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Angus M, Heal C, Mcdonough R, Currie V, Mcdonough A, Siddique I, Horner D. Patients returning to the emergency department with symptoms of cauda equina syndrome: do the symptoms differ with radiological cauda equina compression? Br J Neurosurg 2024:1-4. [PMID: 39210555 DOI: 10.1080/02688697.2024.2396948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The guidance for clinicians on who requires further investigation when suspecting cauda equina syndrome has become clearer in England following the publication of the national recommendations. This does not have specific advice for those patients who have had recent imaging with no compression, returning to a healthcare provider with a change in symptoms. These cases can cause difficulty for clinicians with limited access to imaging who can often be reassured by previous imaging. METHOD This study presents a retrospective review of the case notes of 45 patients presenting on two occasions to the same Emergency Department who underwent magnetic resonance imaging due to the clinical diagnosis of cauda equina syndrome. Those with compression of the cauda equina on the second visit were compared to those without a compressive cause for their symptoms. RESULTS Patients presenting with an increased number of clinical symptoms associated with cauda equina syndrome on their return visit were more likely to have compression of the cauda equina on imaging. CONCLUSION The small numbers in this study would suggest caution, however, if patients present with an increasing number of symptoms further imaging should be considered, even with previous reassuring scans.
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Affiliation(s)
- Michelle Angus
- Department of Spinal Surgery, Manchester Centre for Clinical Neurosciences, Salford, UK
| | - Calvin Heal
- Division of Population Health, The University of Manchester, Manchester, UK
| | - Rebecca Mcdonough
- MCAS St Helens Community Health Services, Merseycare NHS Foundation Trust, UK
| | - Vicki Currie
- Emergency Department, Salford Care Organisation, Northern Care Alliance, Salford, UK
| | - Andrew Mcdonough
- Orthopaedic Department, Salford Care Organisation, Northern Care Alliance, Salford, UK
| | - Irfan Siddique
- Department of Spinal Surgery, Manchester Centre for Clinical Neurosciences, Salford, UK
| | - Daniel Horner
- Emergency Department, Salford Care Organisation, Northern Care Alliance, Salford, UK
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Mavroudis I, Kazis D, Kamal FZ, Gurzu IL, Ciobica A, Pădurariu M, Novac B, Iordache A. Understanding Functional Neurological Disorder: Recent Insights and Diagnostic Challenges. Int J Mol Sci 2024; 25:4470. [PMID: 38674056 PMCID: PMC11050230 DOI: 10.3390/ijms25084470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/10/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Functional neurological disorder (FND), formerly called conversion disorder, is a condition characterized by neurological symptoms that lack an identifiable organic purpose. These signs, which can consist of motor, sensory, or cognitive disturbances, are not deliberately produced and often vary in severity. Its diagnosis is predicated on clinical evaluation and the exclusion of other medical or psychiatric situations. Its treatment typically involves a multidisciplinary technique addressing each of the neurological symptoms and underlying psychological factors via a mixture of medical management, psychotherapy, and supportive interventions. Recent advances in neuroimaging and a deeper exploration of its epidemiology, pathophysiology, and clinical presentation have shed new light on this disorder. This paper synthesizes the current knowledge on FND, focusing on its epidemiology and underlying mechanisms, neuroimaging insights, and the differentiation of FND from feigning or malingering. This review highlights the phenotypic heterogeneity of FND and the diagnostic challenges it presents. It also discusses the significant role of neuroimaging in unraveling the complex neural underpinnings of FND and its potential in predicting treatment response. This paper underscores the importance of a nuanced understanding of FND in informing clinical practice and guiding future research. With advancements in neuroimaging techniques and growing recognition of the disorder's multifaceted nature, the paper suggests a promising trajectory toward more effective, personalized treatment strategies and a better overall understanding of the disorder.
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Affiliation(s)
- Ioannis Mavroudis
- Department of Neuroscience, Leeds Teaching Hospitals, NHS Trust, Leeds LS2 9JT, UK;
- Faculty of Medicine, Leeds University, Leeds LS2 9JT, UK
| | - Dimitrios Kazis
- Third Department of Neurology, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Fatima Zahra Kamal
- Higher Institute of Nursing Professions and Health Technical (ISPITS), Marrakech 40000, Morocco
- Laboratory of Physical Chemistry of Processes and Materials, Faculty of Sciences and Techniques, Hassan First University, Settat 26000, Morocco
| | - Irina-Luciana Gurzu
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania (A.I.)
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, Alexandru Ioan Cuza University of Iasi, Carol I Avenue 20th A, 700505 Iasi, Romania
- Center of Biomedical Research, Romanian Academy, Iasi Branch, Teodor Codrescu 2, 700481 Iasi, Romania
- Academy of Romanian Scientists, 3 Ilfov, 050044 Bucharest, Romania
- Preclinical Department, Apollonia University, Păcurari Street 11, 700511 Iasi, Romania
| | - Manuela Pădurariu
- “Socola” Institute of Psychiatry, Șoseaua Bucium 36, 700282 Iasi, Romania;
| | - Bogdan Novac
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania (A.I.)
| | - Alin Iordache
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania (A.I.)
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O'Connor L, Egan J, McGuire BE. " It's changed forever": the lived experience of sexuality and sexual functioning in women with cauda equina syndrome (CES). Disabil Rehabil 2024:1-7. [PMID: 38497669 DOI: 10.1080/09638288.2024.2330665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 03/09/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE To explore women's lived experiences of intimacy, sexuality and sexual functioning in the context of cauda equina syndrome (CES). METHODS Ten women completed an in-depth semi-structured interview exploring the psychosocial impact of CES on their sexuality and data were analyzed using Interpretative Phenomenological Analysis (IPA). RESULTS One superordinate theme was generated: "Sexuality forever altered, it's changed completely," reflecting the enduring impact of CES on women's sexuality. Five subordinate themes emerged reflecting a range of changed roles and relationships, primarily associated with loss of sexual identity and a sense that health professionals did not prioritize sexual functioning (1): Loss of worth as a sexual being: "Feel like a nothing" (2) Relationships have changed: "It's not a meeting of equals anymore" (3) Lack of professional support: "We don't like to talk about anything below the waist" (4) Challenges for motherhood: "What kind of future will they have with a mother like me…" and (5) Finding ways of coping: "Closed the door on it." CONCLUSION Findings highlight the detrimental effect of CES, directly and indirectly, on women's sexuality. There is a need for a multidisciplinary approach to address the physical, emotional, cognitive, and behavioural effects experienced in relation to sexuality as part of a rehabilitative process.
