Suspected Cauda Equina Syndrome CES

1. Red Flags: Has the patient developed any of the following?

Difficulty initiating micturition or impaired sensation of urinary flow
Altered perianal, perineal or genital sensation S2-S5 dermatomes – area may be small or as big as a horses’ saddle (subjectively reports or objectively tested)
Severe or progressive neurological deficit of both legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
Loss of sensation of rectal fullness
Sexual dysfunction (achievement of erection or ability to ejaculate, loss of genital sensation)

If Yes to ANY proceed to 2.

If NO to ALL consider other diagnosis and possibility of GP follow-up

Yes Proceed to 3.
No – does the patient have a:
- Calderdale GP: Referral can be made via message centre to the ED reception team indicating: “Calderdale Spinal MSK” for urgent outpatient follow-up
- Non-Calderdale GP: Proceed to 3. (Access to Spinal MSK clinic is currently being negotiated)

If a patient is unable to void then undertake a bladder scan and if > 600ml, catheterise the patient and document if sensate and perform a documented catheter tug outcome.
If a patient is able to void, carefully document the following:- Pre void volume & Post Void Residual volume (PVR);
- If PVR <200ml this does not exclude CES
- If PVR >200ml in a patient with suspected CES then CES is 20 times more likely. (if MRI not available locally contact Neurosurgery directly)
- If PVR>600ml catheterise and document if sensate and catheter tug. This avoids bladder distension injury.

In hours
- ED will arrange the MRI scan and review the results and refer to Neurosurgery as required.
  - Weekdays 09:00-20:30
  - Weekends 09:00-15:00
Out of hours
- Patient requires referral to Neurosurgeons stating we are unable to MRI OOH do they recommend transfer to LGI for MRI?
- If Neurosurgeons do not accept for immediate transfer needs referral to Orthopaedics on call
- Patient requires admission: then this is under the orthopaedic team.