OrthoRevision Updates
For the interview, being well-versed in these guidelines not only ensures but also highlights your commitment to staying current in the field, and, most importantly, sets you apart from other interview candidates. Candidates should be aware of the Getting It Right First Time (GIRFT) initiative in February 2023, focusing on the management of suspected Cauda Equina Syndrome (CES).
The guidelines are quite lengthy, but included below are some key clinical summary updates. Important changes include the lack of need for a PR examination, MRI within 4 hours of onset of symptoms, and radiology reporting protocols.
Understanding the Rarity and Severity of CES
Cauda Equina Syndrome is a rare but serious spinal condition characterised by radicular and/or back pain. The updated GIRFT guidelines emphasise the rarity of CES (1 to 3 in 100,000 populations) and stress the need for immediate assessment, investigation, and treatment to prevent permanent loss of function.
Key Learning Points from GIRFT Guidelines
Definition and Rarity
CES is a rare but serious spinal condition presenting with radicular and/or back pain.
Incidence: 1 to 3 in 100,000 populations.
Immediate assessment, investigation, and treatment are crucial to prevent permanent loss of function.
Symptoms and Presentation
CES symptoms include radicular pain, back pain, bladder/bowel dysfunction, sexual dysfunction, and lower limb paralysis.
No single symptom or sign is definitive; clinical presentation varies.
Emergency Referral Criteria
Emergency referral is warranted for leg/back pain with recent onset or worsening symptoms, including difficulty initiating micturition, altered perianal/genital sensation, severe neurological deficit, and sexual dysfunction.
Warning Signs
Sudden onset bilateral radicular leg pain or unilateral leg pain progression may indicate CES and requires urgent referral.
Safety Netting
Patients with back pain and specific symptoms should be educated on when to seek urgent clinical opinion.
Warning card and video resources are provided for patient awareness.
Emergency and Urgent Referrals
Emergency referral to the nearest hospital with MRI for ongoing CES symptoms.
Urgent referral for sudden onset bilateral radicular leg pain or progression to bilateral without CES symptoms.
Emergency MRI within four hours of request for suspected CES.
Referral Documentation
Detailed documentation for emergency and urgent referrals, including assessment details, symptoms, and examination findings.
Digital rectal examination is not necessary for urgent referrals.
Bladder Scan
Bladder scan as an adjunct in CES assessment; not a standalone diagnostic tool.
Catheterisation may be needed based on post-void residual volume.
Imaging and MRI Protocol
Sagittal T2 weighted MRI sequence is crucial for screening.
Emergency MRI within four hours of request for suspected CES.
Additional images if CE compression identified; shorter sequences for patients unable to lie still.
MRI Reporting and Service Provision
On-call surgical teams can review out-of-hours MRI scans.
Radiology service should progress towards a 24/7 provision with a focus on CES cases.
Local protocols for rapid reporting to referring clinicians within one hour.
A roadmap for MRI service development, aiming for year-round provision, especially for emergency cases like CES.
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