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Suspected cauda equina syndrome — MSRA MCQ

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Moderateall topics relevant for this examSuspected cauda equina syndromeMSRA

A 44-year-old man presents with severe low back pain after lifting a heavy box 2 days ago. The pain now radiates down the posterior aspect of his left leg to the lateral foot. Since this morning, he has noticed numbness around the anus and genitals and says he cannot tell when his bladder is full, although he has passed urine twice without incontinence. He has no fever, weight loss, history of malignancy or intravenous drug use. Examination shows normal power at the hips, knees and ankles, symmetrical knee and ankle reflexes, and reduced pinprick sensation in the perineum. He is haemodynamically stable. What is the most appropriate management now?

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Correct answer: D — Refer immediately via the local emergency pathway for assessment for cauda equina syndrome

This presentation requires immediate referral for assessment for cauda equina syndrome (CES). The decisive features are severe low back pain with radicular leg pain plus new perineal sensory disturbance and altered bladder sensation. Urinary retention or overflow incontinence need not be established before referral: new perineal numbness alone in this clinical context meets the NICE threshold for immediate assessment via local pathways. A same-day community MRI may appear prompt, but it risks delaying emergency specialist assessment and is not the appropriate primary-care route when CES is suspected. Measuring a post-void residual volume can contribute to secondary-care assessment but must not be used to exclude CES or defer referral in a patient with saddle sensory change. A 2-week musculoskeletal pathway is appropriate for non-emergency radiculopathy, not new cauda equina features. Conservative treatment and physiotherapy are appropriate for uncomplicated sciatica but are unsafe here because delayed decompression in CES may lead to permanent bladder, bowel, sexual or neurological dysfunction. Normal limb power and reflexes do not negate the urgent significance of new perineal numbness and bladder sensory disturbance.

Reference: NICE NG127: Suspected neurological conditions: recognition and referral — Recommendations for adults aged over 16 (2019) — https://www.nice.org.uk/guidance/ng127/chapter/Recommendations-for-adults-aged-over-16