES. Methods Semi‐structured interviews were conducted with musculoskeletal physiotherapists. Verbatim transcripts were analysed using an interpretive paradigm and thematic analysis. Ethical approval Ethical approval was obtained from a university Ethics committee and NHS Research and Development. Findings Five interlinking themes emerged. The themes of worry in relation to risk management and communication difficulties seemed to represent significant challenges. The remaining themes were described as antidotes to these challenges: Lightening the load with teamwork and shared responsibility, the usefulness of a clear pathway and perception of improved confidence and competence with experience and training. Discussion The findings are discussed in the context of other literature, and practical recommendations are made relating to pathway implementation, team working, communication aids, training on CES and measures to care for staff wellbeing. Conclusion Findings suggest that it is important to be aware of and address the challenges faced by physiotherapists in order to care for clinicians' wellbeing and ensure a safe and smooth journey for persons with suspected CES. Summary Video: https://www.youtube.com/watch?v=lIHqCKIQ1jk&t=90s

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Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals

Cited by 19 publications

References 18 publications

What is the incidence of cauda equina syndrome? A systematic review

What is the incidence of cauda equina syndrome? A systematic review

Compliance With the Cauda Equina Pathway: Results of a Closed-Loop Audit

Physiotherapists' experiences of managing persons with suspected cauda equina syndrome: Overcoming the challenges

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