Suspected Cauda-EquinaSyndrome: Moving the

Physiotherapy Consultation from Capability to

Competency

Elaine Buchanan, MSc MCSP

Consultant Physiotherapistelaine.buchanan@ouh.nhs.uk

A Sad Story

Persisting:

• Low Back Pain

• Ankle instability

• Perineal sensory loss:

• major sexual difficulties

Self- catheterises several times a day:

• Which she finds humiliating

• Recurrent urinary tract infections

• Attends continence service

Cauda Equina Syndrome

Depression:

• Feels inadequate as a wife and a woman

• Profound impact on relationship

• Medication

• Intense psychological support.

No longer participates in sport

Works part time

Cauda Equina Syndrome

Variable manifestation of:• Back pain with unilateral or bilateral leg pain

And one or more of the following

• Perianal/perineal sensory loss

• Bladder disturbance

• Rectal sphincter dysfunction

• Sexual impotence

and may also have lower limb weakness or sensory loss

Due to a number of conditions:

• Most commonly degenerative (disc herniation, canal stenosis)

• Other causes: neoplastic, infective, traumatic, vascular, iatrogenic, endocrine, biochemical, inflammatory, idiopathic, thrombotic, haemorrhagic.

Medico-Legal

One of the most commonly litigated diagnoses

– Failure to identify

– Failure to escalate

– Delay in management

Substantial costs are a reflection of the damaging and distressing nature of the condition.

The Solution

All clinicians across the back pain pathway are competent in the recognition and assessment of suspected Cauda-Equina Syndrome and that they make timely referral to a spinal surgical service who have the competency to provide timely investigation and decompression of the lumbar spine.

Relevance to Physiotherapy

Failure to identify

• Lack of knowledge of Cauda Equina Syndrome

• Failure to identify bladder, bowel dysfunction and perianal/saddle sensation

• Reliance on subjective information only

• Few MSK physiotherapists carry out objective assessment for suspected CES

• Symptoms and signs associated with CES change but are not always reviewed following the initial assessment

• Reliance of previous clinicians evaluation

Failure to escalate

• Lack of objective findings increases the risk of

• Missed diagnosis (CES:I)

• Emergency referral for CES:I not being accepted

Delay in management

• Referral to another medical clinician for objective assessment.

• End of day/Friday presentations

Physiotherapists Are Capable of:

Competency can be developed

Examination and assessment of the pelvic floor complexis within the scope of physiotherapy practice

•Taking a history

•Testing neurology

•Testing a muscle

Oxfordshire Musculoskeletal Triage Service2012 Training

Cauda Equina Syndrome

• Cause, clinical presentation

• Diagnostic groups: – CES: Retention– CES: Incomplete

• Prognostic significance of:– complete versus incomplete CES– sphincter involvement– sensory deficit

• Management of CES-R and CES-I

Significance of delays in diagnosis and surgical referral

Oxfordshire Musculoskeletal Triage Service2012 Training

Objective assessment skills:

• Informed consent for objective CES examination

• Chaperone policy

Testing: • Perianal sensation• Resting anal tone• Anal sphincter squeeze

Oxfordshire Musculoskeletal Triage Service2012 Training

Patient explanation:• CES

– Symptoms

– Prevalence

• Examination

– what needs to be tested

– why it is important

– consequences of lack of information and delay

Communication

Warning patients:

– What to do should symptoms develop

– Consequences of delayed management

– Immediate emergency visit

Patient information booklet

Concise case presentation

Oxfordshire Musculoskeletal Triage Service2012 Training

Paperwork:

• Patient completed screening form

• Suspected CES checklist

Skills to:

• Complete paperwork

• Interpret information

Support for clinical reasoning/advice

• Spinal Consultant Physiotherapist

• Spinal Extended Scope Practitioner

• On-Call clinicians

Trust Policies

• Consent policy

• Chaperone policy

• On-Call referral protocol

• Core competency for all MSK Physiotherapists in department

Trust Meetings:

Spinal Team Clinical Governance

Physiotherapy Clinical Governance

On-Call doctors Training

648

105

No CES Checklist

CES Checklist

MSK Triage: Case Note Review 2013

• 4/12 retrospective review of electronic case notes

• 753 back pain assessments

735

18

No on-Call referral

On Call referral

Volume of suspected CES consultations varies between clinicians

• CES Checklist used 14%

• 2.5% referred to spinal on-call service

Self Rated Competence

Competence

• Use of the CES checklist

• Diagnosis of CES

• Significance of delayed management

• Testing:

– Peri-anal sensation

– Anal tone

– Anal squeeze

• Making emergency on-call referral

Lacks competence/confidence

• Pelvic floor anatomy

• Prevalence of bladder/bowel disturbance in general population.

• Differentiating CES: incomplete from CES: retention

• What to do with a patient who does not wish to consent to objective examination

Conclusion

• Delays in management are a significant contributor to poor outcome in Cauda-Equina Syndrome

• Physiotherapists are capable doing a Cauda-Equina Syndrome assessment

• Competency can be developed