Suspected Cauda Equina Syndrome Research Articles

Cauda equina syndrome in the emergency department: a 2-year retrospective review

Cauda equina syndrome if a rare but life-changing clinical condition inwhich pressure is exerted on the group of nerve roots known collectivelyas cauda equina.It was first described in 1934. It has an incident ranging from 2.7 to4.0 per 100,000.It is more common in women with a mean age of 42 years.It can lead to loss of control of pelvic organs and legs, with a risk ofpermanent loss of sensory and motor control in the area supplied by thecauda equina.The setting for the study was the emergency department in a LargeUrban Teaching Hospital. A Retrospective Chart Review over 2 yearsfrom January 2022 to December 2023 was conducted. Adult patientsaged 18 years and over presenting with suspected cauda equina syndrome(CES) were included. We found a CES prevalence of 0.07% of all EDattendances or 74 per 100,000. There was a female preponderance of70% versus 30% male. A total of 74% of cases were aged between 24and 65 years at one peak, and a spike after the age of 75 years. Mostcases (92%) were managed conservatively. A total of 100 patients (68%)were admitted or transferred, while 32% were discharged. A total of 140patients (95%) met the National Institute for Health and Care Excellence(NICE) red flag symptoms. In conclusion, CES is rare (< 0.5% of ED presentations). There was anage peak between 25 and 65 years, with a spike after the age of 75 years.It has a large female preponderance in keeping with the observation fromother studies. Ninety five per cent of cases in our cohort met the NICEred flag criteria. Most cases were managed locally and conservatively.

Suspected Cauda Equina Syndrome: Can the Presence of an Orthopaedic Doctor in the Emergency Department Reduce Waiting Times for MRI Scans and Inpatient Stays?

Introduction Cauda equina syndrome (CES) is a very rare but devastating surgical emergency that can lead to permanent bowel, bladder or sexual dysfunction and lower limb paralysis. Although it is a clinical syndrome, an MRI scan is a critical diagnostic investigation for these patients and should be done as soon as possible. Our hospital is a district general hospital with no spinal services on site. There is a protocol in place for the management of these patients locally with MRI scanning during daytime hours. However, if the patient presents after 8 pm, they are discussed with the tertiary spinal centre, which then advises if the patient requires transfer overnight for urgent scanning.Considering an MRI scan is a critical diagnostic step for these patients,we introduced a role for an orthopaedic doctor in the Emergency Department (ED) to assess all of these patientsbefore collecting data for the second cycle. The aim of this audit was to see the effect of having an orthopaedic doctor in the ED for the assessment of these patients and its impact on waiting times and admission rates. Methods A closed-loop audit cycle was done looking into all referrals to trauma and orthopaedics with acute back pain and suspected CES in a district general hospital with no spinal services on site. The first cycle was between September 30, 2020, and May 31, 2021, and included 93 patients in total. Following this, a role for an orthopaedic doctor in ED was introduced from December 1, 2021, to January 31, 2022, for assessment of these patients. Data was then collected retrospectively for all patients referred during this period (n=36). Data was extracted from all relevant clinical systems including electronic patient record (EPR), Patient Pass (Patient Pass Ltd, Greater Manchester, England), which is the system used to digitally communicate with regional spinal services, and PACS (picture archiving and communication systems). The data was collated on a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, Washinton, United States) and analysed. Results Data were collected for a total of 36 patients in the second cycle following the introduction of an orthopaedic doctor in the ED. The age of patients referred was 30-89 yearswith a mean age of 51; 44.4% were male (n=16) and 55.5% female (n=20). All the patients who were referred received their MRI scan and report within 24 hours of presentation to the ED. In the first cycle of the audit, the mean waiting time for an MRI scan had been 12.5 hours, which was reduced to eight hours following the introduction of an orthopaedic doctor in the ED during daytime hours. This was stratified further according to the time patients presented to the hospital. From 8 am to 4 pm, the mean waiting time for an MRI scan was 9.5 hours pre-intervention and 5.5 hours after. From 4 pm to 12 am, the mean waiting timewas 18 hours before and 13 hours after, and from 12 am to 8 am, the waiting time for scans improved from 8.5 hours to 6.5 hours. The number of patients discharged on the same day greatly improved from 29% (n=27) in the initial study to 58% (n=21). This decreased unnecessary inpatient stays from 71% (n=66) to 42% (n=15). Conclusion This study showed that an orthopaedic doctor in the ED for the acute assessment of patients referred with possible CES is an effective way of improving their management. This decreases waiting times for MRI scans and therefore allows the patient to be managed more efficiently.