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Affiliation(s)
- Laura O'Connor
- School of Psychology & Centre for Pain Research, National University of Ireland Galway, Galway, Ireland
| | - Jonathan Egan
- School of Psychology & Centre for Pain Research, National University of Ireland Galway, Galway, Ireland
| | - Brian E McGuire
- School of Psychology & Centre for Pain Research, National University of Ireland Galway, Galway, Ireland
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Todd NV. Bladder ultrasonography in the assessment of cauda equina syndrome in the emergency department: a literature review. Ann R Coll Surg Engl 2024; 106:9-12. [PMID: 37051769 PMCID: PMC10757877 DOI: 10.1308/rcsann.2022.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 04/14/2023] Open
Abstract
For cauda equina syndrome (CES), current clinical assessment in the emergency department usually involves perianal sensation (PAS) and anal tone (AT). Neither reliably predict magnetic resonance imaging (MRI) demonstrating a large central disc prolapse (MRI+). Other clinical examination findings increase the probability of MRI+. Other tests of sacral nerve root function include anal squeeze (AS) and the bulbocavernosus reflex (BCR). If BCR, PAS and AT, and AS are combined and they are all normal, CES can be excluded in almost all cases. Portable bladder ultrasonography is now commonly used to assess bladder function, particularly in measuring the post-void residual urinary volume (PVR). PVR is deemed normal at <50ml. If the PVR is <200ml and there are no objective signs, MRI+ is rare. If the PVR is >200ml, MRI+ is found in 43% of cases. The combined assessment of PAS, AT and AS (and BCR in selected cases) and PVR increases the specificity and sensitivity of a clinical diagnosis of CES (i.e. maximising MRI+ and minimising MRI-). Recommendations for when to perform MRI are made.
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Affiliation(s)
- NV Todd
- Nuffield Health Newcastle-upon-Tyne Hospital, UK
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Carle-Toulemonde G, Goutte J, Do-Quang-Cantagrel N, Mouchabac S, Joly C, Garcin B. Overall comorbidities in functional neurological disorder: A narrative review. L'ENCEPHALE 2023:S0013-7006(23)00086-6. [PMID: 37414721 DOI: 10.1016/j.encep.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION The importance to assess and include the frequent comorbidities in the personalised care management plan of patients with functional neurological disorders (FND) has arisen through the years. FND patients are not only complaining from motor and/or sensory symptoms. They also report some non-specific symptoms that participate to the burden of FND. In this narrative review, we aim to better describe these comorbidities in terms of prevalence, clinical characteristics and their variability depending on the subtype of FND. METHODS The literature was searched for on Medline and PubMed. The search was narrowed to articles between 2000 and 2022. RESULTS Fatigue is the most common symptom reported in relation to FND (from 47 to 93%), followed by cognitive symptoms (from 80 to 85%). Psychiatric disorders are reported in 40 to 100% FND patients, depending on the FND subtype (functional motor disorder [FMD], functional dissociative seizures [FDS]…) but also on the type of psychiatric disorder (anxiety disorders being the most frequent, followed by mood disorders and neurodevelopmental disorders). Stress factors such as childhood trauma exposure (emotional neglect and physical abuse predominantly) have also been identified in up to 75% of FND patients, along with maladaptive coping strategies. Organic disorders are commonly reported in FND, such as neurological disorders (including epilepsy in FDS [20%] and FMD in Parkinson's Disease [7%]). Somatic symptom disorders including chronic pain syndromes are frequently associated to FND (about 50%). To be noted, recent data also suggest a high comorbidity between FND and hypermobile Ehlers Danlos Syndrome (about 55%). CONCLUSION Put together, this narrative review highlights the high burden of FND patients, not only due to somatosensory alterations but also by considering the frequent comorbidities reported. Thus, such comorbidities must be taken into consideration when defining the FND personalised care management strategy for the patients.
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Affiliation(s)
| | - Julie Goutte
- Internal Medicine Department, Saint-Etienne University Hospital, Saint-Priest-en-Jarez, France
| | | | - Stéphane Mouchabac
- Sorbonne University, Department of Psychiatry, AP-HP, Saint-Antoine University Hospital, Paris, France
| | - Charlotte Joly
- Neurology Department, Assistance Publique-Hôpitaux de Paris, AP-HP Avicenne University Hospital, Bobigny, France
| | - Béatrice Garcin
- Neurology Department, Assistance Publique-Hôpitaux de Paris, AP-HP Avicenne University Hospital, Bobigny, France
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Kimber D, Pigott T. Cauda equina screening in Physiotherapy: A qualitative study of physiotherapists in a community musculoskeletal service: Are we asking the right questions and are we asking the questions right? Musculoskelet Sci Pract 2023; 65:102773. [PMID: 37201228 DOI: 10.1016/j.msksp.2023.102773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/11/2023] [Accepted: 05/03/2023] [Indexed: 05/20/2023]
Abstract
Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition. Thirty physiotherapists working in a community musculoskeletal service were purposively sampled and participated in semi-structured interviews. Data was transcribed and thematically analysed. All participants routinely asked bladder, bowel function and saddle anaesthesia screening questions although only 9 routinely asked about sexual function. Whether questions are asked in the correct way has never been studied. Sufficient depth of questioning, using lay terminology and explicit language was achieved by two-thirds of participants. Less than half of the participants framed the questions before asking them and only 5 participants combined all four dimensions. Whilst most clinicians felt comfortable asking general CES questions, half reported feeling uncomfortable when asking about sexual function. Issues around; gender, culture and language were also highlighted. Four main themes emerged from this study; i) Physiotherapists ask the right questions but frequently omit sexual function questions, ii) mostly, Physiotherapists ask CES questions in a way that patients understand however, there needs to be improvement in framing the context of the questions, iii) Physiotherapists generally feel comfortable with CES screening but there is some awkwardness surrounding discussion of sexual function and iv) Physiotherapists perceive there to be barriers to effective CES screening caused by culture and language.
