Cauda equina syndrome-most frequent referral diagnosis to a tertiary spinal centre: a retrospective study

Cauda equina syndrome (CES) is a rare but critical surgical emergency, with a global incidence of 1-3 cases per 100,000 annually. Despite its rarity, CES has paradoxically emerged as one of the most common referral diagnoses to tertiary spinal centres. This discrepancy between referral rates and the actual prevalence of CES raises concerns about potential over-referral and inefficiencies in clinical pathways. This study aimed to evaluate compliance with national guidelines from the British Association of Spine Surgeons (BASS) and Getting It Right First Time (GIRFT) concerning the streamlined referral pathways and timely magnetic resonance imaging (MRI) utilisation for suspected CES at a major tertiary spinal centre in the UK.

A retrospective audit was conducted on all urgent and emergency CES referrals (n=353) received by a tertiary spinal centre via an electronic referral system over a 15-week period (June-September 2023). Electronic patient records were retrospectively reviewed to assess compliance with national CES pathway standards, particularly the proportion of patients receiving MRI scans prior to referral and within 24 hours of symptom presentation. Data analysis was performed using IBM SPSS.

Of the 353 urgent and emergency referrals, 102 (29%) were for suspected CES, but only 6 cases (1.7%) were confirmed and required surgical intervention. MRI scans were completed before referral in 48% of suspected CES cases, with 94% being within 24 hours of presenting with symptoms. Compliance rates significantly differed between daytime (72%) and out-of-hours referrals (31%).

Despite clear national guidelines, adherence to recommended CES pathways remains suboptimal, particularly regarding timely MRI access and pre-referral imaging. Variations in guideline compliance, especially out-of-hours, highlight the need for improved access and workforce adjustments to optimise resource utilisation, reduce inappropriate referrals, and prioritise care for true CES patients.