The National Suspected Cauda Equina Syndrome Pathway: implications for physiotherapists

The National Suspected Cauda Equina Syndrome Pathway: implications for physiotherapists

Evaluation of individuals who repeatedly present with suspected cauda equina syndrome

Evaluation of individuals who repeatedly present with suspected cauda equina syndrome

Expediting the Management of Suspected Cauda Equina Syndrome (CES) in the Emergency Department Through Clinical Pathway Design at a District General Hospital: A Quality Improvement Project.

Cauda equina syndrome (CES) is an uncommon condition that occurs due to compression of the terminal portion of the spinal cord. Early recognition and intervention in CES are crucial for an improved prognosis. Delayed diagnosis and action may lead to irreversible adverse effects, i.e., permanent disability, and in some circumstances can lead to litigation. The aim of this quality improvement project (QIP) was to identify areas for improvement and expedite the management of suspected CES patients presenting to the hospital. This was a retrospective study in which patients admitted to the Poole district hospital were analyzed in three groups with more than 50patients in each subset group. The first group was audited from 1stOctober 2020 to 27thNovember 2020; a re-audit on the second group of patients was done from 1stJune 2021 to 16thJuly 2021;the third group was re-audited from 1stof January 2022 to 31stof March 2022. There were a total of 168 patients in all audit groups, of whom 71% were female. The mean time from getting triaged to having an MRI improved from 13hrs 54mins to 10hrs 39mins. The total inpatient length of stay (LOS) of less than 24 hours was 28% in the first cycle andimproved to 54.4% by the third cycle of the audit. Eight patients exhibited a diagnosis of cauda equina syndrome (CES) and were sent to the tertiary care center. This quality improvement project identified delays in requesting the MRIfor the diagnosis of CES and was addressed by ED booking the scans directly. This, in turn, reduced the length of stay in the hospital for patients who did not have cauda equina syndrome.

A service evaluation of the management of patients with suspected cauda equina syndrome from an outpatient physiotherapy service in the United Kingdom

BackgroundThe expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources. AimTo evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome. DesignService evaluation with an embedded case series of patients with radiological CES. MethodThe records of patients who were identified by their outpatient physiotherapists as having suspected CES (n-231) over a 27-month period were included. Data was extracted from patients’ medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series. ResultsIn 79% of cases, it was decided that emergency referral was not required. The remaining 21% of patients were referred to the emergency department and 49% of these had an emergency MRI. In the case series of seven patients with cauda equina compression on MRI, four patients had a disc bulge and underwent emergency surgery. One patient had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis. Two patients had stenosis and decided against surgical intervention. ConclusionsFindings from this service evaluation suggest support for the use of safety netting and an effective communication chain to facilitate effective management of patients with suspected CES.

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

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

Survey of non-spinal orthopaedic consultant surgeons at three district general hospitals regarding regional spinal services

Patients with emergency spinal pathologies such as suspected cauda equina syndrome are often admitted under non-spinal orthopaedic surgeons at district general hospitals (DGHs). Emergent investigation in the form of magnetic resonance imaging (MRI) is frequently required prior to potential referral to the tertiary spinal centre despite many DGHs not having out-of-hours MRI provision. Anecdotally, there is considerable anxiety among non-spinal orthopaedic surgeons working in DGHs around the admission and investigation of emergency spinal pathologies under their care. We sought to survey and formalise the opinions of non-spinal on-call orthopaedic consultants at three DGHs with regard to admission, investigation, local infrastructure and regional support provided to them when emergency spinal pathologies are admitted under their care. The consultants surveyed reported being very uncomfortable managing emergency spinal cases admitted under their care. It was felt that the hospitals provided inadequate infrastructure, especially in terms of obtaining timely imaging. There is a lack of local outpatient spinal provision, a lack of consistent advice from the regional centre, and a feeling of patient, personal and organisational vulnerability with the current implementation of the regional spinal pathway. There was a high preference for a restructuring of the spinal pathway as well as a desire for on-site spinal opinions. The results of this survey demonstrate the considerable unease experienced by non-spinal trauma and orthopaedic consultants at district general hospitals with regard to the management of spinal pathology. We hypothesise that this is not limited to this region but is a sentiment echoed nationally.

