SRS293 - Too many cooks? The impact of multiple reviews on Cauda Equina pathway delays

Cauda equina syndrome (CES) is an orthopedic emergency. The common causes of CES are intervertebral disc prolapse and traumatic injuries of the spine. We report an unusual case of vertebral endplate erosion into the spinal canal leading to CES. We report a 37-year-old male patient who had a history of low back pain radiating to both the legs for 1 month. He was receiving treatment at a local hospital. He presented to our emergency department with the inability to stand, walk, or void for 1 day. Radiographs and magnetic resonance imaging confirmed CES due to intervertebral disc prolapse. Our patient's diagnosis of vertebral endplate extrusion was made intraoperatively when the extruded material was found to be hard in consistency, and histopathological analysis confirmed the diagnosis. A diagnosis of vertebral endplate causing CES has been reported only in adolescents but never in adults. Preoperative computed tomography scans can help in easy diagnosis.

A prospective, observational cohort study. The aim of this study was to determine the role of pre and postvoid bladder scan in predicting cauda equina syndrome (CES). The thesis was that bladder scanning [specifically postvoid residual (PVR) volume] would have higher diagnostic accuracy than physical examination alone. CES is an ill-defined condition with a spectrum of presenting symptoms. There is neither a combination of clinical symptoms and/or signs that reliably predicts cauda equina compression nor single defining clinical criterion that has 100% predictive value to confirm or exclude CES. Patients with suspected CES admitted over a 6-month period at a single institution were prospectively assessed by physical examination (including digital rectal examination and pin prick perianal sensation) and bladder ultrasound scanning (recording pre- and PVR volume). These results were compared with the subsequent magnetic resonance imaging (MRI) scans and those patients who had emergent surgery for CES. Ninety-two patients were included in the study (52 women) with a mean age of 44.9 years.An MRI scan demonstrating causing compression of the cauda equina was present in only 18% (17/92).The sensitivity of anal tone to predict CES was 52.9%. Peri-anal numbness (either unilateral or bilateral) had sensitivity of 82.3% and negative predictive value of 92%.For nonoperated group (without CES), mean PVR was 199 mL (95% confidence interval ± 59 mL). On the basis of receiver operating curves, the optimal bladder volume cut-off for predicting CES was ≥200 mL for PVR volume. A PVR of <200 mL gave CES probability of 3.6%. If >200 mL, then the probability of having CES is 43% (P < 0.000003). A PVR <200 mL had a negative predictive value of 97%. Bladder scanning was a useful adjunct in the diagnosis of CES. It had a better negative predictive value than physical examination. 3.

Cauda equina syndrome is a rare, severe spinal condition requiring urgent evaluation and co-ordinated care. This article addresses educational priorities and care practices for nurses managing cauda equina syndrome, based on a survey of patients with the syndrome. The aim was to review literature, Getting It Right First Time guidelines, Freedom of Information surveys, and a patient survey conducted by support group Cauda Equina Spinal Cord Injury regarding bladder and bowel dysfunction following cauda equina syndrome diagnosis and surgery. Delays in diagnosis, variations in care and unmet patient needs were researched. An anonymous online survey, including multiple choice and open-ended questions, was developed and hosted on the Enalyzer platform from 11 August to 3 September 2023. The online survey collected data on diagnosis, management and quality of life for those living with cauda equina syndrome. Participants were recruited via a members-only Facebook page. Data from 137 responses was collected and analysed. This article integrates Getting It Right First Time national reports, Freedom Of Information responses from NHS trusts and published literature, highlighting roles for nurses and specialist services. Responses indicated diagnostic inconsistencies, low adoption of the cauda equina pathway, and suggested that there had been significant impact on patients' bladder, bowel and sexual function, as well as mental wellbeing. Nurse-led specialist services, improved training in neurogenic management, guideline adherence, clear referral pathways and patient information are recommended.

