A Study Into the Use of Post-Void Bladder Scanning as Part of a Clinical Algorithm for the Assessment of Patients With Suspected Acute Cauda Equina Syndrome

All patients with suspected CES will be seen and assessed by a member of the on-call team i.e. either a spinal fellow, spinal SpR, orthopaedic SpR or junior doctor, on presentation. Clinical features will be documented and stored in the patient notes. This document will then be photocopied for use in the study. Digital rectal examination will be performed to assess anal sphincter tone, voluntary control (anal contraction) and sensation of sharp and light touch with a chaperone present. Those with abnormal perianal sensation will be admitted and referred for urgent MRI. (NB: For the purposes of this study, these patients will also undergo pre and post-micturition bladder scans in order to allow the correlation between perianal sensation and residual urine volume to be assessed thoroughly.)

Bladder scanning will be used to measure pre and post-micturition residual urine volume in patients with normal perianal sensation. The on-call spinal registrar, fellow or consultant will conduct the bladder scanning using the BARDSCAN IIs ultrasound device. Patients with residual urine volume greater than 100ml will be admitted and referred for urgent MRI. Patients with normal perianal sensation and residual urine volume less than 100ml however will be discharged and receive an MRI scan as an outpatient within 5 days of presentation. These patients will be advised that if there is any progression of their symptoms that they should re-attend hospital. Any patient who re-attends, whilst waiting for their out-patient MRI, will be admitted for an urgent MRI.

Assessment of patients unable to void following pre-micturition bladder scan will depend upon bladder volume. Those measuring greater than 100ml will be catheterised and sent for MRI, whereas patients with less than 100ml will be encouraged to try again in 1 hour. Patients who fail to void at this time will also be catheterised and sent for MRI.

Patient Follow-up All patients will be followed-up by the consultant responsible for their care. Patients operated on for confirmed CES will be seen in clinic at six weeks and six months following surgery (or as required). Patients who do not require surgery will be seen in the next available clinic (usually within two weeks). Any unfortunate patients who continue to experience bladder and/or bowel dysfunction as a complication of CES will be referred to urology, urogynaecology, neurology and/ or colorectal services as appropriate.

Data Synthesis, Management and Analysis A pro forma will be used to assess all cases of suspected CES. This will be completed as part of the initial assessment by a member of the on-call spinal team and stored in the patient's notes. Demographic data will also be collected. These documents will be photocopied from the notes and data transferred to an Excel spread sheet and stored on an RD&E NHS password protected computer. Hospital number will serve as the only patient identifier. Photocopies will be stored in the spinal research office, which will be locked when not in use. Data will be stored for ten years following the end of the study period before destruction.