Same Day Emergency Clinic (SDEC) Cauda Equina Syndrome (CES)

This information is for patients who have been referred to to be seen in the Same Day Emergency Care (SDEC) department.

This is in the Brunel building of Southmead hospital, Gate 36, Level 1. This is for investigations to rule out acute Cauda Equina Syndrome (CES), which may be one of the causes for your symptoms.

What is CES?

CES is caused by compression of the nerves travelling down the central spinal column of your lumbar spine (lower back), which control your legs, bladder, bowel, and sexual function. Disc prolapse or degenerative changes can put pressure on these nerves and may require urgent surgical intervention if you have new (acute):

Numbness/altered sensation in the buttocks, inner thighs, genital/saddle (bottom) area which is new or not normal for you.
Pain in the lower back and legs, with or without leg weakness and numbness, which is severe or getting worse.
Sudden difficulty with bladder or bowel function, including loss of feeling and control (incontinence), not being able to pass, or have the urge to pass urine (retention) which is not normal for you.
Loss of sexual function/feeling, which is not normal for you, including (for men) an inability to achieve erections or ejaculation.

CES is a relatively rare but serious condition, affecting between 1-3 in 100,000 people. This is just 2–6% of all lumbar disc problems which require surgery.

Urgent diagnosis is extremely important so we can treat it as soon as possible. We know that earlier surgery is associated with better outcomes, particularly when symptoms are recent onset and progressive (new and getting worse).

Most surgeons prefer to carry out surgery as soon as it is safe.

What happens when I come to the SDEC?

Before you have arrive to SDEC you will have already been assessed by a clinician. This may be your GP, the physiotherapist, or emergency department clinician.
Your assessment will have met the criteria to rule out CES and you will have been referred to the emergency Neurosurgery service for an MRI of your lumbo-sacral spine (lower back). The MRI scanning unit is located at Gate 19 on Level 2. Once you have had your MRI, you will be asked to return to SDEC Gate 36, Level 1.
After your MRI, the SDEC team managed by nurses will contact the on-call neurosurgery registrar to review your referral and MRI scan with the report.
Whilst awaiting the MRI report, we may ask for a pre- and post-void bladder scan which will require you to tell the SDEC nurses before and after you pass urine.
If there is no evidence of cauda equina compression following assessment of your case the Neurosurgery registrar will tell the SDEC nurses by phone after discussing with the on-call consultant. You will be discharged with relevant advice.
If there are any concerns identified, the Neurosurgery registrar will see you in person to discuss options. You may be asked to only drink clear fluids until then in case you need urgent surgery.

Reason for urgent surgical intervention may include:

True cauda equina compression.
Nerve root compression which may be causing foot drop.

What is an MRI scan?

An MRI scan is a way of assessing the space around your nerves of your lower back. It requires lying flat for approximately 30 minutes in a scanning unit.

Please tell the MRI radiographer and the SDEC team if you have any of the following:

A permanent pacemaker.
Any surgical clip inserted in a previous operation or procedure.
Ever had a metallic foreign body in your eye.
Severe claustrophobia or inability to lie flat.

Will I need any other tests?

As part of this assessment, and depending on your symptoms, you may require a scan of your bladder. This is an ultrasound scan where gel is applied to your lower abdomen to assess your bladder.

Measurements need to be taken both before and after you go to the toilet to empty your bladder (pee). Therefore, please try not to pass urine until you have your assessment. If you need to use the toilet before your assessment, please speak to one of the nursing staff.

If I don’t need an operation, why do I still have pain and what do I do next?

Pain can be caused by degenerative changes to the spine that are not always seen on the MRI scan. This may cause you to experience abnormal sensory changes, low back spasm, foot weakness and even bladder, bowel problems and erectile dysfunction in men. Without nerve compression shown on the MRI, surgery will not be required.

In these cases, we will advise you see your GP for a pain review and consider stronger pain killers and referral to MATS (Musculoskeletal Assessment and Treatment Services) for further treatments.

Stronger pain killers such as amitriptyline, gabapentin, pregabalin that work specifically on nerves, should be started by a clinician who can monitor your progress and side-effects. SDEC will be able to provide simple pain killers and laxatives to prevent constipation.

The SDEC is only able to diagnose or rule out CES which is a neurosurgical emergency. If this is ruled out, you will be asked to see the GP to consider other diagnoses that may cause referred back/leg pain (e.g. abdominal/pelvic pathology).

What happens if I get worse when I go home?

If you develop any new symptoms when you go home, please seek urgent medical advice as the assessment done in the SDEC does not exclude future problems. It is important you seek advice urgently (within 24 hours of onset) if you develop:

New leg/foot weakness.
Bowel/bladder problems not related to severe levels of pain (new incontinence, inability to start or stop void, new urinary retention, or constipation unrelated to medications)lower back pain with buttock or leg pain that is getting worse.
New sensory changes affecting your buttock (bottom), for example you cannot feel when wiping.
New loss of sexual function or feeling during sex.

Whilst you are in severe pain, please avoid strenuous levels of exercise, heavy weightlifting, long distance running that may make your pain worse and make you prone to injuries. Gentle exercises and physical activity are encouraged as reduced mobility may make your symptoms worse.

Is there anything else I should be aware of?

Whilst attending SDEC please do not have anything to eat and only have clear fluids until the neurosurgery registrar and the SDEC nursing team have discussed your case. This is in case you require any form of anaesthetic for an operation to relieve any pressure on your nerves.

Please consider any additional arrangements that may need to make such as childcare, contacting your work or family whilst you await your assessment, investigations and results.