156 A QIP on Improving Approach Towards Suspected Cauda Equina Syndrome Referrals

Abstract Aim To improve the assessment, documentation, and management of suspected Cauda Equina Syndrome (?CES) referrals by supporting and educating new doctors joining T&O Method A survey was done to assess the level of training received by Junior Doctors in Assessment, Documentation, and Management of a ?CES Referral. A need for such training was established from the Survey Report. Teaching was organized and an Infographic poster was published to aid new doctors in safe assessment, documentation, and management of? CES cases. A post Survey was done to assess the impact. Results There was a significant need for teaching and training regarding the approach towards dealing with a suspected Cauda Equina Syndrome patient. The teaching was very well received. 90% of the participants believed that the QIP and the infographic poster were useful in training, will be a helpful guide for new doctors in assessment, documentation, and management of suspected Cauda Equina Syndrome patients, and will lead to improvement in patient care and documentation. Conclusions Suspected Cauda Equina Syndrome bears a huge significance in Emergency Care and Trauma and Orthopaedics. Mismanagement of such a case and unnecessary delays can have a drastic impact on a patient’s life and as such can also lead to significant medico-legal implications from the managing team. Teaching and training regarding approach towards a suspected Cauda Equina Syndrome can lead to significant improvement in the competence and confidence of the Junior Doctors and New Trainees and thus lead to better patient care, better documentation standards, and potentially prevent unnecessary delays.

Early experience of a local pathway on the waiting time for MRI in patients presenting to a UK district general hospital with suspected cauda equina syndrome

Aim This study evaluated the impact of the Salisbury Protocol for Assessment of Cauda Equina Syndrome (SPACES) on the waiting time for MRI in patients presenting with suspected Cauda Equina Syndrome (sCES) within a UK district general hospital. Patients and methods All consecutive patients undergoing an MRI scan in our hospital, for sCES, over a 12 month period, prior to and following the introduction of SPACES, were identified. Patient's gender, age, MRI diagnosis, time from MRI request to imaging and outcome were recorded. Results In the year prior to the introduction of SPACES, 66 patients underwent MRI for sCES, out of which 10.6% had cauda equina compression (CEC), 63.5% had other spinal pathology and 25% had a normal scan. In the year after introduction of SPACES, 160 patients underwent MRI for sCES out of which 6.2% had CEC, 70.7% had other spinal pathology and 23% had a normal scan. Despite the referrals for sCES increasing by more than 2-fold following the introduction of SPACES, the median time from MRI request to scan decreased from 9.1 to 4.2 hours (p = 0.106, Mann-Whitney-U) and the number of patients transferred to the regional hub hospital decreased from 7 to 3. Conclusion Implementation of SPACES for patients with sCES resulted in a substantial reduction in waiting time for MRI and decreased the number of transfers to the regional hub hospital. Based on our early experience, we encourage other centres within the UK to introduce such a pathway locally, to improve the management of patients with sCES.

Post-void bladder ultrasound in suspected cauda equina syndrome—data from medicolegal cases and relevance to magnetic resonance imaging scanning

ObjectivePost-void residual (PVR) scans of less than 200 ml are increasingly being used to rule out the likelihood of cauda equina syndrome (CES) and to delay emergency MRI scanning in suspected cases. This study was done to review a series of 50 MRI confirmed cases of CES and to test the hypothesis that a PVR of less than 200 ml was unlikely to be present.MethodsFifty consecutive medicolegal cases involving CES were audited. Records were reviewed to see if PVR scans were done. MRI scans were reviewed, clinical and radiological diagnosis reviewed, and treatment recorded.ResultsOut of 50 CES cases, 26 had had PVR scans. In 14/26 (54%) the PVR scan was ≤ 200 ml. In one case, the CES diagnosis was in question leaving 13/26 (50%) cases where there was a clear clinical and MRI diagnosis of CES despite the PVR being ≤ 200 ml. All 13 were classified as incomplete cauda equina syndrome (CESI) and all proceeded to emergency decompression.ConclusionsThis study is the first in the literature to demonstrate that there is a significant group of CES patients who require emergency decompression but have PVRs ≤ 200 ml.The results demonstrate the existence of a significant group of CESI patients whose bladder function may be deteriorating, but they have not yet reached the point where the PVR is over 200 ml. Given the accepted understanding that CESI is best treated with emergency decompression, such patients are likely to have worse outcomes if MRI scanning and therefore surgery is delayed. We recommend the following:PVR is recommended as an assessment tool in suspected CES.A PVR of ≤ 200 reduces the likelihood of having CES but does not exclude it; clinical suspicion of CES should always lead to an MRI scan.Further investigation of PVR as a prognostic tool is recommended.