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Affiliation(s)
- Damien Kimber
- MSK Service, Birmingham Community Healthcare NHS Trust, 1 Priestley Wharf, Holt Street, Aston, Birmingham, B7 4BN, UK.
| | - Tim Pigott
- Trauma & Orthopaedics, University of Salford School of Health & Society, The Crescent, Salford, M5 4WT, UK
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Zhang Y, Dai Z, Zhao T, Tian J, Xu J, Zhang J. Publication Trends and Hot Spots in Cauda Equina Syndrome: A Bibliometric Analysis and Visualization of Current Research. World Neurosurg 2023; 173:115-121. [PMID: 36754352 DOI: 10.1016/j.wneu.2023.01.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cauda Equina Syndrome (CES) is a relatively uncommon and complex disorder. Recently, there has been a surge in research on CES. Although the research directions are multifarious, the overall research trends are unclear at present. We aimed to identify the 100 most cited articles on CES and analyze the hot spots trends regarding CES related research by bibliometric analysis. METHODS Articles were obtained by conducting an English language search of the Web of Science Core Collection Databases with the keywords "cauda equina syndrome." The initial 390 articles returned from the search were analyzed by VOSviewer. Next, the top 100 most cited articles were further analyzed by title, authors, journal, year of publication, total citations, country of origin, institution, and keywords. RESULTS A total of 390 publications were identified. The top 100 most cited articles were listed in descending order of total citations (range: 196-11). These articles originated from 24 countries; among these countries, the United Kingdom contributed the most publications (n = 29). The most prolific journal was Spine (n = 27), and the University of Edinburgh was the most productive institution (n = 9). CONCLUSIONS The number of publications on CES increased steadily, with a stable rise in recent years. Some publications have been cited more than 100 times, indicating that these findings are widely accepted by relevant clinicians and contribute significantly to the knowledge of CES. This study represents the first bibliometric analysis and visualization of hot spots analysis and research trends on CES. We believe that this will aid clinical researchers in targeting future areas of research.
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Affiliation(s)
- Yaping Zhang
- General Office of the Administration, Zhejiang Provincial People's Hospital, Hangzhou, China; Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China
| | - Zhanqiu Dai
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China; Department of Orthopaedics, The Second Affiliated Hospital of Bengbu Medical College, Anhui, China; Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingxiao Zhao
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China
| | - Jinlong Tian
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China; Department of Orthopaedics, The Second Affiliated Hospital of Bengbu Medical College, Anhui, China
| | - Jiongnan Xu
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China; The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jun Zhang
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China; Department of Orthopedics, Zhejiang Provincial People's Hospital Bijie Hospital, Bijie, Guizhou, China.
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Nalajala N, Panchal M, Gotting L. Impact of single multidisciplinary triage system and straight to test process evaluation at surrey integrated musculoskeletal services. JOURNAL OF INTEGRATED CARE 2023. [DOI: 10.1108/jica-11-2022-0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
PurposeOrthopaedics, rheumatology, pain management, specialist radiology and therapy services were brought under one umbrella to form Northwest Surrey integrated musculoskeletal (IMSK) services and introduced advance clinical practice, a multi-disciplinary team triage with a formalised straight to test (STT) process defined in 2018. Historically, prior to these services' integration, there were a primary and second care triage systems within individual specialities. The aim of this service evaluation is to assess the impact of a single IMSK multidisciplinary triage (MDT) system and the efficacy of STT from triage, which allows patients to be sent for diagnostics based on the cluster of symptoms and past medical history in order to achieve early identification of serious pathologies. This is a complex adaptive system with pathways spanning into the core areas of orthopaedics, rheumatology, therapies, pain management services, radiology and some less frequent specialities such as neurology, oncology, vascular and gynaecology. One of the objectives of this study was to identify how many referrals were triaged to consultants, Advance practice and therapies. In addition, the authors wanted to highlight the proportion of referrals that were sent straight to test from triage and the percentage of these that had sinister pathology identified. This information would then be compared against existing red flag literature to identify common themes. This study aims to discuss the aforementioned objectives.Design/methodology/approachData were extracted retrospectively from a hospital database from January to December 2019 for all the adult musculoskeletal service referrals. The data collected were analysed on a Microsoft Excel sheet with information including date of triage, hospital number, ordering clinician, body part, type of diagnostic, indications for scanning, outcome for STT, serious pathology findings (named code 5 within our trust) and outcome of appointment.FindingsA total of 47,039 referrals were received into the IMSK service. Of these referrals 19,967 were directly referred to therapies, with 27,072 referrals received into the IMSK service MDT process. Within triage, 718 patients were directed to STT to rule out serious pathology. A total of 28 patients (3.9%) had sinister pathology identified on their investigation. A total of 46% of patients were discharged from their first consultation following STT. Overall, 50% of the total number of referrals into the IMSK service was seen by advanced practitioners with 16% of patients directed to consultants with pre-consultation diagnostic work up.Originality/valueThis service evaluation highlights that STT allows early access to diagnostics, resulting in quicker access to identification of sinister pathology. A one stop MDT system has been shown to be effective in guiding the referral to the right place with increased referrals into allied health advance practice clinics and access to therapies directly. It has resulted in a reduction of unwarranted referrals to consultant care, duplication of investigations and identified patients on multiple pathways.
