Catherine Reilly reports on clinicians’ concerns about the HSE National Guideline for Cauda Equina Syndrome
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 the hospital network, senior clinicians have warned the HSE Chief Clinical Officer (CCO) Dr Colm Henry.
The HSE document was launched in May 2024. It is the first Irish national clinical guideline for CES. In a social media post marking its publication, Dr Henry stated the guideline would “impact significantly on patient outcomes”.
However, in the past year, senior figures in emergency medicine (EM) and hospital clinical directors have contacted Dr Henry to highlight its inoperability, according to correspondence released to the Medical Independent (MI) under Freedom of Information law.
The communications indicate the guideline may elevate rather than reduce clinical risk in the absence of dedicated implementation resourcing.
The extent of EM’s role in the assessment pathway has also been robustly challenged. EM doctors’ concerns relate to resource deficits, the impact on overall patient care, as well as the high medico-legal burden associated with CES.
Permanent disability
CES is a rare syndrome involving compression or damage to the lumbosacral nerve roots of the cauda equina. It can lead to severe disability, including permanent limb paralysis and loss of bowel, bladder, and sexual function. The HSE does not hold centralised data on annual case numbers.
Disc herniation (which can be acute or ‘acute on chronic’) is the most common cause. It can also arise due to compression of degenerative joints, tumours, infections, or bone fragments in fractures.
In addition to the severe personal impacts, the syndrome carries a high medico-legal burden. The State Claims Agency finalised 41 claims relating to CES between 2008 and 2018, resulting in paid damages of almost €21 million.
The ‘gold standard’ for definitive diagnosis is MRI scanning in conjunction with clinical evaluation (history and exam). The speed at which CES is diagnosed – and surgical treatment commenced – is critical to successful patient outcomes.
The HSE guideline aims to provide “evidence-based and consensus recommendations” for the index reviewing healthcare provider on the need for and timing of an MRI scan. It also provides guidance on “appropriate onward referral to specialist services and aims to streamline pre-transfer and pre-operative work up from the moment of the patients’ first presentation”.
The document sets out a pathway when a patient presents to an emergency department (ED) with back pain and a possible new neurological finding concerning for CES. It outlines ‘red flag’ symptoms that individually or in combination raise suspicion for CES and indicate the need for urgent MRI.
These include impaired perianal/perineal/saddle sensation; loss of sensation of bladder filling or micturition; loss of sensation of rectal fullness; new onset bilateral radicular pain; bowel or bladder dysfunction (ie, incontinence, retention or other disturbances of normal function); and bilateral leg symptoms with new neurology. It employs a SPRINT mnemonic (S-Saddle paraesthesia; P-new onset bilateral radicular Pain; R-Retention; I-Incontinence; N-New motor findings; T-Time for MRI).
The pathway describes the assessment process for “ED staff”. It proposes they use a SPRINT proforma for initial assessment, examination and documentation of same in the suspected CES patient, including stipulations for the measurement of post void residual on index review.
All cases of suspected CES “should have an urgent MRI scan”. While the guideline advises that the local orthopaedic referral unit must be informed to allow “urgent assessment”, the MRI should still be “arranged and followed up” by senior ED staff.
“MRI scans should be carried out in the referring unit where possible to minimise delays as well as unnecessary transfers.” Where possible, patients with MRI-confirmed CES should be referred via the local orthopaedic or neurosurgical service to a tertiary unit offering spinal decompression surgery.
The guideline acknowledges problems with MRI access. Hospitals will need to discuss with stakeholders how MRI can be facilitated outside “normal working hours”, it states.
Development
The HSE National Clinical Programme for Trauma and Orthopaedic Surgery (NCPTOS) led the guideline development process. A 12-person guideline development group included eight people representing trauma/orthopaedic surgery. Neurosurgery, emergency medicine, rehabilitation medicine, and radiology were each represented by one clinician.
A recent paper in European Spine Journal, authored by Irish trauma and orthopaedic specialists who developed the HSE guideline, provided some insight into its strong focus on EM’s role. The authors reviewed CES international guidelines and current evidence on assessment and early identification. They stated that international data showed the benefit of a pathway eliminating the need for involvement of spinal or orthopaedic services at an early assessment stage and which ‘empowered’ ED staff in early decision-making and discussion with local radiologists to expedite MRI scanning. “This in turn will allow for earlier and likely overall more appropriate referral to tertiary spinal services.”