An audit of referrals for suspected cauda equina syndrome at a tertiary neurosurgical centre during the COVID-19 pandemic

An audit of referrals for suspected cauda equina syndrome at a tertiary neurosurgical centre during the COVID-19 pandemic

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

IntroductionThe 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.MethodsThe 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.ResultsThere 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.ConclusionWe 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.

Suspected Cauda Equina Syndrome, who you gonna call? Evaluating the impact of education and on-call support on referrals to A&E

Purpose: Cauda Equina Syndrome (CES) is an emergency diagnosis presenting with a myriad of different red flag symptoms of bladder and bowel dysfunction, saddle anaesthesia, bilateral radiculopathy, and/or sexual dysfunction. Diagnosis is clinically challenging and is only established with confirmatory radiological compression of the cauda equina nerves. Despite a level of disagreement in what constitutes CES, timely management of this condition in order to preserve the function of affected systems appears key.

Evaluation of the role of anal tone and perianal sensation examination in the assessment of suspected cauda equina syndrome

Purpose Cauda equina syndrome (CES) can present with a varied constellation of clinical signs and symptoms, which together with the time-sensitive nature of the condition and risk of catastrophic clinical outcome, presents a significant challenge to those assessing patients with this suspected diagnosis. Anal tone is commonly tested during initial assessment using a digital rectal examination (DRE). This study aims to evaluate the diagnostic value of anal tone and perianal sensation assessment in patients with suspected CES and report modern prevalence data on CES within a neurosciences centre. Materials and methods Consecutive patients with suspected CES presenting over three years to the Emergency Department (ED) of a busy tertiary centre were included in the study. History and examination findings, documented in the ED notes, were assessed and these variables were correlated with the presence or absence of cauda equina compression on subsequent magnetic resonance imaging (MRI). Results Out of 1005 patients with suspected CES, 117 (11.6%) had MRI confirmed cauda equina compression (MRI + ve CES). 35% of MRI + ve patients and 31% of MRI -ve patients had reduced anal tone. Using univariate and multivariable logistic regression analyses, no associations were found between abnormal anal tone and MRI + ve CES for patients of all ages. The univariate logistic regression analysis identified altered perianal sensation to be significantly associated with MRI + ve CES in patients ≤42 years old. This association was no longer present when an adjusted multivariable logistic regression was performed. Conclusion The prevalence of MRI + ve CES was 11.6%. Our findings suggest that the clinical finding of reduced anal tone has no demonstrable diagnostic value for those with suspected CES, either in itself or in combination with other clinical findings. Further studies are needed to confirm the diagnostic efficacy of assessing perianal sensation in this context.

Implementation of a cauda equina service in a medium-sized district general hospital in the UK.

This project explored how the implementation of national guidance for investigation and management of patients with suspected cauda equina syndrome impacted on service provision. Retrospective analysis of patients with suspected cauda equina syndrome during 12 months before the implementation of the national guidelines were compared with data from the 21 months following. Monthly mean numbers of referrals for suspected cauda equina syndrome increased from 10.1 to 18.9 (P<0.001). Statistically significant increases were also seen in the total number of magnetic resonance imaging scans for suspected cauda equina syndrome, and the number of magnetic resonance imaging scans performed out of hours. The mean time interval, from magnetic resonance imaging scan confirming cauda equina syndrome to starting emergency decompressive surgery, reduced from 14.87 hours to 9.57 hours. Compliance with the national guidance for suspected cauda equina syndrome is imperative for patients to receive optimal treatment. However, this project has demonstrated challenges related to increased pressure on resources.

1436 A Stab in The Back: Assessment of Suspected Cauda Equina Syndrome by The Emergency Department Prior To Referral to Orthopaedics in A District General Hospital

Abstract Introduction Within the UK, Cauda Equina Syndrome (CES) is a rare surgical emergency which has the potential to cause significant morbidity. Within hospitals that do not have an on-site neurosurgical service, assessment of potential CES patients is performed in the Emergency Department (ED) prior to referral to either local orthopaedic or regional neurosurgical services. Delay or inefficiency in this assessment can result in delayed treatment and worsens patient outcomes. Method A retrospective study with patients identified from the orthopaedic trauma meeting lists over a 6-month period. Only patients assessed by the emergency department were included (25 total). Direct referrals and those with infective symptoms were excluded. ED clinical notes were assessed, and the documentation was compared against a standard from the American Spinal Cord Injury Association. Documentation of pre- and post-void bladder scan was also assessed. Results Of the 25 total patients, 60% had a full lower limb neurological examination documented. 20% had no documented neurological examination and 20% had an incomplete neurological examination. Only 68% of patients had a Per Rectal exam performed, of those 94% had perianal sensation assessed. 56% of patients did not have a post-void bladder scan documented. Conclusions Limitations to initial ED assessment of likely CES patients can delay diagnosis and treatment which can have devastating consequences for the patient. The data is limited by reliance on an accurate trauma list and exclusion of patients who were referred directly to neurosurgery from ED. Our recommendations include introduction of a CES assessment proforma within ED and a re-audit cycle.

