Title : Utilisation and diagnostic performance of the SuCCESS cauda equina triage tool in a UK District General Hospital (DGHs)
Abstract:
Background: Delayed diagnosis of Cauda Equina Syndrome (CES) in District General Hospitals (DGHs) remains a major cause of avoidable morbidity and litigation. Traditional "red flag" checklists perform poorly as standalone decision aids, and there is limited real rld evaluation of structured CES scoring systems in DGH settings. The Suspected Cauda Equina Syndrome Score (SuCCESS) is a recently proposed composite triage tool designed to ris ratify patients with suspected CES, with excellent sensitivity and negative predictive value reported in its original tertia ntre study, but utilisation and its implementation outside spinal units have not been described.
Objectives: To describe and evaluate utilisation and diagnostic performance of the SuCCESS score for all suspected CES cases in a UK DGH settting, using decompression nfirmed CES as the reference standard.
Methods: We performed a retrospective cohort study of adults presenting to the emergency department with suspected CES between 1 January 2024 and 31 December 2025. We included all patients in whom CES was considered in ED documentation or MRI requests and excluded cases without CES suspicion or metastatic spinal cord compression. Data were extracted from the electronic records like Gerner, Evolve and CareCentric, with imaging reviewed on PACS and neurosurgical clinic correspondence used to confirm urgent decompression. For each case, SuCCESS scores were reconstructed from all documented history and examination. The reference standard was decompression-confirmed CES, defined as urgent surgical decompression following MRI evidence of cauda equina compression and concordant clinicalfeatures, consistent with the original SuCCESS definition. Sensitivity, specificity, Positive Predictive Value (PPV) and NPV were calculated forthe prespecified SuCCESS threshold of 3.
Results: 31 O patients were included. 21 had decompression-confirmed CES (prevalence 6.8%). Mean age was 51 years (median 51, range 19-91); 187patients were female. ASuCCESS threshold of 3 identified 17 of 21 decompression-confirmed CES cases (true positives), with 4 false negatives and 92 false positives. This corresponded to sensitivity 81.0%, specificity 68.2%, PPV 15.6% and NPV 98.0%. These results contrast with the 100% sensitivity and NPV and 54% specificity reported in the original SuCCESS validation, suggesting reduced sensitivity but higher specificity in our DGH cohort.
Conclusions: In this DGH cohort, SuCCESS 3 demonstrated good rule-out performance (NPV 98.0%) but was less sensitive than in the original study, missing4 patients who required urgent decompression. The tool appears useful as a structured decision-support aid and to standardise CES assessment and referral but should not be used in isolation to decide on MRI acquisition. Prospective multicentre work is needed to refine thresholds, assess calibration in different settings and determine whether local recalibration can safely improve sensitivity.
