Cauda equina syndrome: Changes to NICE CKS red flags

Failure or delay in diagnosis of cauda equina syndrome can be catastrophic and leave GPs open to costly negligence claims. Dr Philip White from MPS explains changes to NICE Clinical Knowledge Summaries' red flag symptoms for this condition, which should support earlier referral.

An MRI of the lumbar spine on a 29-year-old female with cauda equina syndrome (Pitcure: Scott Camazine/Science Photo Library)
An MRI of the lumbar spine on a 29-year-old female with cauda equina syndrome (Pitcure: Scott Camazine/Science Photo Library)

Rare and complex clinical conditions can often present the greatest risks in clinical practice and result in costly clinical regligence claims. Because you may only see one or two presentations of some conditions in your entire career, when it does come along it can be difficult to spot.

You may not remember much about it, it may not present itself obviously to start with or may overlap with the signs and symptoms of more common conditions. Sometimes it can take time before the picture develops enough to suspect the diagnosis.

But if the diagnosis is missed, or delayed, it can be catastrophic.

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Cauda equina syndrome

Cauda equina syndrome ticks all of those boxes. It is a rare and severe narrowing of the spinal canal usually caused by a prolapsed intervertebral disc.

The bundle of delicate nerves in the lower back, known as the ‘cauda equina’ (horse’s tail), suddenly becomes severely compressed, causing problems such as numbness and weakness in the legs, numbness between the legs, not being able to urinate or control the bladder, and loss of bowel control.

The condition can progress quickly, and requires emergency hospital admission and surgery.

It is a condition where most failures to diagnose, result from a failure to suspect. Early diagnosis requires spotting specific symptoms, then getting an MRI scan, within hours in order to prevent irreversible nerve damage and disability.

Impact of delayed diagnosis

The impact of a missed or delayed diagnosis on patient safety is clear, but these errors also leave healthcare professionals open to costly clinical negligence claims.

Research by MPS in 2016 found that failure or delay in diagnosis of cauda equina syndrome was one of the top five errors that led to the most expensive GP claims. From 2013 to 2017 we received 105 claims involving cauda equina syndrome – most of these arising from primary care.

Such cases typically settle for six-figure sums where negligence is established, although in some cases where the resulting issues have led to long-term care being required, the costs can run into millions.

Through our involvement in these cases it became clear that the previous NICE Clinical Knowledge Summaries (CKS) red flag symptoms for cauda equina syndrome created too high a threshold for urgent investigation, and were not explicit enough - meaning some patients were not being referred for treatment, or being referred too late.

Earlier this year we approached Dr Gerry Morrow, medical director at Clarity Informatics who oversees the Clinical Knowledge Summaries on cauda equina syndrome, with our suggestions for a revision which could make the red flags safer for patients and clinicians. After reviewing supportive evidence from MPS neurosurgical expert, Mr Richard Cowie, he agreed to the rewrite.

Updated red flags

The updated red flags, which are now more explicit and enable earlier referral, are:

  • Bilateral sciatica
  • Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
  • Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible urinary retention with overflow urinary incontinence
  • Loss of sensation of rectal fullness, if untreated this may lead to irreversible faecal incontinence
  • Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
  • Laxity of the anal sphincter.

GPs, as frontline doctors, will benefit from these updates most. But doctors in A&E, junior orthopaedic surgeons and junior neurosurgeons, will also benefit along with any other clinician that sees patients with back pain.

We are pleased to have worked with CKS to bring about these changes and hope to collaborate again on similar guideline updates.This not only has the potential to make medical practice safer for patients, but can also help to prevent clinical negligence claims from occurring.

The full updated guidance can be viewed here.

  • Dr Philip White is medical claims adviser at MPS

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