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Jayakumar N, Ferguson L, Nissen J, Holliman D. Surgical decompressions for cauda equina syndrome during COVID-19. Br J Neurosurg 2023; 37:231-233. [PMID: 33345629 DOI: 10.1080/02688697.2020.1861434] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The novel coronarvirus disease (COVID-19) has had a major impact on provision of spinal neurosurgery across the world, especially in the UK, with a significant fall in operating and patient volumes, and elective clinical activities. It is unclear whether the pandemic has affected the volume of urgent spinal procedures in the UK, especially surgical decompressions for cauda equina syndrome (CES). METHODS Therefore, we conducted a retrospective analysis of theatre records and electronic operation notes at our institution to identify all procedures performed for CES before (December 2019 to February 2020) and during (March 2020 to May 2020) the COVID-19 pandemic. Statistical analyses were performed on SPSS v22 (IBM). RESULTS Forty-four patients underwent surgical decompressions during the study period. Over half (54.5%) were female and the median age was 45 years (range = 22-78 years). Three in four procedures were performed at L4-5 and L5-S1 levels (79.5%). There was no statistically significant difference in the number of decompressions performed each month [χ2(5)=1.818; p = 0.874]. On the other hand, the number of referrals for suspected or confirmed CES fell by 81.8% between December 2019 and April 2020. CONCLUSIONS Our results did not show any statistically significant decline in the volume of surgical decompressions performed for CES despite the considerable fall in electronic referrals for CES and degenerative spinal conditions. This suggests that patients with critical neurological symptoms continued to present and were treated appropriately despite the restrictions imposed on spinal surgeons during the pandemic.
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Affiliation(s)
- Nithish Jayakumar
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Lucie Ferguson
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Justin Nissen
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Damian Holliman
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Sobański D, Staszkiewicz R, Stachura M, Gadzieliński M, Grabarek BO. Presentation, Diagnosis, and Management of Lower Back Pain Associated with Spinal Stenosis: A Narrative Review. Med Sci Monit 2023; 29:e939237. [PMID: 36814366 PMCID: PMC9972697 DOI: 10.12659/msm.939237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 01/25/2023] Open
Abstract
Lower back pain (LBP) is an extremely common symptom experienced by people of all ages and is also one of the most frequent causes of disability worldwide. This article aims to review the presentation, diagnosis, and management of lower back pain associated with spinal stenosis. The paper we prepared was classified as a "literature narrative review." Nonetheless, when searching for manuscripts included in our work and reviewing them critically, we concentrated on the keywords: "lower back pain", "lumbar spine stenosis", "diagnostic", "rehabilitation", "neurosurgery", "spine", and "elderly". The incidence of chronic lower back pain (CLBP) increases linearly starting with the third decade of life until 60 years old, and it more often affects women. The course of non-specific LBP above all depends on factors not connected with the spine, which include psychological, behavioral, and social factors, determined by the way the condition is perceived by the patient the environment. Lumbar spine stenosis (LSS) is an age-related process of degeneration of the intervertebral discs, ligamentum flavum, and facet joints, which results in narrowing of the space around the neurovascular structures of the spine. Diagnosis of spinal pain syndromes includes radiography (RTG), computed tomography (CT), and magnetic resonance imaging (MRI). Based on the results of imaging studies, neurological examination, and the severity of the disease, treatment can consist of analgesics and rehabilitation, or, when conservative methods are insufficient, surgical treatment is indicated.
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Affiliation(s)
- Dawid Sobański
- Department of Histology, Cytophysiology and Embryology, Academy of Silesia, Katowice, Poland
- Department of Neurosurgery, Szpital sw. Rafała in Cracow, Cracow, Poland
| | - Rafał Staszkiewicz
- Department of Histology, Cytophysiology and Embryology, Academy of Silesia, Katowice, Poland
- Department of Neurosurgery, 5 Military Clinical Hospital with the SP ZOZ Polyclinic in Cracow, Cracow, Poland
| | - Magdalena Stachura
- Department of Neurosurgery, Szpital sw. Rafała in Cracow, Cracow, Poland
- Department of Children’s Neurosurgery, Jagiellonian University Medical College, Cracow, Poland
| | - Marcin Gadzieliński
- Department of Neurosurgery, 5 Military Clinical Hospital with the SP ZOZ Polyclinic in Cracow, Cracow, Poland
| | - Beniamin Oskar Grabarek
- Department of Histology, Cytophysiology and Embryology, Academy of Silesia, Katowice, Poland
- Department of Neurosurgery, 5 Military Clinical Hospital with the SP ZOZ Polyclinic in Cracow, Cracow, Poland
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Woodfield J, Lammy S, Jamjoom AA, Fadelalla MA, Copley PC, Arora M, Glasmacher SA, Abdelsadg M, Scicluna G, Poon MT, Pronin S, Leung AH, Darwish S, Demetriades AK, Brown J, Eames N, Statham PF, Hoeritzauer I. Demographics of Cauda Equina Syndrome: A Population-Based Incidence Study. Neuroepidemiology 2023; 56:460-468. [PMID: 36315989 PMCID: PMC9945186 DOI: 10.1159/000527727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/15/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Cauda equina syndrome (CES) has significant medical, social, and legal consequences. Understanding the number of people presenting with CES and their demographic features is essential for planning healthcare services to ensure timely and appropriate management. We aimed to establish the incidence of CES in a single country and stratify incidence by age, gender, and socioeconomic status. As no consensus clinical definition of CES exists, we compared incidence using different diagnostic criteria. METHODS All patients presenting with radiological compression of the cauda equina due to degenerative disc disease and clinical CES requiring emergency surgical decompression during a 1-year period were identified at all centres performing emergency spinal surgery across Scotland. Initial patient identification occurred during the emergency hospital admission, and case ascertainment was checked using ICD-10 diagnostic coding. Clinical information was reviewed, and incidence rates for all demographic and clinical groups were calculated. RESULTS We identified 149 patients with CES in 1 year from a total population of 5.4 million, giving a crude incidence of 2.7 (95% CI: 2.3-3.2) per 100,000 per year. CES occurred more commonly in females and in the 30-49 years age range, with an incidence per year of 7.2 (95% CI: 4.7-10.6) per 100,000 females age 30-39. There was no association between CES and socioeconomic status. CES requiring catheterization had an incidence of 1.1 (95% CI: 0.8-1.5) per 100,000 adults per year. The use of ICD-10 codes alone to identify cases gave much higher incidence rates, but was inaccurate, with 55% (117/211) of patients with a new ICD-10 code for CES found not to have CES on clinical notes review. CONCLUSION CES occurred more commonly in females and in those between 30 and 49 years and had no association with socioeconomic status. The incidence of CES in Scotland is at least four times higher than previous European estimates of 0.3-0.6 per 100,000 population per year. Incidence varies with clinical diagnostic criteria. To enable comparison of rates of CES across populations, we recommend using standardized clinical and radiological criteria and standardization for population structure.
