Award Title: The Cauda Equina Syndrome Early Recognition (CESER) Study: A mixed-methods study to improve diagnosis of cauda equina syndrome in the Emergency Department.
Funder: Department of Health and Social Care

Abstract: Background:Cauda equina syndrome (CES) describes the symptoms caused by compression of multiple sacral and lumbar nerve roots within the vertebral canal. It is a spinal emergency and often leads to irreversible life-changing disability. Delayed decompression is believed to worsen prognosis but the gold standard diagnostic tool (MRI scanning) is not always immediately available.Aim:The aims of this study are to (1) determine whether patients with suspected CES can be risk-stratified using clinical features, (2) report current outcomes for patients with suspected CES, (3) describe variation in pathway design across the NHS, and (4) make recommendations about the optimal design of clinical pathways for patients with suspected CES.Workstream 1:A systematic review of diagnostic studies will synthesise the existing literature and pool data using appropriate techniques for meta-analysis. This will determine to what degree clinical features can predict which patients with low back pain should undergo emergency MRI. Workstream 2:A multi-centre prospective cohort study will be used to evaluate the clinical features identified in Workstream 1 to determine whether or not they can be safely used to risk-stratify patients with suspected CES. This study will also describe variation in the management of patients with suspected CES (e.g. time to imaging, inter-hospital transfer, and decompression) as well as establish the prognosis of patients with CES and those whose symptoms are not explained by the initial MRI. A small subset of patients (30) will undergo qualitative interviews focussed on what is important to patients in relation to their experience of symptoms and health seeking activity, emergency care, diagnosis, treatment and early phase of recovery. Workstream 3:A facilities audit and care pathway mapping exercise will be undertaken using nominated clinicians at each acute NHS hospital. This will map CES pathways and protocols currently in use around the UK to identify unexplained variation and to highlight examples of innovative practice aimed at achieving prompt diagnosis. The different models of evaluating patients with suspected cauda equina syndrome will be categorised and evaluated for cost effectiveness using data from Workstream 2. Workstream 4:A structured guideline development exercise will be undertaken to consider the evidence from Workstreams 1-3 and establish recommendations around which local pathways and national guidelines can be developed. Impact:This programme will improve the assessment of individual patients and the design of clinical pathways for patients with suspected CES. It will therefore facilitate rapid diagnosis of patients with CES, improve patient outcomes, and reduce healthcare costs.

Lay Abstract: 'Cauda equina syndrome' describes symptoms caused by a disc from the spine pushing on the nerves at the end of the spinal cord. These nerves supply the legs, bladder, anus and sexual organs, and can become damaged if compressed for too long. Most patients with cauda equina syndrome require an emergency operation to take pressure off the nerves.Although lots of people attend Emergency Departments with back pain, very few have cauda equina syndrome. Unfortunately, cauda equina syndrome can be difficult to diagnose and we do not know whether any particular pattern of symptoms can help us rule out the diagnosis without a MRI scan. This is a problem as MRI scanning is not available in all hospitals at night and we know that some patients end up waiting too long before getting a diagnosis.This study will try to determine whether any pattern of symptoms can help us identify which patients are very unlikely to have cauda equina syndrome. It will also help determine how patients should be treated when they arrive at an Emergency Department with symptoms that could be caused by cauda equina syndrome.First, we will use data from previous studies to see whether these found that symptoms or signs on a physical examination can show which patients have cauda equina syndrome.Second, we will recruit 2000 patients into a study run across a number of different NHS hospitals. These patients will be examined carefully by a doctor before anyone knows the result of their MRI scan. We will then take the results of the MRI scan and look back to see whether any signs or symptoms were particularly helpful in working out which patients would end up with a final diagnosis of cauda equina syndrome. We will contact all patients at 6-weeks, 6-months, and 12-months to ask whether they still have symptoms. A smaller group of patients will be interviewed to learn more about their experiences of being assessed for cauda equina syndrome.Third, we will ask all NHS hospitals how they manage patients who might have cauda equina syndrome. This will help us determine where there are obvious problems or delays and major differences between hospitals. It will also help us identify hospitals that have found useful ways to diagnose cauda equina syndrome quickly. We will use this information, together with the data from the large study of 2000 patients, to estimate the cost effectiveness of different methods of managing patients with suspected cauda equina syndrome.Finally, we will ask a group of patients and professionals to consider all of this evidence and develop recommendations about how individual clinicians and the systems they work in should act when assessing a patient who might have cauda equina syndrome.These four studies have been designed to help all hospitals provide high-quality care across the NHS for patients that might have cauda equina syndrome. This should make healthcare more efficient (and so possibly cheaper) at the same time as reducing harm to patients.

Research Activity Codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health Categories: MUSCULOSKELETAL;NEUROLOGICAL