# Enhancing Clinical Documentation and Management of Cauda Equina Syndrome: The Development and Impact of a Structured Assessment Proforma

## TL;DR

A structured assessment tool improved documentation and reduced delays in managing cauda equina syndrome, a serious spinal condition requiring urgent surgery.

## Contribution

A custom-designed proforma was developed and shown to significantly enhance clinical documentation and reduce referral delays for cauda equina syndrome.

## Key findings

- Perianal pinprick testing improved from 24% to 88% after implementing the proforma.
- Bladder function documentation increased from 62% to 98%.
- Referral delays for urgent surgical intervention were reduced by seven hours.

## Abstract

Background

Cauda equina syndrome (CES) is a neurosurgical emergency associated with potentially devastating neurological sequelae and significant medico-legal implications. Timely surgical decompression is critical; however, effective management relies on precise documentation of clinical findings. In many settings, documentation of key neurovascular assessments remains suboptimal. This study aimed to evaluate and improve the quality of clinical documentation in suspected CES cases by implementing a structured assessment proforma, thereby facilitating timely and accurate clinical evaluation, expediting neurosurgical referral, and mitigating legal risks.

Methodology

A retrospective review was conducted to compare documentation practices in 50 patients with suspected CES before and 50 patients after the introduction of a custom-designed proforma in the Trauma and Orthopaedic Department. Documentation was evaluated for the following nine key parameters: clinical history, motor examination, sensory examination, bladder function, bowel function, reflexes, perianal pinprick test, sexual dysfunction assessment, and radicular pain. Referral times for urgent surgical intervention were also recorded.

Results

Implementation of the proforma significantly improved documentation rates. Perianal pinprick testing increased from 12 (24%) cases pre-proforma to 44 (88%) cases post-proforma. Bladder function documentation improved from 31 (62%) cases to 49 (98%) cases, and sexual history documentation increased from six (12%) cases to 46 (92%) cases. Among patients requiring urgent surgical intervention, the time from referral to definitive management was reduced by an estimated seven hours. Eight urgent cases were identified pre-proforma, compared to five post-proforma.

Conclusions

The structured assessment proforma significantly enhanced the completeness of neurovascular documentation and streamlined the management of suspected CES cases, resulting in a notable reduction in referral delays for urgent intervention. Adoption of such a proforma may improve diagnostic accuracy, expedite neurosurgical referrals, and reduce medico-legal risk.