MI understands the NCPTOS developed a business case to support 24/7 access to urgent MRI scanning in all trauma units. However, a HSE spokesperson provided no confirmation of dedicated funding.
“The guideline does not state there should be access to 24/7 MRI; additionally, out-of-hours provision of MRI is a local decision based on local resources and will need to be determined at site level,” according to the spokesperson.
Communications
This resource vacuum has led to numerous clinicians communicating with the CCO’s office.
In June 2024, the then Clinical Lead for the HSE National Emergency Medicine Programme (EMP) emailed Dr Henry to convey his and EM colleagues’ “deepest concern”. Dr Gerry McCarthy stated the detailed guideline pathways “can have no validity whatsoever in the current environment, where access to urgent MRI scan outside of usual working hours, even when a true spinal emergency such as CES is at issue, is nigh impossible in most EDs/hospitals in the country”.
He said EM clinicians felt they were being placed in an impossible position that would “certainly leave them vulnerable to criticism in future legal actions, given the distressing sequalae of cauda equina syndrome, even when treated on an urgent basis…”.
While the guideline was “largely clinically appropriate” Dr McCarthy expressed his and EM colleagues’ incredulity about the apparent inclusion of new onset unilateral radiculopathy as a standalone red flag requiring urgent MRI to rule out CES. Dr McCarthy stated this may be part of a “constellation” of symptoms pointing towards CES, rather than a standalone red flag. MI has established that the HSE uploaded two versions of the CES guideline to its website (one referencing “new radicular pain” as a red flag and the other “new onset bilateral radicular pain”). The HSE informed MI the finalised version includes new onset bilateral radicular pain among the red flags.
Dr McCarthy is listed as a member of the guideline development group. In his email to Dr Henry, he stated his input included one meeting with colleagues from the NCPTOS alongside the Dean of the Faculty of Radiologists. He said he had been advised that a business case relating to urgent MRI access had been submitted. The EMP had no hesitation supporting such a business case, with the understanding that networked access for local EDs/hospitals in cases of suspected CES would be realised.
The EM consultant outlined that he had been asked to review the completed guideline. He was “happy enough to endorse [the document], in the context of the unambiguous understanding that it could and would not be enacted until such facilitated access to MRI scanning had been achieved”. In conclusion, Dr McCarthy requested an “urgent” meeting with stakeholders to consider the “best way forward”.
In response, Dr Henry stated his belief that the guideline was a product of collaboration. It had passed through internal approval processes in his office. However, he stated implementation was “clearly dependent on ready, timely access to MRI”. He suggested a meeting with Dr McCarthy along with representatives of the NCPTOS.
In August 2024, the then Clinical Director of Dublin Midlands Hospital Group (DMHG), Prof Paul Ridgway, also cited difficulties implementing the guideline. In an email to Dr Siobhán Ní Bhríaín, who holds delegated responsibility for HSE national clinical programmes, Prof Ridgway stated that on weekdays hospitals could mostly manage out-of-hours cases with urgent MRIs first thing in the morning. However, most of the sites did not have MRI at weekends, especially following the withdrawal of radiology outsourcing. Delaying MRI until a Monday would represent a “significant individual clinical risk”.
Prof Ridgway said it was “custom and practice” that high-suspicion CES cases would be referred to the national spinal injuries unit (NSIU) at the Mater Misericordiae University Hospital (MMUH) in Dublin for out-of-hours MRI. He referenced an MMUH audit which found 14 per cent of all patients who had an out-of-hours MRI for suspected CES required surgical management. While he understood the need for the NSIU to manage demand, the weekend patient requiring MRI represented a “significant potential delay to surgery”.
“At present DMHG/Region B does not have such a unit and so with your permission I will continue to recommend to sites to advocate for transfer for MRI and specialist opinion in the NSIU as per custom and practice to date.”
IAEM
In early January 2025, the President of the Irish Association for Emergency Medicine (IAEM), Prof Conor Deasy, wrote to Dr Henry. He stated the IAEM would have to publicly disassociate EM from the guideline unless it was removed and a process instigated to develop a “deliverable” replacement.
As clinicians responsible for the initial assessment of patients with back pain in EDs, Prof Deasy stated “we clearly recognise the importance of having an
agreed evidence-based and properly resourced guideline”.