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Affiliation(s)
- Julie Woodfield
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK,*Julie Woodfield,
| | - Simon Lammy
- Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Aimun A.B. Jamjoom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK,Department of Neurosurgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | | | | | - Mohit Arora
- Department of Neurosurgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Stella A. Glasmacher
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Mohamed Abdelsadg
- Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Glasgow, UK,Department of Neurosurgery, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Gabrielle Scicluna
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Michael T.C. Poon
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK,Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Savva Pronin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Andraay H.C. Leung
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Stacey Darwish
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, UK
| | | | - Jennifer Brown
- Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Niall Eames
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, UK
| | | | - Ingrid Hoeritzauer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
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Bou GA, Garcia-Santibanez R, Castilho AJ, Hutto SK. Neurosarcoidosis of the Cauda Equina. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/4/e1170. [PMID: 35487693 PMCID: PMC9128042 DOI: 10.1212/nxi.0000000000001170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/10/2022] [Indexed: 01/28/2023]
Abstract
Background and ObjectivesSarcoidosis is a multisystem granulomatous disease affecting the nervous system in 3%–5% of cases. It can affect almost any component of the nervous system. Involvement of the cauda equina is an understudied phenotype, and questions remain regarding its natural history and optimal approach to management. This study aims to study the long-term clinical evolution of neurosarcoidosis affecting the cauda equina, response to treatment, and clinical and radiographic outcomes.MethodsPatients with neurosarcoidosis treated at Emory University between January 1, 2011, and December 8, 2021, were retrospectively evaluated for manifestations of cauda equina disease and included if disease of the cauda equina could be substantiated by MRI or EMG.ResultsOf 216 cases, 14 (6.5%) involved the cauda equina. The median age was 49.5 years, and most were female (85.7%) and African American (64.3%). Chronic (>28 days) presentations were most common (78.6%), but acute (<7 days, 14.3%) and subacute (7–28 days, 7.1%) were also seen. The median modified Rankin Scale (mRS) score at nadir was 3 (range 2–4). Symptoms were asymmetric in 78.6% and included leg numbness (85.7%), leg weakness (64.3%), perineal numbness (35.7%), pain (42.3%), and incontinence (21.4%). On MRI, the cauda equina enhanced in 100%, appeared nodular in 78.6%, and was diffusely involved in 71.4%. Coexisting myelitis was common (cervical 28.6%, thoracic 35.7%, and conus medullaris 28.6%). Intracranial inflammation included leptomeningitis (71.4%) and cranial neuropathies (57.1%). Electrodiagnostic studies were conducted in 3 with only one showing features consistent with a radicular process. Serum and CSF angiotensin-converting enzyme levels were elevated in 38.5% and 0.0%, respectively. CSF white blood cell and protein were elevated in 92.9%. Corticosteroids were tried in all patients with durable stabilization or improvement in only 3 (21.4%). Second-line agents associated with improvement included methotrexate/infliximab (3/4, 75%), methotrexate (3/4, 75.0%), and azathioprine (1/1, 100%). During a median follow-up of 22.5 months, the final median mRS score was 3. Relapses occurred at a median of 6 months in 21.4%. In 9 patients with MRI follow-up, 6 improved (66.7%), 1 stabilized (11.1%), and 2 worsened (22.2%).DiscussionCharacteristic features of cauda equina involvement by neurosarcoidosis include chronically delayed presentations, nodular enhancement on MRI, poor response to corticosteroids, and substantial resultant neurologic disability.
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Cauda equina syndrome - from timely treatment to the timing of out-of-hours surgery. Acta Neurochir (Wien) 2022; 164:1201-1202. [PMID: 35352153 DOI: 10.1007/s00701-022-05174-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/01/2022]
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Todd N, Dangas K, Lavy C. Post-void bladder ultrasound in suspected cauda equina syndrome-data from medicolegal cases and relevance to magnetic resonance imaging scanning. INTERNATIONAL ORTHOPAEDICS 2022; 46:1375-1380. [PMID: 35182176 PMCID: PMC9117366 DOI: 10.1007/s00264-022-05341-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/05/2022] [Indexed: 11/12/2022]
Abstract
Objective Post-void residual (PVR) scans of less than 200 ml are increasingly being used to rule out the likelihood of cauda equina syndrome (CES) and to delay emergency MRI scanning in suspected cases. This study was done to review a series of 50 MRI confirmed cases of CES and to test the hypothesis that a PVR of less than 200 ml was unlikely to be present. Methods Fifty consecutive medicolegal cases involving CES were audited. Records were reviewed to see if PVR scans were done. MRI scans were reviewed, clinical and radiological diagnosis reviewed, and treatment recorded. Results Out of 50 CES cases, 26 had had PVR scans. In 14/26 (54%) the PVR scan was ≤ 200 ml. In one case, the CES diagnosis was in question leaving 13/26 (50%) cases where there was a clear clinical and MRI diagnosis of CES despite the PVR being ≤ 200 ml. All 13 were classified as incomplete cauda equina syndrome (CESI) and all proceeded to emergency decompression. Conclusions This study is the first in the literature to demonstrate that there is a significant group of CES patients who require emergency decompression but have PVRs ≤ 200 ml. The results demonstrate the existence of a significant group of CESI patients whose bladder function may be deteriorating, but they have not yet reached the point where the PVR is over 200 ml. Given the accepted understanding that CESI is best treated with emergency decompression, such patients are likely to have worse outcomes if MRI scanning and therefore surgery is delayed. We recommend the following:PVR is recommended as an assessment tool in suspected CES. A PVR of ≤ 200 reduces the likelihood of having CES but does not exclude it; clinical suspicion of CES should always lead to an MRI scan. Further investigation of PVR as a prognostic tool is recommended.
