HNY Policy and Pathway Repository - York

Only act on Clinical presentation of Cauda Equina syndrome not radiology report of cauda equina compression. This pathway concerns itself with clinical presentations only.

Therapists should be aware that this is for guidance only. Patients with significantly deteriorating function (e.g. rapidly progressing paresis) should be managed with appropriate immediate action. Also see Trust Metastatic Spinal Cord Compression pathway & Acute Motor Loss Pathway

Symptoms suggestive of Cauda Equina Syndrome requiring immediate action:

Patients who report any of the following which are present on the day of attendance and are less than 3 months in duration require immediate action:

• Saddle area numbness/parasthesia
• Urinary incontinence/retention
• Faecal incontinence

 

Isolated constipation would not be an indication for an emergency MRI since this is a common symptom with back pain and is often related to codeine related products.

Counsel patient regarding indications for immediate attendance at A&E. Indications include:

• Deterioration of urological symptoms,
• Development of symptoms listed as suggestive of CES requiring immediate action.

Issue written information

In ESP clinic

• MRI next available urgent slot.
  • MRI positive for CES - urgent referral for spinal orthopaedic consultation
  • MRI negative for CES - continue on lumbar spine pathway
• If index of suspicion of CES is such, consider concurrent urgent referral to spinal orthopaedics and discussion with spinal orthopaedic consultant/ED.

In MSK physio 

• Speak to ESP/Band 7 to ascertain whether symptoms warrant further management.  If symptoms were not on original referral it should be assumed that GP is not aware of them.
• Discuss patient with GP. Make them aware of new red flag symptoms. Ask specifically if GP can explain red flag symptoms medically and if they think symptoms could be related to CES. You are seeking a medical opinion on the new symptoms.
  • GP wishes to take on management of patient following symptom change. Discharge back to GP.
  • GP can explain symptoms medically and does not wish to review. DOCUMENT in patient notes. Does this re-assure?
    • YES – Continue on spinal pathway.
    • NO – Discuss with ESP regarding potential review

Symptoms indicative of a potential CES requiring urgent action:

Patients who present with:

• Significant motor weakness e.g. Isolated foot drop (Oxford grade < 3)
• Progressive neurological deficit in lower extremities
• Bilateral true sciatica
• Spinal pain/Sciatica with urological symptoms, e.g. stress incontinence, bladder frequency, urgency.
• A report of any of the following but not present on the day of attendance or are greater than 3 months in duration.
  • Saddle area numbness,
  • Urinary incontinence/retention
  • Faecal incontinence
• Sexual dysfunction
• Paresis (gait disturbance)