New pathway launched to diagnose Cauda Equina Syndrome without delay

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A new pathway is available to help clinicians better diagnose and treat patients suspected of having Cauda Equina Syndrome, a rare but serious spinal condition.

The pathway has been developed by Getting It Right First Time (GIRFT), a national programme within NHS England designed to improve patient care through service reviews and data-driven evidence.

What is Cauda Equina Syndrome?

Cauda Equina Syndrome (CES) is a rare but serious spinal injury. It is more often than not caused by a disc compressing the nerves found at the base of the spinal cord, however, it can also be caused by tumours, haematomas, trauma, infection or spinal/epidural anaesthetic.

It is not uncommon for people to suffer a ‘slipped disc’ in the lower part of the spine. Normally, the disc will bulge out to the left or the right, which irritates the root of the main nerve to the leg on that side of the body. This can cause pain (known as ‘sciatica’), altered sensation and sometimes weakness in the leg.

With Cauda Equina Syndrome, the disc bulges centrally rather than to one side. It can affect the buttocks and the area between the legs and can result in problems with bladder, bowel and sexual function.

Why is this new pathway needed?

This new route into care aims to help ensure patients receive appropriate care and diagnosis without delay. Unfortunately, Cauda Equina Syndrome symptoms are sometimes missed by medical professionals and diagnosed as a slipped disc. The diagnosis and treatment window for Cauda Equina Syndrome is small and without prompt treatment, it can be debilitating and permanent.

The new Cauda Equina Syndrome pathway follows recommendations from a GIRFT report on spinal services in 2019, highlighting that some patients with suspected CES were not being referred in line with agreed treatment protocols. The report recommended measures for Trusts to follow, including urgent referral by a senior decision-maker for an MRI in the hospital the patient attends.

The GIRFT pathway offers best practices along all stages of patient care, from an initial GP visit or conversation with a pharmacist to surgery. The pathway includes new advice about patient referrals (including recommendations about imaging), surgical techniques, pain relief and post-operative care.

The new CES pathway, developed by more than 60 health professionals, supports clinical teams to diagnose and treat Cauda Equina Syndrome without delay, to improve patient outcomes.

What are the key changes?

The key changes in diagnosing and treating Cauda Equina Syndrome under the new pathway include:

  • An emergency referral for an MRI scan within four hours for anyone presenting with leg pain and/or back pain with any ‘red flag’ symptoms. Where this is not possible (for example, if it is a local hospital without a 24-hour scanning facility), an urgent out-of-hours scan should be sought.
  • MRI scan images should be reviewed urgently, and this can happen without a referral to a radiologist for a radiology report if one is not available to ensure faster treatment.
  • If Cauda Equina Syndrome is confirmed, surgery must happen within 24 hours of MRI imaging.

What was the previous guidance for diagnosing Cauda Equina?

Before this pathway was implemented in 2023, clinicians were informed by NICE Guidelines, internal policies and general best practice guidance when diagnosing and treating CES. This led to an inconsistent approach to diagnosis and treatment which increased medical negligence claims.

What happens when Cauda Equina Syndrome isn’t treated quickly?

If symptoms of Cauda Equina are ignored, there is a high risk of permanent spinal injury and nerve damage.

If Cauda Equina Syndrome is misdiagnosed as sciatica or back pain, or there is a delay in diagnosing and treating it, the situation can deteriorate quickly. Once diagnosed, emergency surgery may be needed within 24 to 48 hours to relieve compression of the nerve. This gives the maximum potential for sensory and motor functions to improve, however, even with prompt treatment, some patients will still experience low back or leg pain, bladder or bowel issues and other physical problems.

If Cauda Equina symptoms are not followed up quickly enough, permanent and preventable injuries could occur, such as limited mobility, saddle and groin anaesthesia, permanent incontinence, sexual dysfunction, loss of sensation in the lower body, and even paralysis.

Red flag symptoms of Cauda Equina

Most episodes of back pain and/or sciatica will get better with time. Treatment is usually managed by GPs without the need for hospital referral. However, there are some ‘red flag’ symptoms that should not be ignored and require urgent treatment.

The red flag symptoms of possible Cauda Equina Syndrome include:

  • Pain radiating down one or both legs and/or severe lower back pain
  • Loss of feeling and/or pins and needles between your thighs or genitals
  • Numbness in or around your bottom
  • Increasing difficulty when trying to urinate or controlling urination
  • Loss of sensation when passing urine or having a bowel movement
  • Not knowing when your bladder is full or empty
  • Inability to stop a bowel movement
  • A change in the ability to achieve an erection or ejaculate
  • A loss of sensation during sexual intercourse

For a full list of symptoms, click here.


The GIRFT pathway is a positive step towards better outcomes for those with Cauda Equina Syndrome because it provides the much-needed consistency which has previously been lacking. As medical negligence solicitors, this consistency must be welcomed as it is likely to lead to improvements in patient care and the prevention of avoidable injury.

If you or a loved one has been diagnosed with Cauda Equina Syndrome, there are organisations that can help you adjust to your new way of life. One of these is Cauda Equina Champions Charity, a patient-led organisation that provides a range of services, including a helpline, an online support group, and psychological and psychosexual therapies.

You can also find some useful information on the Spinal Injuries Association (SIA) website; an organisation our medical negligence solicitors work closely with.

Further information

If you have suffered as a result of a delay in diagnosing Cauda Equina Syndrome, our medical negligence solicitors may be able to help you claim compensation. Whilst compensation cannot undo the damage this delay has caused, it can help fund any additional treatment or care you need, as well as compensate for lost or reduced earnings as the result of your spinal injury.

Call our friendly team for an initial chat on 0117 325 2929 or fill out our online enquiry form.


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