Audit of patients presenting to Emergency Department with suspected CES and their subsequent management including Surgery.

Purpose

To identify presenting signs and symptoms of patients, attending the Emergency Department, who were suspected of having Cauda Equina Syndrome (CES) and to describe the variable presentations of patients who subsequently require surgical intervention.

Physiotherapists should remain vigilant
as these results suggest that patients can identify a wide range of problems, at first presentation, which can be less helpful in reaching a diagnosis.

Approach

A retrospective audit of the clinical notes of patients attending the Emergency Department of a large level 1 trauma centre, with suspected CES, was undertaken using a proforma designed to enhance clinical decision making in this group. The proforma has a number of questions designed to act as an Aide Memoire for Red Flags issues as well as a part for the recording of a clinical examination.

Outcomes

Of the 119418 patient attending the ED in the audit period, 3864 had reported Back Pain or an injury of the spine. During the same period 477 were initially identified as having possible cauda equine syndrome. Of those 477 with possible CES, 301 patients had an initial complaint of back pain or injury spine. The remainder described a wide variety of symptoms which did not necessarily include back pain but also including symptoms less frequently associated with CES including flank pain, blood in stools and dizziness.

Whilst most patients in the group of 477 had an MRI, in the hospital within 24 hours, 28 had a prior MRI scan which were recent enough to be considered relevant for use in the clinical decision making process. Following review, by neurosurgery with the benefit of a recent MRI scan, of those patients with suspected CES, 62 had decompression surgery within 2 days, 16 had surgery within 4 weeks, 11 had surgery within 12 weeks, 24 had nerve root injections during their admission and 364 were returned to their GP for onward management. On discussion with the Neurosurgeons it was not possible to identify definitively those patients with CES, and so a pragmatic outcome of the need for surgery and the degree of urgency is reported. Of the 28 who were suspected of having CES, and did not complain of back pain, there were 3 who were deemed to require surgery within 2 days or 4 weeks.  

Cauda Equina may present in patients who do not describe signs and symptoms more commonly associated with this serious spinal problem. Physiotherapists should remain vigilant as these results suggest that patients can identify a wide range of problems, at first presentation, which can be less helpful in reaching a diagnosis. Early identification of CES is important as prompt surgical treatment is associated with successful outcome.

Cost and savings

With increased scrutiny of an at-risk group we did not have any missed Cauda Equinas which are currently costing in the region of £600.000 in legal cost to the NHS.

Implications

As more physiotherapist move into extended roles such as See and Treat and First Contact Practitioners and within other settings of Unplanned and Emergency care such as Emergency Departments there is a need to maintain and improve awareness of the wide range of patterns of clinical presentation associated with CES. Further work will be required to develop a robust set of clinical features suggestive of Cauda Equina.

Top three learning points

  1. Red Flags are poor indicators of serious pathology but do act to identify patients needing further investigation many patients undergoing MRI scans acutely do not have significant features requiring emergency surgery.
  2. Not all Cauda Equina patients present with Back Pain.
  3. Record keeping in this at risk group is variable and leaves individual clinicians at serious risk.

 

Fund acknowledgements

This project was not associated with any funding source as it was undertaken as a Clinical Audit. 

Additional notes

This work was presented at Physiotherapy UK 2019

For further information about this work please contact Michael Jubb.