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Affiliation(s)
- Nicholas Todd
- Newcastle Nuffield Hospital, Newcastle upon Tyne, UK
| | - Katerina Dangas
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK.
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Lavy C, Marks P, Dangas K, Todd N. Cauda equina syndrome-a practical guide to definition and classification. INTERNATIONAL ORTHOPAEDICS 2021; 46:165-169. [PMID: 34862914 PMCID: PMC8782783 DOI: 10.1007/s00264-021-05273-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 12/25/2022]
Abstract
Purpose International uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians when discussing CES with patients and relatives, and for medicolegal purposes. Methods We reviewed published literature using PubMed on definition and classification of cauda equina syndrome since 2000 (21 years). Using the search terms ‘cauda equina’ and ‘definition’ or ‘classification’, we found and reviewed 212 papers. Results There were 17 different definitions of CES used in the literature. There were three well-defined methods of classification of CES. The two-stage system of incomplete CES (CESI) versus CES with retention (CESR) is the most commonly used classification, and has prognostic value although the details of this continue to be debated. Conclusion We used the existing literature to propose a clear definition of CES. We also drew on peer-reviewed published literature that has helped to amplify and expand the CESI/CESR dichotomy, adding categories that are both less severe than CESI, and more severe than CESR, and we propose clear definitions in a table form to assist current and future discussion and management of CES.
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Affiliation(s)
- Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK.
| | - Paul Marks
- Office of Her Majestys' Coroner, Kingston upon Hull, UK
| | - Katerina Dangas
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Nicholas Todd
- Newcastle Nuffield Hospital, Newcastle upon Tyne, UK
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Angus M, Curtis-Lopez CM, Carrasco R, Currie V, Siddique I, Horner DE. Determination of potential risk characteristics for cauda equina compression in emergency department patients presenting with atraumatic back pain: a 4-year retrospective cohort analysis within a tertiary referral neurosciences centre. Emerg Med J 2021; 39:emermed-2020-210540. [PMID: 34642235 DOI: 10.1136/emermed-2020-210540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/02/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Atraumatic back pain is an increasingly common presentation to the ED. A minority of these cases will have significant structural pathology, resulting in acute cauda equina compression (CEC). Although clinicians often look for 'red flags' to identify potential CEC, the prognostic accuracy of these presenting symptoms and clinical examination findings is unclear. We sought to evaluate the accuracy of individual clinical features in a large cohort of ED patients with atraumatic backpain and reference standard imaging, for the diagnosis of CEC. METHODS A retrospective case note review from 2014 to 2018 within an established ED atraumatic back pain pathway, undertaken at the largest tertiary spinal referral centre in the UK. We analysed routine data, collected prospectively by treating clinicians within a structured electronic health record clinical proforma. Data on signs and symptoms in 996 patients with suspected CEC referred for definitive MRI over a 4-year study period were extracted and compared against a final reference standard diagnosis. RESULTS We identified 111 patients with radiological evidence of CEC within the cohort referred for definitive imaging (111/996, 11.1%), of whom 109 (98.2%) underwent operative intervention. Patients with CEC were more likely to present with bilateral leg pain (OR=2.2), dermatomal sensory loss (OR 1.8) and bilateral absent ankle or ankle and knee jerks (OR=2.9). Subjective weakness was found to be associated with CEC on univariate but not multivariate analysis. We found no relationship between digital rectal examination findings and the diagnosis of CEC. CONCLUSIONS In our cohort, factors independently associated with CEC diagnosis on MRI included bilateral leg pain, dermatomal sensory loss. Loss of lower limb reflexes was strongly suggestive of CES (likelihood ratio 3.4 on multivariate logistic regression). Our findings raise questions about the diagnostic utility of invasive digital rectal examination.
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Affiliation(s)
- Michelle Angus
- Department of Spinal Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Roberto Carrasco
- School of Medicine, The University of Manchester, Manchester, UK
| | - Vicki Currie
- Department of Spinal Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Irfan Siddique
- Complex Spines, Salford Royal NHS Foundation Trust, Salford, UK
| | - Daniel E Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
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Hoeritzauer I, Carson A, Statham P, Demetriades A, Stone J. Author Response: Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study. Neurology 2021; 97:456-457. [PMID: 34534096 DOI: 10.1212/wnl.0000000000012503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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The role of bladder volume for diagnosing cauda equina syndrome. Am J Emerg Med 2021; 48:336-337. [PMID: 34391580 DOI: 10.1016/j.ajem.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/22/2022] Open
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Hoeritzauer I, Stanton B, Carson A, Stone J. 'Scan-negative' cauda equina syndrome: what to do when there is no neurosurgical cause. Pract Neurol 2021; 22:6-13. [PMID: 34389643 DOI: 10.1136/practneurol-2020-002830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/03/2022]
Abstract
Suspected cauda equina syndrome is a common presentation in emergency departments, but most patients (≥70%) have no cauda equina compression on imaging. As neurologists become more involved with 'front door' neurology, referral rates of patients with these symptoms are increasing. A small proportion of patients without structural pathology have other neurological causes: we discuss the differential diagnosis and how to recognise these. New data on the clinical features of patients with 'scan-negative' cauda equina syndrome suggest that the symptoms are usually triggered by acute pain (with or without root impingement) causing changes in brain-bladder feedback in vulnerable individuals, exacerbated by medication and anxiety, and commonly presenting with features of functional neurological disorder.
