Clinical Guidance
National Suspected Pathway, Emergency & Urgent referral guidelines
Triage of the patient is the first step in this pathway. It is important to note that CES does not have a set clinical pattern; no single symptom or combination of symptoms has good diagnostic accuracy.
Additionally, negative physical tests do not rule out CES if positive subjective symptoms are present.
CES Symptoms less than two weeks, Emergency referral
An emergency referral to the nearest facility with Emergency MRI provision is warranted for a patient presenting with leg pain and/or back pain with a suggestion of recent onset (within 14 days) or deterioration of any of the following symptoms:
- Difficulty initiating micturition or impaired sensation of urinary flow;
- Altered perianal, perineal or genital sensation S2-S5 dermatomes – the area may be small or as big as a horse’s saddle (subjectively reported or objectively tested);
- Severe or progressive neurological deficit of both legs, such as major motor weakness with knee extension, ankle eversion or foot dorsiflexion;
- Loss of sensation of rectal fullness;
- Sexual dysfunction – inability to achieve erection or to ejaculate, or loss of genital sensation.
CES Symptoms more than two weeks and static, Urgent referral
The patient should be referred urgently (to be seen within two weeks) to the nearest MSK triage service if they present with:
- Sudden onset bilateral radicular leg pain (sciatica).
- Unilateral radicular leg pain that has progressed to bilateral without CES signs or symptoms.
- CES signs or symptoms over 14 days and are static and remain so.
Warning Signs
Sudden onset bilateral radicular leg pain or unilateral radicular leg pain that has progressed to bilateral leg pain (sciatica) may be a warning symptom that CES may occur.
Sudden onset bilateral radicular leg pain (sciatica) or unilateral radicular leg pain that has progressed to bilateral without CES symptoms requires urgent referral (two-week wait) to an MSK triage service.
Safety Netting
Safety netting for patients experiencing back pain with other symptoms is crucial to ensuring patients know how and when to seek help at the appropriate time.
A video and warning card from the Musculoskeletal Association of Chartered Physiotherapists (MACP) has been developed for a patient audience. This is also available on our website. It is accessible in 32 languages, and explains clearly when to access an urgent clinical opinion:
Making an emergency referral
The patient should be referred to the nearest hospital with emergency MRI facility (patient should attend hospital now) if they present with ongoing CES symptoms or signs which started within the last two weeks. An emergency referral after a telephone assessment identifying CES symptoms is acceptable if immediate face to face review is not possible or will delay referral. In many cases, patients will be seen in an Emergency Department (ED)
Referral Documentation
An emergency referral for suspected CES should document the following:
- Patient assessment details;
- Time and date of assessment;
- Examination findings;
- Physical examination of power and sensation in the lower limbs;
- Signs and symptoms of CES present including duration, frequency and progression;
- Who and at what time the case was referred to in secondary care;
- Recommended advice received and from whom if felt did not require emergency referral;
- a digital rectal examination is not necessary, but subjective perianal sensation should be recorded.
The patient should be provided with their clinical summary/pro-forma to take to secondary care if the referral is accepted.