However, he believed the HSE guideline placed “completely unreasonable demands” on EM doctors without the required resources – particularly 24/7 MRI access. “It purports to make those in EM professionally and medico-legally accountable for care which is not deliverable by them currently in Ireland.”
The current document was “causing severe inter-professional conflict on the frontline and apparently placing all of us in EM at significant risk, adding to the already recognised pressure of the work, without any possibility of patient benefit”.
Dr Henry stated the NCPTOS and the EMP were being engaged on the matter.
It purports to make those in EM professionally and medico-legally accountable for care which is not deliverable by them currently in Ireland
‘Mitigation steps’
An inability to implement the guideline has continued to be communicated to
the CCO.
In January 2025, the Lead Clinical Director at Tallaght University Hospital (TUH), Dr Peter Lavin, advised that TUH had been “unable to adopt or adhere to” the guideline due to the lack of access to out-of-hours MRI at night and weekends.
The hospital had implemented internal mitigation steps, including ringfencing the first MRI slot in the morning from Monday to Friday for cases referred as possible CES from the ED.
Historically out-of-hours MRI access was provided by the MMUH, he explained.
“This required an Orthopaedic Surgeon in the Mater to accept governance for the patient while they underwent the MRI Spine examination. While some clinicians in the Mater Hospital have been open to supporting this arrangement, there is no formal protocol or SLA [service level agreement] describing this arrangement…. Some of the Orthopaedic Consultants in the Mater will only accept the referral from a Senior Orthopaedic Clinician rather than an ED clinician, leading to delays in performing the MRI.”
TUH had escalated its concerns via the former hospital group structure. More recently it had engaged with local management on the necessity for out-of-hours MRI and whether there was scope for a rotational involvement between centres.
With the current staffing level, it was “not possible” to extend MRI scanning on a 7/7 or 24/7 basis without “significantly impacting” on the ability to provide an MRI service within the working week. Such a move would have a “major adverse effect on patient flow and hospital occupancy levels”.
Dr Lavin stated there would be additional benefits for patient flow with a 7/7 MRI service as it would shorten the length-of-stay for some other medical patients.
“We would appreciate your support for provision of a 7/7 MRI service in TUH. We recognise that this would need to happen in an incremental fashion due to funding/staffing constraints.”
HSE response
The HSE informed MI: “Both the National Clinical Programme for Emergency Medicine and the National Clinical Programme for Trauma and Orthopaedic Surgery met recently and there is no disagreement of the merit of this guideline.”
The guideline is based on the NHS’s Getting it Right First Time Spinal Surgery: National Suspected Cauda Equina Syndrome Pathway and was devised in the “best interests of patients”.
The document was developed “collaboratively over a three-year period”. It was “endorsed unequivocally” by the RCSI Council and the HSE CCO Clinical Forum.
All HSE guidelines are “subject to review” based on stakeholder feedback. An amendment will be made to the pathway for new neurological findings ongoing for over two weeks that are not consistent with CES. Instead of an ED review, for some patients a review “in an alternative clinic” may be more appropriate.
A spokesperson for the MMUH said it follows the HSE guideline. There is currently no SLA in place for out-of-hours MRI provision for suspected CES. A recent audit showed 220 MRIs per annum were required out-of-hours for this group, with 32 per cent referred externally.
Ms Bairbre O Sullivan, Head of Services at Spinal Injuries Ireland, told MI referrals of people with CES to the organisation have increased significantly in recent years, though the reasons were unclear. There were 31 referrals last year.
“Our CES online chat group is the most attended out of all our different support groups. We’re not entirely sure what that indicates, but it does seem to be where people find the most support – perhaps reflecting the challenges that CES brings and the need for shared experiences.”
Ideally, hospitals would have structured emergency MRI pathways to ensure patients with suspected CES do not face unnecessary delays. “We also believe there’s a need for a national framework that improves CES management, particularly in the community, with stronger referral systems to include collaboration between stakeholders.”
Most service users have reported “delayed recognition” in general practice and EDs as the “main block” to diagnosis, according to Ms O’Sullivan.
“People have been sent home with paracetamol, despite having symptoms of CES such as numbness in the saddle area or bladder problems. As back pain is so prevalent, patients can find it difficult to get someone to take them seriously. It’s only if the clinician has a knowledge of CES that patients are treated as an emergency and referred for urgent MRIs.”
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