The Suspected Cauda Equina Syndrome Score (SuCESS): Development and Validation of a Clinical Triage Tool
Vaishnavi Sharma1, Elie Najjar1, Rodrigo Muscogliati1, Shahbaz Khan1
1Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Objective:
To develop and validate a bedside clinical triage tool SuCESS (Suspected Cauda Equina Syndrome Score) to safely rule out Cauda equina syndrome (CES) and improve accuracy of CES detection.
Background:
Cauda equina syndrome (CES) is a serious spinal emergency. Yet, over 80% of urgent MRIs for suspected CES show no compression, creating strain on imaging services and delaying care. Thus, we conducted this study to develop and validate a besdside clinical triage tool.
Design/Methods:
We retrospectively derived SuCESS using 259 patients referred to a UK tertiary spinal unit (2016–2018). Six variables—saddle anaesthesia, reduced perianal sensation, motor weakness, bilateral sciatica, bladder post-void residual volume (PVR), and urethral catheterisation—were identified through logistic regression, random forest, and XGBoost, then combined into an eight-point score. Penalised regression reduced overfitting. External validation was performed in two independent cohorts from 2020 and 2023 (n = 444). Primary outcomes were sensitivity and negative predictive value (NPV) for surgically confirmed CES. Model performance was evaluated with area under the curve (AUC), Brier score, calibration, and decision curve analysis.
Results:
At a threshold of ≥3.0, SuCESS achieved 100% sensitivity and 100% NPV across all cohorts, identifying all 64 confirmed CES cases. Specificity rose from 37% in the development cohort to 54% in validation. AUC improved from 0.70 to 0.85, with Brier scores improving from 0.26 to 0.13. Use of the score could have safely deferred 38.7% of urgent MRIs, based on bedside data alone.
Conclusions:
SuCESS is the first validated CES triage tool to demonstrate perfect sensitivity. It provides a pragmatic framework for reducing unnecessary MRI requests while maintaining diagnostic safety in spinal referrals.
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