I am walking-do I need an admission?: A new cauda equina integrated care pathway for ambulant patients

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Manish Desai

London Spinal Cord Injury Centre–Royal National Orthopaedic Hospital NHS Trust, UK

: J Spine Neurosurg

Abstract

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Introduction: Cauda equina syndrome (CES) is a potentially devastating event with life-changing long-term hidden neurological disabilities. This may be visible, such as impaired mobility, but will also involve invisible disability such as neuropathic pain, urogenital and bowel dysfunction, psychological sequelae, adjustment disorder, alongside vocational and relationship issues. Traditionally, paraplegic CES patients are referred for inpatient rehabilitation, whereas ambulant CES patients are treated as outpatients. This requires multiple separate referrals and appointments, usually over at least a year, with the risk of fragmented care and missed follow-up. To address this, we created an innovative integrated care pathway (ICP) for ambulant CES patients, for a three-week fast-track holistic inpatient rehabilitation programme. We are the first centre in the country to implement this. Aim: The aim of this study was to examine the effectiveness of the pathway, benefits to patients and outcomes of rehabilitation. Method: A 12 month prospective analysis of ambulant CES–ICP admissions was conducted. Results: Over 12 months, there were 19 CES–ICP admissions (59% male, age range 18–65). The most common aetiology was disc prolapse, followed by trauma and infection. Most patients had issues around spinal injury education (89%), bladder (89%) and bowel (100%) management, orthotics (74%), and psychological impact (79%) addressed during their admission. However, only around a third accessed the sexual function nurse specialist, and only two-thirds had a formal documented discussion around diagnosis and prognosis with a consultant. The rehabilitation outcomes in terms of bladder and bowel self management showed that all patients achieved safe and effective control. Conclusion: The CES–ICP is an innovative, holistic, inpatient rehabilitation programme with structured goals around patient education and self-management. This is particularly important for getting ambulant CES patients with invisible disability, back on track.

Biography

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Manish Desai is working as a Consultant in Spinal Injuries and Trauma Rehabilitation at the London Spinal Cord Injury Centre, Royal National Orthopaedic Hospital NHS Trust, Stanmore and the Wellington Hospital, London. His routine work involves specialist spinal rehabilitation of complex traumatic and non-traumatic spinal injuries in adult patients, management of complex spasticity with botulinum toxin injections, ITB, nerve blocks, osteoporosis, neuropathic pain, and musculoskeletal interventions. His ultimate aim is to make technological advances (robotics, exoskeletons, FES-functional electrical stimulation, and tetraplegic hand surgery) affordable and available to every spinal cord injured patient, to improve outcomes and reduce impairement. His special interests include “Malignant or metastatic spinal cord compression (MSCC), cauda equina syndrome and management of spinal injuries with polytrauma”. He has successfully developed a regional specialist spinal rehabilitation service for MSCC and cauda equina syndrome, at London Spinal Cord Injury Centre (SCIC). He is passionate about education in spinal cord injuries and has regularly contributed to the Spinal Injuries Association, London SCIC Spinal Injuries Study Day and British Society of Rehabilitation Medicine Spinal Injuries Study Day. He was recently awarded Fellowship (FRCP) by the Royal College of Physicians, London, and “The Best Services for Tetraplegia” award by Regain Sports Charity for Tetraplegics.