1. Key conditions/ procedures
Patients presenting with suspected cauda equina syndrome* or cord compression irrespective of the underlying aetiology (including infection).
2. Assessment
For patients presenting to their local ED with symptoms suggestive of cauda equina syndrome or cord compression the following should be carried out in the first instance:
a) Full clinical examination and history, including neurological assessment +/- PR examination
b) If cauda equina or cord compression is still indicated following above, carry out post micturition bladder scan**
i. If post-micturition residual bladder volume is > 200 ml – Spine MRI scan should be performed as an emergency
ii. If post-micturition residual bladder volume is < 200 ml – Spine MRI should be performed during the next available appointment (within 24 hours) or first thing in the morning for patients presenting overnight.
MR Spine should preferably be whole spine however screening Sagittal T2 sections through the cervical and thoracic spine along with a full scan of the lumbar spine will suffice.
As per British Association of Spinal Surgeons (BASS) guidance, MRI for suspected cauda equina/cord compression must take precedence over routine booked cases and reason for any delay should be clearly documented and audited.
If MRI is contraindicated, the case should be discussed with the Neurosurgical team at RPH.
MRI scans should be performed as follows:
c) During the hours of 08.00-20.00 Monday to Sunday – local trust to carry out MRI scan. Responsibility for reporting sits with the local site/outsourcing company as appropriate in accordance with local arrangements
d) During the hours of 20.00-08.00 Monday to Sunday – local trust clinician to contact LTH Neurosurgeon on call (01772 716565 bleep 9000), who will make a clinical decision as to the urgency of MRI and whether the patient should be transferred to RPH
If the Neurosurgeon on call determines that the patient can wait until the morning for MRI scan, this must be carried out locally as first scan in the morning. (It may be advised by the neurosurgical team to keep the patient starved so that urgent transfer and surgery can be performed after the scan if it is positive).
It is acknowledged that for patients presenting to their local ED after 19.00, it may not be possible to carry out the MRI scan before the scanning department closes. In these instances, assessment/diagnostics should be undertaken as per a) and b) above, prior to discussion with LTH Neurosurgeon on call, if required, as per d) above.
Similarly, for patients presenting to their local ED from 07.00 onwards, they should undergo assessment and diagnostics locally as per a), b) and c), if required, above.
3. Procedure
Confirmed cauda equina or cord compression on the MRI, accompanied by clinical signs of cauda equina syndrome, will result in emergency decompression surgery at RPH.
4. Post-operative
Post-operative care on neuro-surgery ward at RPH.
5. Repatriation
If MRI confirms that the patient does not have cauda equina syndrome, the patient will immediately be:
- Sent home if fit for discharge
- Transferred back to the referring trust if further inpatient treatment is required. A bed must be kept available to facilitate this.
Following emergency decompression surgery at RPH, the patient will be repatriated to the referring trust once clinically stable, if further inpatient care/recuperation is needed.
All further treatments should be undertaken in the referring trust, as appropriate.
N.B. This is a guideline – treatment decisions should always be made based on clinical presentation.
* Cauda Equina Syndrome Suspected (CESS): a patient presenting with acute back pain or an acute exacerbation of chronic back pain, and/or sciatica alongside disturbance of the bladder or bowel and/or sensory disturbance of the peri-anal region and/or genitalia.
** If bladder scan cannot be performed locally, please measure post-micturition residual volume by catheterisation.