Abstract

ABSTRACT
Background and Purpose
Cauda Equina Syndrome (CES) is a rare but serious spinal condition requiring urgent diagnosis and management. Physiotherapists in UK musculoskeletal (MSK) services increasingly encounter suspected CES cases, but little is known about their clinical decision-making and referral practices. This study aimed to examine the clinical decision-making processes of UK physiotherapists when presented with three clinical vignettes of suspected CES and to identify themes in referral handover methods when emergency care is deemed necessary.

Methods
An online survey featuring three clinical case vignettes was distributed to UK physiotherapists. Respondents were asked about their referral decisions, clinical reasoning, and preferred methods of handover to Accident & Emergency (A&E) services. Thematic analysis was used to identify common clinical reasoning patterns and referral practices.

Results
The presence of altered bladder function was the strongest predictor of referral to A&E, consistent with previous literature. Sexual dysfunction was also a significant referral factor when present. Themes for not referring included recent A&E attendance, plans for in-clinic assessment, specialist consultation, and requesting urgent MRI scanning. A range of handover methods were reported, with written letters and direct phone calls being the most common. Variation in clinical decision-making was evident, particularly regarding timing and urgency of investigations, reflecting some uncertainty around guideline interpretation.

Discussion
Findings demonstrate variability in UK physiotherapists' approaches to suspected CES management, with some respondents opting for community assessment or delayed imaging despite CES's urgent nature. Findings emphasise the need for clearer, unified guidelines on referral pathways and handover methods to reduce delays and improve patient outcomes. Future research should explore the impact of recent guideline updates and include perspectives from other healthcare professionals involved in CES care.