One of the most important considerations from a legal point of view is the status which the pathway may have in terms of representing best practice, and whether deviating from it will be regarded as representing sub-standard care of cauda equina syndrome. Guidelines are rarely regarded as definitive in determining whether there has been breach of duty, but such a carefully researched piece of work as this, deriving from many contributors, is likely to carry great weight in the courts.
A second consideration is the treatment of bilateral sciatica. Bilateral sciatica was added to the NICE guidance as a “red flag” symptom” of CES in amended guidance in 2018, and that guidance suggested emergency referral was mandated if such red flag symptoms suggested CES or another serious underlying cause, but only urgent referral (within two weeks) if red flags exist in the absence of neurological dysfunction. The new pathway is not inconsistent with the NICE guidance, but is clear in stating that sudden onset bilateral radicular pain (bilateral sciatica) should lead to urgent referral within two weeks rather than emergency referral.
The guidance is slightly at odds with GP Notebook, a guide to best practice used by many GPs, which does appear to mandate emergency referral for bilateral sciatica. It is not entirely clear where the pathway now leaves us on bilateral sciatica, but it feels as though its importance as a standalone symptom has been somewhat downgraded.
Is a ‘subjective’ complaint of saddle numbness enough?
The fact that the pathway does not mandate digital rectal examination is important, in the context of the point made by Mr Morris about subjective loss or change of sensation in the saddle area.
Legal practitioners specialising in CES will be very familiar with arguments about signs versus symptoms, and the objective lack of signs such as loss of anal tone trumping subjective complaints of numbness. It seems that now subjective numbness ought to be treated as a genuine red flag sign, without corroborating evidence from examination, which may prove to be very important in the context of litigation.
On a similar note, Mr Morris makes the important point that the size of the area of numbness, or change of sensation, should not be a factor in rating its significance as a symptom, and that this too may play a role in determining the outcome of litigation.
Bladder screening – a welcome clarification
Mr Morris also makes a highly relevant point about the status of bladder scanning.
Patients with suspected CES are often given ultrasound scans of the bladder before and after passing urine, with diagnostic significance being placed upon the level of urine remaining post-voiding.
The pathway makes it clear that a post-void residual volume of less than 200 ml does not exclude CES, and Mr Morris notes that this is a very important statement, given that some emergency departments have used such an outcome as a way of excluding a CES diagnosis. That should no longer be regarded as good practice, which may again be an important factor in litigation.
An update to red flag guidance
The very comprehensive list of red flag symptoms listed by the pathway is also to be welcomed, since it is more comprehensive than the list contained in the NICE Guidance or in the Oxford Handbook of Emergency Medicine.
The list of red flag symptoms in the pathway will be used as the benchmark for the quality of safety-netting advice given to patients with sciatica, going forward, and will become an important document to consider in “failure to warn” cases.
Two-week triage – is it the right cut-off point?
Claire Thornber has expressed concern above that defining the need for emergency treatment by recent onset of symptoms (within two weeks) is dangerous. A survey of the charity’s membership suggests that the onset of bladder symptoms is often significantly more gradual, more often extending over two months. Claire is concerned that this particular criterion may lead to patients needing emergency treatment being wrongly triaged into the less urgent pathway.
On the other hand, Pip White seems confident that the musculo-skeletal practitioners charged with caring for the ”less urgent” group are highly qualified to do so, and can triage and refer back into the emergency pathway as required. Claire’s preference for a four-week criterion may find favour as the pathway evolves in the future.
Four hours to MRI – possible at present?
The pathway recommends that an MRI scan should be performed as soon as possible, “and certainly within four hours of request to radiology”. This is a recommendation which is probably out of kilter with the realities on the ground, in the present context of the availability of MRI scanning facilities.
Undoubtedly in cases which I see in my practice, the delay in performing an MRI scan may be much longer than four hours, and sometimes longer than 12 hours. The pathway also proposes that local provision for a 24-hour MRI scanning facility should be in place by June 2024. Further, the pathway states: “Where this is not possible currently, a standard operating procedure in conjunction with local spinal and radiology services should be in place describing the local pathway for urgent out of hours scanning”. Again, in terms of litigation, such a standard operating procedure will be a very important document in helping to determine liability.
Finally, the pathway provides important guidance for the catheterisation of patients prior to surgery, noting that patients with more than 600 ml in their bladder who are unable to void require catheterisation, and the need for TWOC (trial without catheterisation) post-operatively. This has importance in the context of litigation as urine retention can in and of itself cause permanent bladder injury, and such cases are not uncommon.