“If doubt exists about the diagnosis, the only way this can be resolved is by emergency MRI”
Medicolegal aspects In the context of general practice and accident & emergency, the areas most likely to cause difficulty are, firstly, failure to consider the diagnosis of CES. Secondly, patients may dispute the accuracy of their records, alleging that CES symptoms were present at an earlier date but were not recorded accurately or acted upon. Tirdly, patients may accept that they did not have symptoms of CES at the time of a particular consultation but allege that they should have been given ‘red flag’ warnings about the early symptoms and told to seek emergency medical attention should they occur. Fourthly, there may be a delay in seeking specialist opinion. Tere are two particular additional hazards in hospital care.
Te first is in failing to arrange investigation of suspected CES with appropriate urgency, particularly in units that do not operate an out-of-hours MRI service. Te second is the timing of surgery once the diagnosis has been established. Te degree of urgency with which CESI should be investigated will depend upon the clinical circumstances. In nearly all cases MRI is required as an emergency because of the risk that they may progress to CESR with any delay. If it is not possible to arrange this out of hours then the patient should be transferred elsewhere. On rare occasions where a history of early CES has been obtained but symptoms have been static for some days, it may be acceptable to delay investigation overnight, provided the patient is warned to report any deterioration. Measurement of urinary volumes and post-void residuals may be reassuring. Whilst some clinicians have interpreted the outcome of a
meta-analysis by Ahn et al (2000) as indicating that there is a 48-hour ‘window’ in which to treat CES, this notion is unsafe (Chau et al, 2014). In particular, it does not apply to CESI. Once the diagnosis has been made, CESI will usually be treated as a surgical emergency, regardless of the hour. However, this decision is not always straightforward. Surgery for a large central disc can be challenging and carries a risk of adding to the deficit if performed under less than ideal circumstances. It may be argued, therefore, that it is appropriate to delay decompression by a few hours if, by doing so, the risk will be lessened. As far as surgery for CESR is concerned, meta-analysis
suggests that there may still be merit from emergency decompression (Todd, 2005). However, much of the literature suggests that outcome is no better, and that decompression can
AUTUMN 2015
be delayed until the first case the following day. In the interim, the patient should be catheterised to avoid bladder over- distension leading to secondary detrusor failure.
Minimising the risk A number of measures can be taken to minimise the risk of litigation, although they should not all be seen to represent a standard of care:
• Tink about the diagnosis of CES in every patient with back pain and sciatica. Make a written note if there is no evidence of this condition.
• Warn the patient to seek emergency attention if they develop CES symptoms. Document that they have been told this.
• If CES is suspected, telephone the on-call orthopaedic or neurosurgery team. Do not be reassured if a junior doctor tells you to refer the patient as an urgent out-patient. If you are not satisfied with the response, seek a more senior opinion or tell the patient to attend A&E.
• Lack of an emergency MRI service is not a valid reason to delay investigation. If the degree of clinical urgency cannot be met, refer the patient elsewhere.
• CESI is usually treated as a surgical emergency, regardless of the time of day. If there are good clinical reasons to delay decompression, document why this is justified. If the delay is due to lack of surgical expertise, consider referring the patient elsewhere.
Mr Robert Macfarlane is a consultant neurosurgeon at Addenbrooke’s Hospital, Cambridge, and also provides expert reports for MDDUS
REFERENCES
Ahn UM, et al. Cauda equina syndrome secondary to lumbar disc herniation. A metaanalysis of surgical outcomes. Spine 2000; 25:1515-22
Chau AMT, et al. Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurgery 2014; 81:640-650
Todd NV. Cauda equina syndrome: the timing of surgery probably does influence outcome. British Journal of Neurosurgery 2005; 19:301-6
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