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Affiliation(s)
- Ingrid Hoeritzauer
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Biba Stanton
- Department of Neurology, King's College Hospital, Neuropsychiatry Service, South London & Maudsley NHS Trust, London, UK
| | - Alan Carson
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Hazelwood JE, Hoeritzauer I, Carson A, Stone J, Demetriades AK. Long-term mental wellbeing and functioning after surgery for cauda equina syndrome. PLoS One 2021; 16:e0255530. [PMID: 34358259 PMCID: PMC8345886 DOI: 10.1371/journal.pone.0255530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/17/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Cauda Equina Syndrome (CES) can cause persisting life-changing dysfunction. There is scarce literature regarding the long-term assessment of CES symptoms, and rarer still is the impact of these symptoms on mental wellbeing investigated. This study assessed the long-term patient reported mental wellbeing outcomes of post-operative CES patients. Methods Patients who underwent surgery for CES between August 2013 and November 2014 were identified using an ethically approved database. They then completed validated questionnaires over the telephone assessing their mental and physical functioning (Short-Form 12 Questionnaire), generating the Physical Component Summary (PCS) and Mental Component Summary (MCS). Bladder, bowel and sexual function were also assessed using validated questionnaires. MCS scores were compared to both the Scottish mean and previously published cut-offs indicating patients at risk of depression. Correlations of MCS with bladder, bowel, sexual and physical dysfunction were examined and multifactorial regression to predict MCS from these variables analysed. Independent t-tests assessed the mean difference in MCS between patients presenting with incomplete CES (CES-I) and CES with retention (CES-R) and between those with radiologically confirmed and impending CES. Results Forty-six participants with a mean follow-up time of 43 months completed the study. The mean (±SD) MCS was 49 (±11.8) with 22% demonstrating poor mental health related quality of life in comparison to the Scottish mean. Overall, 37% had scores consistent with being at risk for depression with in the last 30 days, and 45% within the last 12 months. MCS was significantly correlated with Urinary Symptoms Profile (USP) score (-0.608), NBDS score (-0.556), ASEX score (-0.349) and PCS score (0.413) with worse bladder, bowel, sexual and physical dysfunction associated with worse MCS score. Multifactorial regression analysis demonstrated both urinary (USP score p = 0.031) and bowel function (NBDS score p = 0.009) to be significant predictive variables of mental health related quality of life. There were no significant mean differences in MCS between those presenting with CES-I and CES-R or those with radiologically complete and impending CES. Discussion This study demonstrates a high frequency of being at risk for depression in patients with CES and identifies outcome measures (physical, sexual and more so bladder and bowel dysfunction) associated with poorer mental wellbeing. Our large cohort and long follow-up highlight that CES patients should be considered at risk of depression, and the need to consider mental health outcomes following CES surgery.
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Affiliation(s)
- James E. Hazelwood
- Edinburgh Spinal Surgery Outcomes Study Group, Edinburgh, United Kingdom
- Chelsea and Westminster Hospital, London, United Kingdom
| | - Ingrid Hoeritzauer
- Edinburgh Spinal Surgery Outcomes Study Group, Edinburgh, United Kingdom
- Department of Clinical Neurosciences (Neurology), Royal Infirmary of Edinburgh, Little France, Edinburgh, Scotland, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Alan Carson
- Department of Clinical Neurosciences (Neurology), Royal Infirmary of Edinburgh, Little France, Edinburgh, Scotland, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Rehabilitation Medicine, NHS Lothian, Edinburgh, United Kingdom
| | - Jon Stone
- Department of Clinical Neurosciences (Neurology), Royal Infirmary of Edinburgh, Little France, Edinburgh, Scotland, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Andreas K. Demetriades
- Edinburgh Spinal Surgery Outcomes Study Group, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Clinical Neurosciences (Neurosurgery), Royal Infirmary of Edinburgh, Little France, Edinburgh, Scotland, United Kingdom
- * E-mail:
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Finkelstein SA, Cortel‐LeBlanc MA, Cortel‐LeBlanc A, Stone J. Functional neurological disorder in the emergency department. Acad Emerg Med 2021; 28:685-696. [PMID: 33866653 DOI: 10.1111/acem.14263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 12/27/2022]
Abstract
We provide a narrative review of functional neurological disorder (FND, or conversion disorder) for the emergency department (ED). Diagnosis of FND has shifted from a "rule-out" disorder to one now based on the recognition of positive clinical signs, allowing the ED physician to make a suspected or likely diagnosis of FND. PubMed, Google Scholar, academic books, and a hand search through review article references were used to conduct a literature review. We review clinical features and diagnostic pitfalls for the most common functional neurologic presentations to the ED, including functional limb weakness, functional (nonepileptic) seizures, and functional movement disorders. We provide practical advice for discussing FND as a possible diagnosis and suggestions for initial steps in workup and management plans.
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Affiliation(s)
| | - Miguel A. Cortel‐LeBlanc
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
- The Ottawa Hospital Ottawa Ontario Canada
- Queensway Carleton Hospital Ottawa Ontario Canada
| | - Achelle Cortel‐LeBlanc
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
- Queensway Carleton Hospital Ottawa Ontario Canada
| | - Jon Stone
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh UK
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Kang MS, Kim MK, Kim YE, Kim JH, Kim BJ, Lee HL. Two cases of myelin oligodendrocyte glycoprotein antibody-associated disease presenting with Cauda Equina Syndrome without conus myelitis. Mult Scler Relat Disord 2021; 52:103017. [PMID: 34023773 DOI: 10.1016/j.msard.2021.103017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
Myelin oligodendrocyte glycoprotein antibody-associated disorder (MOGAD) is a central nervous system inflammatory disorder associated with MOG antibodies. Two patients with clinical symptoms of cauda equina syndrome had positive serum MOG antibody tests, and spinal magnetic resonance imaging showed cauda equina enhancement. They were diagnosed with incomplete cauda equina syndrome associated with MOGAD. A few cases of lumbosacral radiculomyelitis associated with MOGAD have been reported; however, this is the first report of isolated lumbosacral radiculitis associated with MOGAD without transverse myelitis. The MOG antibody test should be considered for cauda equina syndrome without compressive lesions.
