Referral from primary care musculoskeletal services to Accident and Emergency for suspected cauda equine syndrome

Purpose

Cauda equine syndrome (CES) is a medical emergency, requiring immediate referral for investigation and early surgical decompression for a favourable outcome (1). Southern Health NHS Foundation Trust (SHFT) musculoskeletal services manage suspected CES with immediate referral to accident and emergency (A&E) at the University of Southampton NHS Trust (UHS) where urgent imaging and surgical decompression can take place.

This evaluation aimed to describe the demographics and clinical features of referred patients, plus summarise the medical management and clinical outcome following A&E examination.

Approach

A retrospective review of all suspected CES referrals to A&E at UHS was made over a 15 month period (Jan 2016 to April 2017). The rationale for evaluation was to:

1.Estimate if referral rates were in line with anticipated prevalence of the condition.

2.Generate data for bench marking.

3.Evaluate the appropriateness and justification for each referral.

Outcomes

A total of 35 referrals were made from the SHFT musculoskeletal services to A&E at UHS. Approximately two-thirds were for female patients (n=24) and the mean age of patients was 48.6 years (age range from 20 – 81 years).

Over a twelve month period 30 referrals were made to A&E. This represented a referral rate from the SHFT adult population for suspected CES of 0.01% or 1 in every 8533 people per year.

No pattern emerged regarding the type of dysfunction and duration of symptoms and this finding is consistent with an audit performed by the British Association of Spinal Surgeons (BASS) of 45 patients requiring surgical decompression for CES (2).

Approximately one third of patients (13/35) were discharged following clinical examination in A&E, whereas two-thirds (22/35) were admitted required further investigation with MRI and consultant examination. Of these, three (9%) underwent urgent surgical decompression to prevent progression of CES, twelve were subsequently discharged with CES excluded after MRI and the remaining seven had an alternative diagnosis, with four being referred for a neurological opinion (e.g. multiple sclerosis); one referred to oncology; one underwent surgical decompression for cervical myelopathy and one was discharged with a thoracic fracture.

Implications

This evaluation demonstrates vigilance in the management of potential CES and is concordant with BASS recommendations (1). The referral rate of 0.03% was lower than the reported incidence 0.04% (3), however this was to be expected as this cohort was not representative of all patients with potential CES presenting to A&E.

The referral rate of 35 in 15 months was considered appropriate based on comparison with an evaluation performed by East Lancashire Hospital NHS Trust who serve a similar adult population. Their service referred 27 suspected CES to A&E in a 9 month period (4)

Implications of this evaluation:

Results justify the low threshold of suspicion of CES, as the pathway aims to prevent potential progression of neural ischaemia to complete CES.

Education regarding the management of suspected CES will be mandatory for all new clinicians and will be reviewed at annual study days.

Modifications will be made for future data collection so duration of symptoms is more accurately recorded to evaluate reasons or barriers to emergency management.

Top three learning points

A high negative finding rate on MRI for CES of 90% is acceptable and is consistent with the literature.

Documentation of a careful neurological examination, clinical reasoning and actions with cases of suspected CES is critical to mitigate litigation.

Fund acknowledgements

This work was not funded.

Additional notes

References

1. Germon et al (2015). British Association of Spine Surgeons standards of care for cauda equine syndrome. The Spine Journal. 15 (3):S4

2. NG et al (2004). Cauda equine syndrome: An audit. Can we do better?. The Journal of Orthopaedic Medicine 26 (2) 98-101

3. Mukherjee et al (2013). Cauda equine syndrome: a clinical review for the frontline clinician. Br J Hosp Med (Lond) 74 (8): 460-4

4. Corbett and Whitaker 2015) Development of a pathway for patients with (suspected) cauda equine syndrome. Physiotherapy UK, Liverpool

Further information about this work, contact Martin Kerridge-Weeks at Solent NHS Trust.