Implementation of a national clinical guideline for cauda equina syndrome improves referral quality and reduces delays to MRI.

Abstract

Background: Cauda equina syndrome (CES) is a neurological emergency with significant potential for permanent morbidity and medicolegal consequences. Timely MRI is essential, yet delays remain common. The Irish Health Service Executive (HSE) published a National Clinical Guideline for CES in June 2024. This study evaluates the impact of its introduction on referral quality and time to MRI in a tertiary, non-spinal centre.

Methods: A retrospective review of all suspected CES referrals from the emergency department to the orthopaedic department was performed over a 40-month period spanning guideline introduction (October 2022 to January 2026). Primary outcomes included triage-to-MRI and referral-to-MRI times. Secondary outcomes encompassed documentation of post-void residual volume (PVR), ASIA score, and red flag symptoms.

Results: 124 pre-guideline and 71 post-guideline referrals were included. Mean triage-to-MRI time decreased from 20.5 to 13.0 h (36.5% reduction; p = 0.017), with standard deviation falling from 16.2 to 7.7 h, indicating greater consistency. The proportion scanned within 24 h rose from 73.9% to 89.1% (p = 0.046). Referral-to-MRI time was substantially longer for out-of-hours/weekend referrals than in-hours referrals in both periods (pre-guideline: 20.3 vs 7.2 h; post-guideline: 12.1 vs 4.3 h). ED-initiated MRI prior to orthopaedic referral increased from 1.5% to 26.1. Documentation improved across all metrics, with ASIA score recording showing the greatest improvement.

Conclusion: Implementation of a national CES guideline significantly improved referral quality and reduced time to MRI. However, a persistent and clinically significant out-of-hours access gap highlights the need for dedicated overnight and weekend MRI pathways as a priority for future service development.