HSE cauda equina guideline ‘unworkable’ without wider MRI access

The HSE National Clinical Guideline for Cauda Equina Syndrome (CES) cannot be implemented due to poor out-of-hours access to magnetic resonance imaging (MRI) across hospitals, senior clinicians have warned the HSE Chief Clinical Officer (CCO) Dr Colm Henry.

The HSE document was launched in May 2024. It is first Irish national clinical guideline for suspected CES, which is a rare but serious spinal surgical emergency. The ‘gold standard’ for definitive diagnosis is MRI scanning in conjunction with clinical evaluation.

In some hospitals, the ‘custom and practice’ has been to refer suspected cases requiring urgent out-of-hours MRI to the Mater Misericordiae University Hospital, Dublin, where the national spinal injuries unit is based. 

However, the HSE guideline states that MRI “should be carried out in the referring unit where possible to minimise delays as well as unnecessary transfers”. The scan should “ideally be ordered, discussed, and followed up by a senior decision-maker in the presenting emergency department”.

It is understood the HSE National Clinical Programme for Trauma and Orthopaedic Surgery (NCPTOS) – which led the guideline development process – submitted a business case to support enhanced access to urgent MRI.

In June 2024, the then Clinical Lead for the HSE National Emergency Medicine Programme (EMP), Dr Gerry McCarthy, informed Dr Henry the guideline pathways “can have no validity whatsoever” in the current environment where access to urgent MRI out-of-hours “is nigh impossible in most emergency departments/hospitals”.

In correspondence dated December 2024, the President of the Irish Association for Emergency Medicine, Prof Conor Deasy, informed the CCO the guideline “purports to make those in emergency medicine professionally and medico-legally accountable for care which is not deliverable by them currently in Ireland”.

In January 2025, the Lead Clinical Director of Tallaght University Hospital, Dr Peter Lavin, contacted the CCO to advise the hospital could not adhere to the guideline without additional infrastructure.

A HSE spokesperson said “out-of-hours provision of MRI is a local decision based on local resources and will need to be determined at site level”.

The guideline was developed “collaboratively” and there was “no disagreement” between the NCPTOS and the EMP on its “merit”. See news feature.