Background Cauda equina syndrome (CES) is a rare but serious condition caused by compression of the lower spinal cord. Early recognition and prompt intervention are essential to prevent irreversible neurological damage. Delays in diagnosis or treatment can lead to permanent disability and may result in significant medicolegal consequences. Aim The aim of this quality improvement project (QIP) was to identify areas for improvement in the diagnosis of CES and update local guidelines in line with the Get It Right First Time (GIRFT) recommendations. Methods and Results This retrospective study, conducted according to GIRFT guidelines, examined patients admitted to the District General Hospital Emergency Department with suspected CES. A total of 37 patients—8 males (21.6%) and 29 females (78.4%)—were assessed over a six-month period from January to June 2023. Patients without CES listed as a differential diagnosis were excluded. Data collected included documentation of neurological examinations, post-void residual scans, perianal sensation assessments, MRI request and completion times, and length of stay. Findings were presented at the Trauma and Orthopedics mortality and morbidity meeting. Overall, 89.19% of MRI scans were completed within 24 hours of request, while 10.81% exceeded this timeframe. Notably, 57% of patients did not undergo a comprehensive neurological examination on admission. Following these findings, a CES proforma was introduced to standardize the assessment process. In the subsequent cycle, documentation improved significantly, demonstrating the effectiveness of the intervention. Conclusion This QIP highlighted key areas requiring improvement, particularly the inconsistent completion of neurological examinations and delays in MRI access for suspected CES cases. Collaboration with the Emergency Department and radiology services led to the implementation of a CES assessment proforma, ensuring timely and consistent evaluation of patients. This structured approach supports earlier diagnosis, aligns with GIRFT standards, and enhances the quality and safety of CES management within our hospital.

Cauda equina syndrome (CES) is a rare clinical entity with an incidence of two per million people annually [1]. Symptoms and signs are very variable. Amongst them are severe low back pain, bilateral or unilateral sciatica, saddle anaesthesia, motor weakness, sensory deficit, and bladder and bowel dysfunction [1, 2]. None of these features has a high predictive value for CES in its own right, and many are common complaints with a variety of possible causes [3]. A high level of suspicion for CES is needed in any clinician who may come across it. Unfortunately, CES is all too often mis-managed [4, 5], resulting in not only devastating consequences for the patient’s quality of life, but also a disproportionately high medico-legal profile and significant risk of litigation [3, 6]. CES is a true spinal surgical emergency which, if untreated, may progress to paraplegia and/or permanent incontinence [2]. Debate as to the optimum timing for decompressive surgery, where cauda equina compression is the cause, is ongoing [2, 7], but prompt diagnosis is mandatory. Although magnetic resonance imaging (MRI) scanning is the diagnostic tool of choice [3], the percentage of patients being scanned for a clinical diagnosis of CES and in whom a compressive lesion is found on imaging is only 22 % [8]. It is important, therefore, to keep an open mind as to the aetiology of the patient’s symptoms. A thorough history and examination should underpin the diagnostic process and should guide further investigation, particularly in those patients whose lumbar spine MRI scans are unremarkable. We present two cases of aortic occlusion mimicking compressive CES that presented to our unit.

To compare the neurological and functional outcomes of early versus delayed surgical decompression in patients with cauda equina syndrome (CES). Descriptive study. Place and Duration of the Study: Department of Neurosurgery, Medical Teaching Institution, Mardan Medical Complex, Mardan, Pakistan, from June 2020 to May 2025. Adult patients diagnosed with CES who underwent surgical decompression were included. Patients were categorised into the early decompression (ED) group (≤48 hours from symptom onset) and the delayed decompression (DD) group (>48 hours from symptom onset). Neurological function was evaluated using the Modified Frankel Scale (MFS) at presentation and at 12-month follow-up. The primary outcome was bladder function recovery, and secondary outcomes included neurological improvement (≥1-grade improvement on the MFS) and the resolution of saddle paraesthesia. The Fisher's exact test was used for statistical analysis. Thirty-six patients were included (mean age: 34 years; 66.7% male). CES with urinary retention (CES-R) was spotted in 77.8% of the cases. The most frequently involved levels were L5-S1 (55.6%) and L4-L5 (44.4%). Early surgery was performed in 15 patients (41.7%), while 21 (58.3%) underwent delayed surgical decompression. At one-year follow-up, persistent bladder dysfunction was distinctly lower in the ED group (13.3%) compared to the DD group (47.6%; p = 0.040). Saddle paraesthesia was more common in the DD group, without any statistical significance. Overall, 88.9% of patients displayed improvement of ≥1 Frankel grade, and most regained independent ambulation. Early surgical decompression within 48 hours of symptom onset is linked with significantly better bladder and neurological outcomes in CES. Systemic delays in diagnosis and referral highlight the urgent need for national CES protocols and efficient referral pathways in resource-limited settings.

Cauda Equina Syndrome and Decreasing Opioid Requirements

Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. The study confirms the low predictive value of 'red flag' symptoms and signs. Of note 'bilateral sciatica' had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed 'low-risk' of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677-682.

