A service evaluation of the management of patients with suspected cauda equina syndrome from an outpatient physiotherapy service in the United Kingdom.

BACKGROUND: The expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources. AIM: To evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome. DESIGN: Service evaluation with an embedded case series of patients with radiological CES. METHOD: The records of patients who were identified by their outpatient physiotherapists as having suspected CES (n-231) over a 27-month period were included. Data was extracted from patients' medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series. RESULTS: In 79% of cases, it was decided that emergency referral was not required. The remaining 21% of patients were referred to the emergency department and 49% of these had an emergency MRI. In the case series of seven patients with cauda equina compression on MRI, four patients had a disc bulge and underwent emergency surgery. One patient had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis. Two patients had stenosis and decided against surgical intervention. CONCLUSIONS: Findings from this service evaluation suggest support for the use of safety netting and an effective communication chain to facilitate effective management of patients with suspected CES.

The complex problem of identifying serious pathology in Musculoskeletal care: Managing clinical risk during the COVID pandemic and beyond.

The expanding scope of physiotherapists has come with an increased level of responsibility to identify 'red flag' signs and symptoms. Red flags can indicate the presence of serious pathology but are notoriously unreliable. This leaves diagnosis heavily reliant on diagnostic investigations which are generally a finite resource within healthcare organisations. The COVID pandemic seems to have further compounded the problem and the possibility of 'missed' or 'delayed' diagnosis is ever-present. This may present a threat to patients' lives, to clinicians' careers and wellbeing, and to organisations' finances and reputations. Although clinical risk in musculoskeletal physiotherapy may never be eliminated, there are opportunities to work towards minimising it. This professional issue will explore the complex problem of identifying serious pathology in musculoskeletal care and will propose strategies to manage the associated risks during the COVID pandemic and beyond. A video abstract is included in Appendix A.

Physiotherapists' experiences of managing persons with suspected cauda equina syndrome: Overcoming the challenges.

INTRODUCTION: Cauda equina syndrome (CES) is rare, but its symptoms are not and musculoskeletal physiotherapists frequently encounter persons with suspected CES. Given that delayed diagnosis of CES can result in devastating consequences for affected persons and costly litigation for healthcare organisations, it is imperative that persons presenting with suspected CES are well managed. However, this may present a challenge to physiotherapists. Therefore, the aim of this study is to explore physiotherapists' experiences of managing persons with suspected CES. METHODS: Semi-structured interviews were conducted with musculoskeletal physiotherapists. Verbatim transcripts were analysed using an interpretive paradigm and thematic analysis. ETHICAL APPROVAL: Ethical approval was obtained from a university Ethics committee and NHS Research and Development. FINDINGS: Five interlinking themes emerged. The themes of worry in relation to risk management and communication difficulties seemed to represent significant challenges. The remaining themes were described as antidotes to these challenges: Lightening the load with teamwork and shared responsibility, the usefulness of a clear pathway and perception of improved confidence and competence with experience and training. DISCUSSION: The findings are discussed in the context of other literature, and practical recommendations are made relating to pathway implementation, team working, communication aids, training on CES and measures to care for staff wellbeing. CONCLUSION: Findings suggest that it is important to be aware of and address the challenges faced by physiotherapists in order to care for clinicians' wellbeing and ensure a safe and smooth journey for persons with suspected CES. Summary Video: https://www.youtube.com/watch?v=lIHqCKIQ1jk&t=90s.