Timely detection and treatment of cauda equina syndrome

The British Association of Spine Surgeons (BASS) welcomes this report and the safety recommendations to improve the care of patients suffering from cauda equina syndrome (CES). We recognise a number of different guidelines and pathways are already available, as well as safety netting advice from nationally recognised bodies (including National Institute of Health and Clinical Excellence, and the Chartered Society of Physiotherapy). We will oversee a review of available documentation and propose consolidated guidance for the recommendations proposed. We will also carry out a survey of surgeons involved in the care of CES patients to inform the process as well as carry out an evidence review of the subject. The aim of the work we will do is to provide a collaborative document (with the Royal College of Surgeons of England, Royal College of Radiologists and the Royal College of Emergency Medicine) to establish agreed standardised terms, a decision making tool, time frames for scanning and referral and improving the surgical aspect of the pathway. We recognise that the majority of patients presenting as suspected CES in the United Kingdom (UK) are not shown to be surgical emergencies and any guidance needs to ensure that the screening process for a suspected CES is as rapid as possible to facilitate access to emergency surgery when required. This may well need a change in current working practice across the UK. Action: Review of current published guidelines with RCR, RCS, RCEM, RCGP, interface clinicians. Review of evidence and a surgeon survey with patient groups, interface clinicians and GPs. Response received on 15 November 2021.

Action: Review of current published guidance with RCR, RCS, RCEM, RCGP, interface clinicians. Review of evidence and surgeon survey with patient groups, interface clinicians and GPs. Response received on 15 November 2021.

The Royal College of Radiologists welcomes this report and extends our sympathies to this patient. We recognise the current difficulties faced by imaging services in providing timely access for all patients requiring MRI scans, particularly those with suspected Cauda Equina Syndrome, and on behalf of the Clinical Imaging Board we have been developing standards for imaging protocols for Cauda Equina Syndrome. This work is taking place in collaboration with partner organisations The Society and College of Radiographers, The Institute of Physics and Engineering in Medicine, The British Society of Skeletal Radiologists, and The British Society of Neuroradiologists. The guidance will support protected time and increased availability of MRI slots to accommodate patients with suspected Cauda Equina Syndrome. Action: Guidance development by Spring 2022. Working party in place through the Clinical Imaging Board. Representation from RCR, SCoR, IPEM, BSNR, BSSR. Response received on 5 November 2021.

Following consideration of the Healthcare Safety Investigation Branch’s report, the National Institute for Health and Care Excellence (NICE) will update its guideline on low back pain and sciatica in over 16s [NG59] to include cauda equina syndrome. Cauda equina syndrome was outside the scope of the original guideline and so it does not make recommendations on the assessment or management of people with this condition. In its guideline on suspected neurological conditions: recognition and referral [NG127], NICE recommends that clinicians refer immediately adults who have severe low back pain radiating into the leg and new-onset disturbance of bladder, bowel or sexual function, or new-onset perineal numbness, to have an assessment for cauda equina syndrome (see recommendation 1.7.3). Action: Commission update of NG59 and update NG59 to include cauda equina syndrome. Response received on 12 November 2021.

Following publication of the Getting It Right First Time (GIRFT) national report for spinal services and the HSIB 2021 investigation into the safety risks of suspected Cauda Equina Syndrome (CES) patients, there has been a significant focus on CES, as per the recommendations outlined in both documents. A national suspected CES pathway has now been developed and published by GIRFT and the former BestMSK programme with input from a multidisciplinary group of more than 60 health professionals, and co-badging from partner organisations including the Royal College of Radiologists, British Association of Spinal Surgeons, British Orthopaedic Association, National Spine Network, Cauda Equina Champions Charity, British Society of Skeletal Radiologists, British Association of Urological Surgeons and the Chartered Society of Physiotherapy. The pathway has been well received and spinal colleagues nationally are now keen to implement this in order to diagnose and treat the condition without delay and improve patient outcomes. Response received on 5 April 2023.