Suspected cauda equina syndrome: no reduction in investigation, referral and treatment during the COVID-19 pandemic

A novel approach to expedite emergency investigation for suspected cauda equina syndrome referrals from community and primary care services: A service evaluation

INTRODUCTION

Although a rare spinal emergency, cauda equina syndrome (CES) can result in significant physical, emotional, and psychological sequalae. Introducing a CES pathway enhances diagnosis but may increase Radiology and Orthopaedic workload. To address this, one NHS hospital in England introduced a novel CES pathway. Utilising a criteria-led pathway, patients were referred directly from community/primary care, via the Emergency Department, for an emergency MRI scan.

OBJECTIVE

To compare the outcomes of patients referred via an original and redesigned Community and Primary Care CES pathway.

DESIGN

A retrospective service evaluation was undertaken of all emergency MRI scans investigating suspected CES via either pathway.

METHODS

Two 3-month time periods were analysed; pre-(original) and post-implementation of the redesigned pathway; time to surgery was reviewed over two 12-month periods.

RESULTS

Increased MRI scan utilisation was seen following the implementation of the redesigned pathway: original n = 50, redesigned n = 128, increasing Radiology workload. However, the redesigned pathway resulted in a reduction in time to MRI from 3h:01m to 1h:02m; reduction in time spent in ED 4h:55m to 3h:24m; reduction in time to surgery 18h:05m to 13h:38m; reduction in out-of-hour scanning from 10 to 2 patients during the evaluation period; and a reduction in on-call Orthopaedic involvement by 38%.

CONCLUSION

All timed outcomes were improved with the implementation of this novel pathway. This suggests expediting MRI scans can result in substantial downstream benefits; albeit while increasing MRI scan utilisation. This pathway aligns with the emergency management of suspected CES under the new national CES pathway in England.

The Effect of COVID-19 National Lockdown on the Time from Presentation to Surgery of Patients with Suspected Cauda Equina Syndrome: Two UK Tertiary Centers' Study

OBJECTIVE

To investigate if COVID-19 UK lockdown measures resulted in a delay in the presentation and treatment of patients with cauda equina syndrome (CES).

METHODS

This is a multicenter retrospective study of patients with surgically treated CES across 3 time periods: April-May 2020 (first lockdown), August-September 2020 (no-lockdown group), and January-February 2021 (second lockdown). Data regarding duration of symptoms, time from referral to admission, time from admission to surgery, and postoperative outcomes were collected.

RESULTS

A total of 56 patients (male: 26, female: 30, mean age: 44.3 years) were included in the study (n = 14, n = 18, and n = 24 in the 3 time periods, respectively). There was no significant difference in duration of symptoms across the time periods (12.6 days vs. 8.2 days vs. 3.8 days) (P = 0.16). Nearly all the patients were admitted within 48 hours of referral (n = 55, 98.2%). The majority of patients were operated on within 48 hours: first lockdown (n = 12, 85.7%), no-lockdown (n = 16, 88.9%), and second lockdown (n = 21, 87.5%). The length of hospital stay was significantly shorter in the second lockdown (3.3 days) versus the other 2 time periods (4.4 days and 6.4 days) (P = 0.02). Thirteen complications were present, with dural tear being the most common (n = 6, 10.7%). Majority reported symptom improvement (n = 53, 94.6%), with a similar number discharged home (n = 54, 96.4%).

CONCLUSION

Despite the pandemic, patients with CES were promptly admitted and operated on with good outcomes. Shorter duration of hospital stay could be attributed to adaptation of spinal services.