HSIB: Timely detection and treatment of cauda equina syndrome (19 August 2021)

Summary

The Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk involving the timely detection and treatment of non-malignant spinal compression (cauda equina syndrome). Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, causing all the nerves in the lower back to become suddenly and severely compressed. If CES is not diagnosed and treated in a timely way it can lead to permanent incontinence, sexual dysfunction and even paralysis.

The investigation was launched after HSIB identified an event where a patient had several GP and hospital presentations before CES was diagnosed.

Content

This investigation focused on:

• Assessing the resilience, consistency and reliability of the pathway(s) for patients experiencing potential red flags for CES.
• Seeking to understand the context and contributory factors influencing the pathway for patients with CES from their first presentation.
• Reviewing the national context surrounding the timely detection and treatment of spinal nerve compression (CES) in patients with back pain.

Safety recommendations

1. HSIB recommends that the British Association of Spine Surgeons, supported by the Royal College of Surgeons of England and the Royal College of Emergency Medicine, develops a decision-making tool to support the identification of patients who need an immediate MRI for suspected CES (which may result in the patient being transferred for MRI if this is not immediately available at the assessing site).
2. HSIB recommends that guidance is developed by the Royal College of Radiologists, supported by the Society and College of Radiographers, stating that all hospitals should reserve the first MRI slot of the day for patients with suspected CES who do not meet the criteria for an ‘emergency’/immediate scan overnight.
3. HSIB recommends that the British Association of Spine Surgeons oversees the development of national guidance to identify how ‘urgent’ and ‘emergency’ requests for scans for suspected CES are defined and prioritised.
4. HSIB recommends that the National Institute for Health and Care Excellence updates its current low back pain guideline to include the symptoms and initial management of CES. This update should include a review of the role of supplementary investigations, such as bladder scanning, in patients with suspected CES.
5. HSIB recommends that NHS England and NHS Improvement develops a national CES pathway. This should define the safety-critical elements of the pathway and highlight areas that can be adapted locally.