Compliance With the Cauda Equina Pathway: Results of a Closed-Loop Audit

Introduction The British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and operative intervention in patients with suspected cauda equina syndrome (CES). Due to the lack of a 24-hour MRI service and the centralisation of neurosurgery to large tertiary centres, there is a need for an evidence-based protocol for the referral of patients presenting with back pain, with red flags to specialist tertiary neurosurgical centres. Methods The standard operating procedure (SOP) at our local hospital outlines steps in the assessment, triage and onward referral of patients presenting with symptoms of acute CES. A closed-loop audit cycle was performed; the first cycle was between September and December 2020 and the second was between January and April 2021. Recommendations made after the first cycle were actioned prior to re-audit. Results There was 100% compliance regarding discussions with neurosurgery following MRI and appropriate management following neurosurgical advice. There was a 21.1% increase in appropriate discussions with neurosurgery by the emergency department (ED), increased accurate documentation of red flags (5% anal tone and 21% perianal sensation). There was a 53% decrease in senior ED doctor referral to neurosurgery, although 100% referrals were discussed with an ED senior prior to referral, and a 20% decrease in compliance regarding neurosurgery plan documentation. Conclusion We were able to improve our compliance with several aspects of the SOP using simple measures. We could not improve one aspect of SOP, namely, a discussion with the specialist centre being performed by a senior doctor. Since CES requires timely management and early scanning, we recommend a robust protocol at the admitting hospital. This paper presents the protocol at our hospital and the rationale behind it. We discuss what affects our compliance with the SOP and how simple interventions have helped us improve.