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ResearchAug 9, 2022

Research aims to identify 'best practice' in NHS responses to cases of cauda equina syndrome

Every NHS hospital will be asked how staff manage patients with cauda equina syndrome as part of a bid to highlight what constitutes best practice. Clinical lecturer David Metcalfe, who is based at the University of Oxford, will lead a study looking into the diagnosis of the spinal condition after being awarded an advanced fellowship worth more than £1 million from the National Institute for Health and Care Research.

Claire Thornber, founder of the Cauda Equina Syndrome Association, welcomed the announcement and looked forward to supporting the study: ‘We are reassured by these efforts to address the issues around cauda equina syndrome diagnosis, management and rehabilitation as so many patients are being lost in a system without pathways.’ 

The study could also have implications for the physiotherapy profession, as practitioners have faced legal action from patients seeking compensation over what they perceive to be shoddy treatment. The Chartered Society of Physiotherapy (CSP) has stated that settlements in such cases can reach £1 million or more.

Photo Credit: Shutterstock
Compensation packages have reached more than 1 million in CES cases, the CSP warns


Cauda equina syndrome is a spinal emergency and this project will help design services to achieve the best possible outcomes for this group of patients [David Metcalfe]

CSP 'learning from litigation' guidance

In guidance on cauda equina syndrome published in 2014, the CSP stresses that back pain is common, whereas cauda equina syndrome is rare. ‘Physiotherapists see many patients with back pain, a large number of whom may come directly to see a physiotherapist without seeing a doctor first,' it notes.

‘As autonomous and accountable diagnostic practitioners, physiotherapists of all levels of experience need to be able to identify those patients who need urgent medical review and act accordingly.’

The CSP’s ‘learning from litigation’ guidance warns that the basis for any claim is that a practitioner failed to examine the patient properly and did not act on so-called ‘red flags’. Physiotherapists may also be accused of having failed to refer the patient on or did not investigate with ‘sufficient urgency’.

‘This does not just affect doctors and surgeons,’ the guidance warns. ‘Physiotherapists have been found to be clinically negligent for failing to act and/or refer on when a patient presented with possible CES [cauda equina syndrome].’

The £1.23 million Cauda Equina Syndrome Early Recognition (CESER) study will have four phases

  • analysis of data from previous studies to identify symptoms that predict which patients have the condition
  • 2,000 patients with suspected cauda equina syndrome will be recruited to the study. They will be examined by a doctor and then receive an MRI scan, in a bid to show which symptoms help to identify patients who are given a final diagnosis of the condition
  • all NHS hospitals will be asked how they manage patients who might have cauda equina syndrome to identify differences and find examples of best practice
  • a range of stakeholders will review the evidence and help develop recommendations about the assessment and diagnosis of patients with suspected cauda equina syndrome


These studies will help provide high-quality care across the NHS for patients that might have cauda equina syndrome with a view to making healthcare more efficient ­– and so possibly cheaper – as well as reducing harm to patients, according to an article posted this week on a University of Oxford website (3 August). Dr Metcalfe, said: ‘Cauda equina syndrome is a spinal emergency and this project will help design services to achieve the best possible outcomes for this group of patients.’ 

Factfile (source: University of Oxford)

Cauda equina syndrome is caused when the nerves at the end of the spinal cord, collectively called the cauda equina, are compressed.

These nerves supply the legs, bladder, anus and sexual organs, and can be permanently damaged if compressed for too long.

Most patients with cauda equina syndrome require an emergency operation to take pressure off the nerves. 

To read more on the study on the University of Oxford website, visit: https://www.ndorms.ox.ac.uk/news/dr-david-metcalfe-awarded-a-nihr-advanced-fellowship?6d92640c-14e6-11ed-8463-065da278fd60

To read a recent PhysioUpdate article on the publication of a topical book on the syndrome – written by physios Tom Jesson and Rob Tyer – visit: https://www.physioupdate.co.uk/learning-zone/two-physiotherapists-write-book-tackling-the-notoriously-difficult-topic-of-cauda-equina-syndrome-/

 To read the CSP's 'learning from litigation' guidance, visit: https://www.csp.org.uk/system/files/learning_from_litigation_cauda_equina_syndrome.pdf

Author: Ian A McMillan
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