Higginson R1, Greenhalgh S2, Mercer C3, Selfe J4
1Nuffield Health, Physiotherapy, Epsom, United Kingdom, 2Bolton NHS Trust, Bolton, United Kingdom, 3WSHT, Spinal Clinic, Worthing, United Kingdom, 4Manchester Metropolitan University, Manchester, United Kingdom
Background: The British Association of Spine Surgeons (BASS) (Germon et al., 2015) produced guidelines relating to the management of patients suspected with Cauda Equina Syndrome (CES).
It is unknown how this guidance currently influences clinical practice within the healthcare setting.
Purpose: In the absence of reliably predictive symptoms and signs, there should be a low threshold for investigating suspected Cauda Equina Syndrome cases with an emergency scan. This clinical audit reviews the management of patients referred to A&E for suspected Cauda Equina Syndrome relative to BASS guidance.
Methods: The clinical records and phone calls for patients that were managed through a national telephone triage service were reviewed. Two Senior Musculoskeletal Physiotherapists and One Advanced Level Physiotherapist who all have over 10 years experience and additional post grad training in musculoskeletal physiotherapy and were all experienced within a triage role, collated the patients medical records of those that were escalated to A&E with the suspicion of CES. The review consisted of the three physiotherapists reviewing the medical notes and recorded phone calls of the included patients to ensure that the record included symptoms of suspected CES, the onward referral included A&E, and a recorded outcome post A&E attendance. This information was then detailed relative to each audited case and reported symptoms were identified and tracked.
Results: 31 patient's that aligned to the BASS definition of CES were included for evaluation in this audit that had been escalated to A&E over a twelve-month period. The results indicate that 53% of the patients that exhibited CES symptoms that aligned with the BASS definition of having a requirement for diagnostic imaging were not investigated with an MRI scan. It is unknown if these patients later developed CES at any stage following discharge from A&E.
Conclusion(s): Managing suspected CES patients is complex and should for this reason adhere to BASS definition and guidance as in the absence of reliably predictive symptoms and signs, there should be a low threshold for investigation with an emergency scan. There appears to be significant variability in the management of this cohort of patients in relation to investigations with MRI scans once referred to emergency departments. Diagnosis of CES is confirmed only by the results of an MRI scan. There is currently guidance on the management of Metastatic Cord Compression (MSCC) released by the National Institute for Health and Care Excellence (NICE, 2008), however at present there is no current national framework for the management of other spinal red flag cases including CES.
Implications: This study has identified that there is a greater need to embed BASS guidance in the management of suspected cases of Cauda Equina Syndrome within Accident and Emergency care. There also in an identified need for a National Framework to offer clinical staff guidance and support in the management of these rare and complex presentations.
Keywords: Cauda Equina, Accident and Emergency, Triage
Funding acknowledgements: No funding was received for this study.
It is unknown how this guidance currently influences clinical practice within the healthcare setting.
Purpose: In the absence of reliably predictive symptoms and signs, there should be a low threshold for investigating suspected Cauda Equina Syndrome cases with an emergency scan. This clinical audit reviews the management of patients referred to A&E for suspected Cauda Equina Syndrome relative to BASS guidance.
Methods: The clinical records and phone calls for patients that were managed through a national telephone triage service were reviewed. Two Senior Musculoskeletal Physiotherapists and One Advanced Level Physiotherapist who all have over 10 years experience and additional post grad training in musculoskeletal physiotherapy and were all experienced within a triage role, collated the patients medical records of those that were escalated to A&E with the suspicion of CES. The review consisted of the three physiotherapists reviewing the medical notes and recorded phone calls of the included patients to ensure that the record included symptoms of suspected CES, the onward referral included A&E, and a recorded outcome post A&E attendance. This information was then detailed relative to each audited case and reported symptoms were identified and tracked.
Results: 31 patient's that aligned to the BASS definition of CES were included for evaluation in this audit that had been escalated to A&E over a twelve-month period. The results indicate that 53% of the patients that exhibited CES symptoms that aligned with the BASS definition of having a requirement for diagnostic imaging were not investigated with an MRI scan. It is unknown if these patients later developed CES at any stage following discharge from A&E.
Conclusion(s): Managing suspected CES patients is complex and should for this reason adhere to BASS definition and guidance as in the absence of reliably predictive symptoms and signs, there should be a low threshold for investigation with an emergency scan. There appears to be significant variability in the management of this cohort of patients in relation to investigations with MRI scans once referred to emergency departments. Diagnosis of CES is confirmed only by the results of an MRI scan. There is currently guidance on the management of Metastatic Cord Compression (MSCC) released by the National Institute for Health and Care Excellence (NICE, 2008), however at present there is no current national framework for the management of other spinal red flag cases including CES.
Implications: This study has identified that there is a greater need to embed BASS guidance in the management of suspected cases of Cauda Equina Syndrome within Accident and Emergency care. There also in an identified need for a National Framework to offer clinical staff guidance and support in the management of these rare and complex presentations.
Keywords: Cauda Equina, Accident and Emergency, Triage
Funding acknowledgements: No funding was received for this study.
Topic: Musculoskeletal: spine; Globalisation: health systems, policies & strategies; Critical care
Ethics approval required: No
Institution: Nuffield Health
Ethics committee: Research Expert Advisory Group (EAG)
Reason not required: This study was a clinical audit
All authors, affiliations and abstracts have been published as submitted.
