Editorial
British Association of Spine Surgeons standards of care for cauda equina syndrome

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Introduction

In 2012, the annual general meeting of the British Association of Spine Surgeons (BASS) gave overwhelming support to the proposition that the society should produce documents describing what it believed to be the best management in aspects of spinal pathology. In particular, it was considered important that any such documents should be completely independent of any other organization. It was decided that the initial project should be to produce guidelines for the standard of care for patients with possible cauda equina syndrome (CES). This was chosen because of an overwhelming impression among the membership that some patients may well be suffering from this condition because of delayed diagnosis and subsequent surgery. It was also considered that the evidence available to determine best practice was insufficient to refute the a priori argument that the earlier a compressed nerve root is decompressed, the more likely it is to recover function. At the same time, in the absence of better evidence, we consider a genuine consensus of members of our society to be valuable.

Neurosurgical members of our society directed us to a document published in 2009 by the Society of British Neurological Surgeons entitled, “Standards of Care for Established and Suspected Cauda Equina Syndrome.” This formed the starting point for our own document which we thought needed to be more dogmatic if it was going to have any chance of helping patients. We were particularly keen that the document should help assist colleagues in primary and secondary care access magnetic resonance image (MRI) scanning. We were very aware that as specialist practitioners, we have a very low threshold for investigating patients with back pain in association with any form of urinary disturbance. It seems paradoxical that less specialist practitioners should have to be more dependent on clinical diagnosis but that they will be heavily criticized if they make a mistake. We are also aware that the strength of document we produced would lie with it being accepted by the spinal surgical fraternity. For this reason, the document was pasted on our society forum, and all further posts were responded to.

We hope that we have produced a document that is in the best interests of the patients potentially affected by this devastating condition. We now need to consider how to promote our opinion and consider the implications for service provision. Our ambition is to work with colleagues in other specialties (eg emergency medicine, GP's etc) to collect data on all patients presenting with potential CES secondary to compression. If we can collect these data on the national spinal registry, it should give us information on the positive predictive value of symptoms and signs.

We are grateful to all those who have contributed to the evolution of this document.

Section snippets

Background

Cauda equina syndrome is a relatively rare but very disabling condition. It causes misery to affected patients, which is reflected in the cost of managing the disability and litigation that results from it. It is possible that a proportion of established CES may be avoidable with appropriate and timely management. We have produced these guidelines to try and improve the care for patients with this condition.

Definitions

A patient presenting with acute (de novo or as an exacerbation of preexisting symptoms)

Summary of feedback from members via discussion forum on the BASS Web site

The aforementioned guidelines were drawn up by the BASS executive committee (2012–2014) after a fair amount of discussion. This was presented to the BASS membership at the Annual General Meeting at BritSpine 2014 at Warwick. The consensus was to publish the guidelines on the discussion forum of the BASS Web site for opinion from the members. Over the 6-month period, the important themes from the subsequent discussion are summarized in the following section.

In patients with unequivocal clinical

Commentary on the guidelines from a medicolegal perspective

These guidelines reflect the evidence base. The clinical diagnosis of CES lacks sensitivity and specificity; no symptom or sign, including direct rectal examination, allows us to diagnose or exclude CES unless and until the lesion is severe and often irreversible [1], [2], [3], [4]. Emergency MRI is part of the triage of the suspected CES patient; MRI should ideally be performed in the district general hospital.

We have learnt to dichotomize the CES patient by the extent of neurologic deficit

Summary

This group of articles looks at the BASS guidelines for CES. TG and AC gave us the background on the long journey taken in publishing this, SA summarized the forum discussion on the BASS Web site, and NT gave us a medicolegal comment.

The guidelines are concise, highlighting the need for prompt MRI scanning and as a consequence emergency surgery in appropriate cases. This has resource implication in terms of MRI availability and a comprehensive spinal on-call system. The question of whether

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FDA device/drug status: Not applicable.

Author disclosures: TG: Nothing to disclsose. SA: Others: Depuy Synthes (D, Fund a fellowship for the Unit), Nuvasive (E, Fund a fellowship for the unit); Personal Fees: Globus Medical (B, Consulting fee for convening a course in 2013, B, Consulting fee for teaching on a course in 2012). ATHC: Nothing do disclose. NVT: Nothing to disclose. AR: Nothing to disclose.

The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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