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Why Cauda Equina Syndrome is often diagnosed so late: the role of protocols and pathways in secondary care

Posted: 05/10/2022


Our previous article highlighted the concerns arising over access to out of hours radiology services. This article takes a look at another issue that can arise in the management of patients presenting to health professionals with signs and symptoms of Cauda Equina Syndrome (CES), particularly in a secondary care setting (ie at a hospital).

Many trusts across the UK will have various procedures, protocols and pathways in place to assist clinicians in the management of a broad spectrum of conditions and injuries, ranging from fractures, to various forms of cancer, to patients presenting with spinal pathology – including CES.

These processes are in place to help direct a health professional to a framework on what should happen and when, from the point of the patient’s initial presentation up until conclusion of treatment. Some processes will also stipulate the timeframes in which certain steps need to be followed, and this is particularly the case where a condition/injury is time sensitive in terms of needing prompt treatment.

There are said to be many benefits in having a form of clinical pathway/protocol in place, as, for example, these processes can provide a clear logical structure on what is required in the assessment and treatment process. When the process is followed, arguably, this should lead to limited scope for error and avoid unnecessary delays in investigation and treatment.

Typically, most patients presenting with symptoms of an acute (ie sudden) onset of CES will present to the emergency department, either by self-presentation or as a result of the advice of another medical professional/health service – for example, an out of hours service, a GP or NHS111.

A good outcome in recovery for a patient with confirmed CES is very much reliant on prompt diagnosis and ‘urgent’ treatment by way of surgical decompression, and so there is an argument that A&E departments - or even out of hours services - across the UK would benefit from having a clear process in which to identify the signs and symptoms of CES and to state what is expected once CES is considered as a likely diagnosis.

An example of such a process at an emergency department at a Central London trust is illustrated below:

‘Consider red flags
Features of Cauda Equina OR motor neurone impairment present
↓ yes
Neurosurgical referral EXT (4207)’

This pathway would mean that a patient with suspected CES would be immediately referred by an emergency clinician to the neurosurgical team for advice on management, which could include an immediate transfer to the specialist unit for investigation, namely, an urgent MRI scan. If the diagnosis is confirmed, they are then prioritised for urgent surgery.

The benefits of having a clear pathway such as this will be significant to a patient, as they will be under the care of a specialist team that understands the condition from a very early stage of their hospital attendance, and, therefore, it will reduce the risk of delays associated with an alternative route of management.

Naomi Holland, a senior associate within the specialist CES team at Penningtons Manches Cooper, comments: “As this article demonstrates, there can be clear benefits of having protocols and pathways in place for many forms of injuries and conditions, and even more so when a particular injury or condition has a small ‘window of opportunity’ for early intervention for a good or full recovery.

“Unfortunately, not all hospitals have specific pathways or protocols in place for every form of injury or condition, and although this does not always give rise to issues, having a process in place that gives clear guidance on what should happen and when can only be a good thing. Another concern, however, that needs to be addressed is the lack of adherence, lack of knowledge of processes, or even a misinterpretation of a particular pathway or process – as this can result in an inappropriate route of management, and thus cause delays in getting the appropriate diagnosis and treatment.

“For example, we currently act for a client who experienced a fairly significant delay in obtaining a diagnosis for CES because the clinicians relied on a pathway for another form of spinal condition that did not carry the same level of urgency for investigation and surgery. This resulted in a delay to surgery and significant long-term and life-changing implications for our client. While there is definitely a valid role for these processes in secondary care, it is important that appropriate training and adherence is given to ensure good outcomes for patients.”


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