Abstract
Introduction
Cauda equina syndrome results from compression of the lumbosacral nerve roots in the thecal sac of the lumbar spine. Prompt diagnosis and emergency treatment is vital to avoid disability from nerve damage, including irreversible loss of bowel and bladder control, lower limb paralysis and chronic pain. National guidance has been published by the Getting It Right First Time (GIRFT) initiative, in conjunction with the Chartered Society of Physiotherapy and the British Association of Spinal Surgeons [[1]]. This short communication reviews the pathway and considers the implications for physiotherapists, particularly first contact practitioners (FCPs) [[2]].
Cauda equina syndrome
CES is a rare but serious condition affecting the bundle of lumbosacral nerve roots as they exit the spinal cord. These nerve roots innervate the lower limbs, genital and perineal region, and are responsible for urinary and anal sphincter control. Compression usually results from a large disc herniation, but infection, tumour and trauma can also be responsible [[3]]. Symptoms of CES include low back with any of the following symptoms: new onset bilateral leg pain, loss of sensation in the genital/perianal/perineal regions, loss of bowel and bladder control and loss of sexual function. It is important to note CES does not have a set clinical pattern. If suspected, immediate referral to a hospital Emergency Department is mandatory for an MRI scan to confirm the diagnosis and to undergo emergency surgical decompression.
GIRFT
The GIRFT initiative was established initially to address issues identified in elective orthopaedic services in the NHS. The aims are to reduce unwarranted variation in treatment provision and share best practices to improve outcomes for patients and value for the NHS [[4]]. The programme has been expanded to include 40 specialities including the provision of physiotherapy services.
National Suspected Cauda Equina Syndrome Pathway
A 2019 GIRFT report found there was significant variation in the way CES was treated [[5]]. This report, along with an 2021 safety review, led to the publication of the National Suspected Cauda Equina Syndrome Pathway in February 2023 [1, 6]. The pathway was published with input from multiple professions including physiotherapy and spine surgery. This guidance builds on a consensus framework by Finucane et al., 2020 [[7]].
Recommendations for triage and diagnosis
The definitions and duration of the ‘red flag’ symptoms have been clarified and quantified. CES should be suspected and emergency referral required if a patient presents with back or leg pain and recent - defined as less than two weeks - onset of any of the following symptoms:
- New difficulty initiating, or impaired sensation of, urinary flow.
- New altered sensation around the perianal, perineal or genital areas. This area may be small or large.
- Severe or progressive lower limb neurological deficits.
- New loss of sensation of rectal fullness.
- New sexual dysfunction i.e. inability to achieve erection or to ejaculate, or loss of vaginal sensation.
Sudden onset bilateral leg pain, or unilateral leg pain that progresses to bilateral or swaps sides, is a warning sign that CES may develop. Such patients - without other CES red flags - require urgent (<2 weeks) referral to MSK services as per local pathways. Patients should be safety-netted by providing access to CES warning cards and videos [[8]]. Patients with static CES symptoms > 2 weeks duration should be referred on this urgent pathway.
Recommendations for examination
All symptoms and examination findings should be clearly documented. Physical examination should include a neurological assessment of lower limb power and sensation. A digital rectal examination is not necessary in the community or triage setting but documentation of subjective perianal sensation is required. Whether or not to formally assess saddle sensation is not specified, although previous consensus recommendations include it [[7]]. It is important to note that negative examination findings do not exclude CES if positive subjective symptoms are present.
Physiotherapy practice has evolved with increasing remote consultations in FCP services, MSK triage clinics and private practice. If a telephone assessment has taken place, it is not necessary to examine the patient face-to-face prior to making an emergency referral.
Conclusion
CES is a rare but devastating diagnosis which demands a high index of suspicion amongst practitioners treating back pain, which is particularly relevant for FCPs working in the community and managing acute cases. The nature and duration of red flag symptoms that trigger an emergency referral has been clarified. With the increase in telephone assessments, confirmation that emergency referral is acceptable without face-to-face review is a pragmatic inclusion. Awareness of this guidance will facilitate communication, documentation and referral of suspected CES.
Ethical Approval
Not applicable.
Funding
Not applicable.
Conflict of interest
There are no conflicts of interest.