Despite the awareness and familiarity of almost every medical professional with the cauda equine compression syndrome (CES), risk factors for a poor prognosis of the disease remain elusive. Even the relationship between subsequent outcome and the time elapsed from the time of appearance of symptoms to surgery taking place remain obscure. The aim of our study, therefore, was to analyze a relatively large population of our own patients studied consecutively, to identify outcome predictors for CES and to propose a clinical score for CES symptoms (Berlin CES score). We screened the hospital's electronic database retrospectively for patients admitted with CES between 2001 and 2010. Since our hospital is a superregional trauma center with standardized emergency room procedures, all patients included in the study underwent the same routine. Using baseline data, we analyzed the following parameters: duration of symptoms, period of time between diagnosis and imaging, respectively, surgery; pre- and postoperative pain, motor deficits, reflex changes, urinary and bowl dysfunctions, reduced anal wink, saddle anesthesia, genital or perianal sensations and residual urine. The semi-quantitative assessment of the neurological outcome was performed by application of the Berlin CES score. Surprisingly, we were not able to identify any single parameters that could reliably predict the outcome of the disease. We were able to show statistically significant correlations between a high preoperatively Berlin CES score (i.e., a weighted summation of bladder dysfunction, rectal dysfunction, genital sensation, perianal sensation, rectal tone and saddle anesthesia) and a poor outcome regarding the postoperative existence of perianal (p<0.001) and genital (p=0.001) hypoesthesia, as well as reduced rectal tone (p=0.0047). There was no significant interference of bladder or bowel function. Further analysis, in which we considered the time between diagnosis and surgery, revealed that both patients operated within 24h and after 48h could benefit from the intervention. Consequently, we were not able to show a correlation between speed of surgical treatment and outcome. Although we analyzed a relatively large cohort, we were not able to identify single parameters that were capable of reliably predicting the outcome of patients with CES. Nonetheless, we were able to show that consideration of multiple parameters of symptomatology would enable an improvement in making a prognosis. In conclusion, we propose establishing a simple semi-quantitative clinical score of the main symptoms of CES.

Priapism, a symptoms of claudication of the cauda equina in spinal stenosis

A prospective patient's database operated on a cauda equina syndrome (CES). The aim of our study was to identify prognosis factors for favorable functional recovery after CES. CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery. One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted. The patients were young with a median age of 46.8 years (range 18-86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery. CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.Level of Evidence: 4.

Introduction: In clinical practice, it is required that a profession not only clearly describe their own roles and responsibilities to other professionals but should also be aware of other professions’ roles in relation to their own. The objective of this study was to assess the perceptions of physicians and allied health care workers (Other health care professionals) of the roles of pharmacists in optimizing care for schizophrenic patients.&#x0D; Methods: A self-administered 17-item validated questionnaire was distributed to 120 health care professionals working at Federal Neuro-Psychiatric Hospital Maiduguri from September to October 2016. Results obtained were analysed using Chi-square test.&#x0D; Results: Health care professionals mostly had positive perceptions with a statistically significant difference (P&lt; 0.05) across all assessed items. However, competent and knowledge of the pharmacists accounting for 93 (83.8%), involvement of the pharmacist in patient care accounting for 91(82%) and reassuring patients to improve quality of life accounting for 98(88.3%) had the highest number of health care professionals with positive perceptions while documenting patient care, monitoring and reemphasizing physicians instructions had the lowest accounting for 69 (62.2%), 74(66.7%) and 74 (66.7%) respectively in the different sections.&#x0D; Conclusions: The health care professionals surveyed mostly had positive perceptions. Thus, pharmacists can leverage on this to meet their roles in optimizing care for schizophrenic patients.&#x0D; Bangladesh J Medicine Jan 2019; 30(1) : 19-23

Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache.

The cauda equina is a collection of peripheral nerves in the common dural sheath within the lumbar spinal canal. Cauda equina syndrome, also known as bilateral acute radicular syndrome, usually is caused by a large, sequestered acute disc rupture at L3-4, L4-5, or L5-S1 that produces partial or complete lesions of the cauda equina–lower motor neuron lesions associated with flaccid paralysis, atrophy, and other conditions. Patients usually present with a history of back symptoms that have worsened precipitously. The syndrome includes back pain, bilateral leg pain, saddle anesthesia, bilateral lower extremity weakness, urinary bladder retention, and lax rectal tone. Cauda equina syndrome is rated using Diagnosis-related estimates (DRE) lumbosacral categories VI or VII. Category VI, Cauda Equina–like Syndrome Without Bowel or Bladder Signs, is used when there is permanent bilateral partial loss of lower extremity function but no bowel or bladder impairment. Category VII, Cauda Equina Syndrome with Bowel or Bladder Impairment, is similar to Category VI but also includes bowel or bladder impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) uses the term cauda equina syndrome with reference to both the thoracolumbar and cervicothoracic spine regions; this usage is unique to the AMA Guides but maintains the internal consistency of the Injury Model, which is the best approach to date for assessing spine impairment.

Obesity and spinal epidural lipomatosis in cauda equina syndrome