Pathway supports clinicians to diagnose and treat Cauda Equina Syndrome without delay

A new pathway helping clinicians to better diagnose and care for patients suspected of having a rare and serious spinal condition is now available from the Getting It Right First Time (GIRFT) team.

Cauda Equina Syndrome (CES) is a spinal surgical emergency which can lead to lower limb paralysis and loss of bowel, bladder and sexual function if not assessed and treated urgently. The condition affects 1-3 people per 100,000 population in England and there are around 8,000 suspected cases every year.

GIRFT has worked collaboratively with a multidisciplinary group of more than 60 health professionals to develop a new interactive pathway for those patients with suspected CES, designed to support clinical teams to diagnose and treat the condition without delay and improve patient outcomes.

The pathway offers best practice along all stages of the patient pathway, from presentation to their GP or in the community, to presentation at hospital and diagnosis, to surgery and on to post-operative care. It is supported by detailed guidance for suspected Cauda Equina Syndrome, outlining when and how to carry out stages of the pathway, including best practice for referrals and imaging, surgical techniques, pain control and other post-operative support.

GIRFT is now planning a webinar (2nd March 2023, 1pm-2.15pm) to discuss the stages of the pathway and to allow clinicians to ask questions.

Speakers include:

  • Mike Hutton, GIRFT clinical lead for spinal surgery
  • Andrew Bennett, NHS England’s national clinical director for musculoskeletal conditions
  • Chris Mercer, consultant physiotherapist at University Hospitals Sussex NHS Foundation Trust
  • David Metcalfe, clinical lecturer in emergency medicine at University of Oxford
  • Rachel Watt, MRI radiographer representing the Society and College of Radiographers (SCoR)
  • David Cumming, NHS England’s national clinical director for neurosurgery and spinal surgery.


The pathway for suspected CES supports implementation of a key recommendation in the GIRFT national specialty report for spinal services (2019), which highlighted that some patients with suspected CES are not being referred for onward care in line with agreed treatment protocols. It recommended measures to support trusts to follow British Association of Spinal Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) guidance on the management of patients with suspected CES, including urgent referral by a senior decision-maker to a 24-hour MRI scanning service performed locally in the hospital of presentation, ensuring no delay.

The GIRFT report also showed that more than 20% of litigation claims for spinal surgery in England relate to CES (based on claims 2013/14 to 2015/16). It is hoped the creation of a standardised pathway will both improve patient care and help to reduce litigation costs.

The pathway comes in response to recommendations set out by the Healthcare Safety Investigation Branch (HSIB) 2021 investigation into the safety risks of suspected CES patients. HSIB recommended a national CES pathway which defined the safety-critical areas and enabled teams to further develop the pathway locally.

It is released on the same day as the Clinical Imaging Board’s guidance MRI provision for Cauda Equina Syndrome, demonstrating close alignment with the CIB’s partners, the Royal College of Radiologists (RCR) and Society and College of Radiographers (SCoR). It was developed in collaboration with the former Best MSK Health improvement programme and is co-badged by 11 professional bodies representing clinicians and patients*.

Mike Hutton, GIRFT’s clinical lead for spinal services and author of the 2019 GIRFT national report, said: “Our GIRFT review found considerable variation in the way suspected CES was diagnosed, as well as in access to MRI out of hours and access to emergency operating lists.

“I am delighted to have collaborated with such a wide cross-specialty group of professionals to define this best practice pathway and guidance, to ensure we are working collectively to improve care for this group of patients.

“We have put patients front and centre in recommending standards for this potentially devastating condition. I strongly believe that, once implemented, this pathway will reduce patient harm.”

*The GIRFT national pathway for suspected CES is co-badged by:

  • British Association of Spine Surgeons
  • British Association of Urological Surgeons
  • British Orthopaedic Association
  • British Society of Skeletal Radiologists
  • Cauda Equina Champions Charity
  • Chartered Society of Physiotherapy
  • National Spine Network
  • The Royal College of Radiologists
  • The Society of Radiographers
  • Society of British Neurological Surgeons
  • Spinal Injuries Association

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