1499 The Statistical Value of Different Clinical Characteristics in Evaluation of Suspected Cauda Equina Syndrome

Abstract Introduction Cauda Equina Syndrome(CES) is a potentially disabling condition caused by compression of the thecal sac in the lumbar spine. Traditional teaching suggests red flags include back pain, sciatica, saddle anaesthesia and bladder disturbance. Current guidelines from the British Association of Spinal Surgeons recommend prompt investigation with MRI should these symptoms be present. Method A retrospective electronic case note review was undertaken from a one-year period to identify patients referred to the on call orthopaedic team with suspected CES and were investigated with MRI. Notes were reviewed for the presence of each clinical characteristic and correlated with MRI findings. Results 334 referrals underwent urgent MRI with 25 scans showing CES. Poor statistical association was observed with unilateral leg pain (sensitivity 0.28, specificity 0.48), back pain (sensitivity 0.92, specificity 0.13) and bladder dysfunction (sensitivity 0.72, specificity 0.36). Much closer statistical association was seen with bilateral leg pain (sensitivity 0.6, specificity 0.7, OR 5.03, 95% CI 2.16-11.68, p0.0002), leg weakness (sensitivity 0.68, specificity of 0.72, OR 5.35, 95% CI 2.23-12.85, p0.0002), leg sensory deficit (sensitivity 0.72, specificity 0.60, OR 3.79, 95% CI 1.54-9.36, p0.004) and altered perianal sensation (sensitivity 0.6, specificity 0.67, OR 3.03, 95% CI 1.31-6.99, p 0.009) Conclusions The diagnostic accuracy for some conventional red flag characteristics in CES is low. In our series back pain, unilateral sciatica and bladder disturbance showed low predictive value while bilateral sciatica, saddle anesthesia and lower limb sensorimotor deficits showed closer association and therefore should be closely evaluated for when reviewing such patients.

Appropriateness of imaging decisions for low back pain presenting to the emergency department: a retrospective chart review study.

Imaging for low back pain is widely regarded as a target for efforts to reduce low-value care. We aimed to estimate the prevalence of the overuse and underuse of lumbar imaging in patients presenting with low back pain to the emergency department (ED). This was a retrospective chart review study of five public hospital EDs in Sydney, Australia, in 2019-20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse). Six hundred and forty-nine patients presented with a complaint of low back pain, of which 158 (24.3%) were referred for imaging. Seventy-nine (12.2%) had a combination of features suggesting that lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95% CI 6.8-11.2%) and 4.3% (28 of 649 cases, 95% CI 3.0-6.1%), respectively. Thirteen cases were classified as underuse because the patients were referred for uninformative imaging modalities (e.g. referred for radiography for suspected cauda equina syndrome). In this study of emergency care, there was evidence of not only overuse of lumbar imaging but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse.

349 Improving Assessment of Patients with Suspected Cauda Equina Syndrome Using A Standardised Proforma

Abstract Introduction Cauda Equina Syndrome (CES) has a devastating impact on the life of affected individuals. Most patients are reviewed by doctors who do not have specialist spinal expertise. NHS Lanarkshire guidelines for CES are based on ‘Standards of Care in Cauda Equina Syndrome’ (Todd and Dickson) 2016. Method Documented assessment of a sample of patients with suspected CES in our hospital was audited against standards set in regional guidelines. A tick-box proforma was introduced to standardise assessment, with re-audit thereafter. Chi-squared was used for statistical analysis. Results Cycle 1 (2018): Documented assessment of findings in 30 patients - bilateral radiculopathy (80%), urinary incontinence (93%), faecal incontinence (73%), anal tone (93%), saddle anaesthesia (83%), bladder volumes (90%) and ASIA chart (20%). Cycle 2 (2019): Documented assessment of above findings was 100% in patients where a proforma was used. Proforma was used in 81% of patients. Conclusions Use of a standardised proforma improved assessment of CES. There was a statistically significant improvement in use of an ASIA chart (P &amp;lt; 0.01) and assessment of faecal incontinence (P = 0.039). Compliance with use of this proforma could be improved further, to enhance patient care. Following the success of the proforma, it is being reviewed for implementation on a regional level.