The cauda equina pathway: pragmatic local solutions to address the bottleneck

The Getting It Right First Time (GIRFT) [1] national pathway set a clear target of a four-hour window for emergency MRI scans. Despite these objectives, the reality, three years on, remains that many district general hospitals (DGHs) simply do not have the radiographer staffing to provide a 24/7 MRI service. A number of systemic issues, such as triage delays, limited scanner availability, slow transfers to specialist spinal teams and ultimately prolonged waits for surgery continue to prevent patients with cauda equina syndrome from reaching surgery before suffering serious injury.

Waiting for an influx of national funding and overnight staffing is not a viable short-term strategy. Instead, clinical teams on the ground are developing practical local workflows.

In the second article in this two-part series, specialist cauda equina claims solicitor Robert Dransfield looks closely at recent clinical literature, particularly the implementation of dedicated scanning pathways and objective risk-scoring tools to identify clear routes to improving patient safety and meeting national targets using existing resources. He explores two of the most promising solutions recently published in the medical literature: the Luton pathway and the SuCESS triage tool.

Streamlining logistics: the Luton pathway

One of the most persistent bottlenecks in the CES pathway is the administrative delay in actually getting a patient into the MRI scanner. Even when a patient arrives during normal working hours, their scan is often delayed by the need for radiology vetting and a lack of available slots on a fully booked MRI list.

A 2026 paper by Naik et al, published in Bone & Joint Open, titled Luton cauda equina syndrome pathway: a pragmatic approach to achieve a national target of time to scan in UK district general hospitals [2], presents an effective ‘bottom-up’ solution to this problem. Rather than focusing on the goal of establishing a 24/7 out-of-hours MRI service, the team at Luton and Dunstable University Hospital completely restructured how they used their existing daytime (07:00 to 18:00) MRI capacity.

The authors recognised that radiology gatekeeping was causing unnecessary friction. Under their new dedicated pathway, patients presenting with BASS-standard red flags are reviewed by an on-call orthopaedic registrar. Crucially, the pathway completely removes the radiology vetting process. The orthopaedic doctor requests the urgent MRI directly, and the MRI radiographer accepts it immediately.

To prevent this from disrupting the daily scanning lists, the hospital reserved three predefined MRI slots every single day strictly for suspected CES patients. If the slots are not required by 17:00, they can be released for other patients, but their presence guarantees that capacity is always waiting for an emergency. Importantly this was aimed to reduce out of hour scanning.

The results of the programme are impressive. By bypassing the vetting process and using reserved slots, the average time to scan at Luton fell from 8 hours and 48 minutes down to to 34 minutes. That is a contrast to other recent papers that reduced times to within 24 hours! The proportion of patients successfully meeting the national four-hour GIRFT target increased from 66% to nearly 90% (89.68%). Furthermore, because they maximised their in-hours capacity, the number of patients needing costly, risky out-of-hours ambulance transfers to the tertiary spinal centre at Addenbrooke’s Hospital was reduced by more than half, falling from 17 to 6. The Luton paper demonstrates that DGHs can achieve national targets promptly, simply by removing internal administrative barriers.

Objectifying risk: the SuCESS score

While the Luton pathway resolves the logistical issue of getting patients into the scanner, the NHS still faces the clinical problem of over-triage. Because missing a CES diagnosis is catastrophic for the patient and indefensible in a medical negligence claim, clinicians understandably maintain a very low threshold for requesting an MRI. As a result, over 80% of urgent MRIs for suspected CES ultimately show no cauda equina compression. This places a heavy, unsustainable burden on radiology departments and can delay imaging for patients who genuinely require surgical intervention.

To address this, researchers at Queen’s Medical Centre in Nottingham developed a validated triage tool to safely reduce unnecessary imaging. In their 2026 paper published in The Bone & Joint Journal, titled The Suspected Cauda Equina Syndrome Score (SuCESS): Development and validation of a clinical triage tool [3], Najjar and colleagues outline a highly effective, multivariable scoring system based entirely on routine bedside clinical data.

The SuCESS tool assigns weighted points to specific clinical findings to objectify a patient’s risk:

• saddle anaesthesia (+2.0 points)
• bladder post-void residual (PVR) volume of 200 ml or more (+2.0 points)
• decreased perianal sensation (+1.5 points)
• motor weakness below Medical Research Council grade 4 (+1.5 points)
• bilateral sciatica (+1.0 point)

What makes the SuCESS paper particularly valuable is how it contextualises bladder scanning. For years, there has been concern about clinicians using a reassuring bladder scan (a PVR under 200ml) as an excuse to discharge a patient or defer an MRI, despite the presence of other red flags. Najjar et al clarify that bladder ultrasound must be used as a positive predictor to complement clinical judgement, not to replace it. In their scoring system, a PVR of 200ml or more actively adds heavy weighting to the score, acting as a functional surrogate for acute urinary retention and pushing the patient toward an immediate scan.

During external validation across multiple temporally distinct cohorts, the SuCESS tool proved remarkably accurate. At a diagnostic threshold of 3.0 points or higher, the tool achieved 100% sensitivity and a 100% negative predictive value. It successfully identified all 64 confirmed cases of CES without a single false negative. The authors concluded that by routinely implementing the SuCESS tool, hospitals could safely defer 38.7% of urgent MRI requests. This significant reduction in volume frees up critical MRI capacity, allowing radiology departments to prioritise the patients who genuinely need life-altering surgical intervention.

Standardising the approach

The benefits of these specific interventions are further supported by other recent quality improvement projects. For instance, a 2025 paper by Conte et al in BMJ Open Quality, titled Improving the suspected cauda equina syndrome pathway at a district general hospital [4], highlights how standardising MRI sequences can save valuable time. By implementing a dedicated CES MRI sequence (sagittal T1, T2-weighted, and STIR images), Medway Hospital reduced the actual time a patient spends inside the MRI scanner from 30 minutes down to just 15 minutes. When combined with dedicated slots like those used in Luton, halving the scan time creates even more daily capacity.

Summary

There is a tension between scanning everybody with MRI as the only reliable diagnostic tool and improving triage to reduce the number of unnecessary scans. Each of these local programmes seem to offer a potential solution. However, there is also a clear tension between the differing methodologies they adopt. This suggests a need for a review of the GIRFT pathway and greater sharing of knowledge. At the very least, GIRFT surely has a duty to publish these programmes. I believe that clinicians and patient advocates working in this field would welcome a reset – perhaps a genuine opportunity to consider what ‘getting it right second time’ would look like.

This article has become somewhat academic. There is a focus on resource, protocols and the cost of litigation. However, my day to day work is rather less theoretical. My clients are suffering a very personal set of symptoms and all have their own journeys from primary care, to emergency departments, to coping with life-changing consequences. I would encourage everyone to look out for Cauda Equina Syndrome Awareness Day on 1 October 2026 to allow some space for individual voices to be heard and for awareness to be raised.

This article was originally published in NR Times.

The first article in the two-part series can be accessed here.