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Affiliation(s)
- Min Sung Kang
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Guro-gu, Seoul 08308, Korea
| | - Min Kyoung Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Guro-gu, Seoul 08308, Korea
| | - Ye Eun Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Guro-gu, Seoul 08308, Korea
| | - Ji Hyun Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Guro-gu, Seoul 08308, Korea
| | - Byoung Joon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hye Lim Lee
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Guro-gu, Seoul 08308, Korea.
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Alshahwani AA, Boktor J, Elbahi A, Banerjee P. A Systematic Review of the Value of a Bladder Scan in Cauda Equina Syndrome Diagnosis. Cureus 2021; 13:e14441. [PMID: 33996305 PMCID: PMC8115683 DOI: 10.7759/cureus.14441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Cauda equina syndrome (CES) is one of the emergency conditions that can lead to devastating permanent functional disabilities, if misdiagnosed. Multiple studies have questioned the reliability of clinical assessment in diagnosing CES, whether some of the features should be considered to be potential red flags. Bladder dysfunction can reflect CE compromise. The post-void residual (PVR) volume bladder scan is useful in CES diagnosis, but to date there has been no single systematic review supporting its use. Furthermore, there is no clear cut-off point to consider PVR statistically significant. The aim of the study is to perform a systematic review of the current evidence behind the use of the PVR bladder scan as a diagnostic tool for CES diagnosis. This was a comprehensive search using Medline, PubMed and Embase. All articles included post-void bladder scans with the mentioned clear cut-off volume as a diagnostic parameter. A total of five study articles from 1955 fit with our inclusion and exclusion criteria. The total number of patients who had a bladder scan was 531. CES was confirmed in 85 cases. Bladder scan diagnosed 70 cases and excluded 327. The best results for both sensitivity and specificity in correlation with the sample of the study were for PVR more than 200 ml. Measuring the post-void urine volume using a bladder scan is an essential tool in the diagnosis of CES. There is a significant correlation between the PVR volume more than 200 ml and higher sensitivity and specificity.
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Affiliation(s)
- Awf A Alshahwani
- Trauma and Orthopaedics, Leicester University Hospital, Leicester, GBR
| | - Joseph Boktor
- Trauma and Orthopaedics, Cardiff University Hospital, Cardiff, GBR
| | - Amr Elbahi
- Trauma and Orthopaedics, Kettering General Hospital, Kettering, GBR
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Woodfield J, Brennan PM, Statham P, Stone J, Hoeritzauer I. Suspected cauda equina syndrome: no reduction in investigation, referral and treatment during the COVID-19 pandemic. Ann R Coll Surg Engl 2021; 103:432-437. [PMID: 33682481 DOI: 10.1308/rcsann.2021.0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Compression of the cauda equina can lead to bladder, bowel and sexual dysfunction with lower limb pain, numbness and weakness. Urgent surgical decompression aims to prevent progressive neurological deficit. Symptoms of cauda equina syndrome (CES), such as back pain, sciatica and bladder dysfunction are common in the population, but the majority of those investigated do not have radiological cauda equina compression. However, a missed diagnosis can have significant medical, social and legal consequences. We investigated the effect of the COVID-19 pandemic on presentation and management of suspected CES. METHODS This retrospective cohort study analysed referral, investigation and treatment of CES in a regional neurosurgical centre during the initial COVID-19 surge between March and May 2020 compared with March to May 2019. RESULTS Referrals for suspected CES were similar during the COVID-19 pandemic (n = 275) compared with 2019 (n = 261, p = 0.596) despite a significant (19%) decrease in total emergency neurosurgical referrals (1248 in 2020 vs 1544 in 2019, p < 0.001). Nineteen (7%) of the suspected CES referrals underwent decompression in 2020, similar to 16 (6%) in 2019 (p = 0.867). There were no differences in outcomes or complications and no evidence of delays in presentation or treatment. CONCLUSIONS Unlike other emergency neurosurgical conditions, the number of referrals for suspected CES and the percentage of referrals with radiological cauda equina compression were unchanged during the COVID-19 pandemic. The persistence of CES referrals when many people stayed away from hospital highlights the distress and worry caused by suspected CES and its symptoms to both patients and healthcare providers.
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Affiliation(s)
- J Woodfield
- University of Edinburgh, UK.,NHS Lothian, UK
| | - P M Brennan
- University of Edinburgh, UK.,NHS Lothian, UK
| | | | - J Stone
- University of Edinburgh, UK.,NHS Lothian, UK
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LoRusso S. Disorders of the Cauda Equina. Continuum (Minneap Minn) 2021; 27:205-224. [PMID: 33522743 DOI: 10.1212/con.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Cauda equina dysfunction (often referred to as cauda equina syndrome) is caused by a diverse group of disorders that affect the lumbosacral nerve roots. It is important to recognize dysfunction of the cauda equina quickly to minimize diagnostic delay and lasting neurologic symptoms. This article describes cauda equina anatomy and the clinical features, differential diagnosis, and management of cauda equina disorders. RECENT FINDINGS The diagnosis of disorders of the cauda equina continues to be a challenge. If a compressive etiology is seen, urgent neurosurgical intervention is recommended. However, many people with clinical features of cauda equina dysfunction will have negative diagnostic studies. If the MRI is negative, it is important to understand the diagnostic evaluation and differential diagnosis so that less common etiologies are not missed. SUMMARY Cauda equina dysfunction most often occurs due to lumbosacral disk herniation. Nondiskogenic causes include vascular, infectious, inflammatory, traumatic, and neoplastic etiologies. Urgent evaluation and surgical intervention are recommended in most cases of compressive cauda equina syndrome. Other types of treatment may also be indicated depending on the etiology.
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Bennett K, Diamond C, Hoeritzauer I, Gardiner P, McWhirter L, Carson A, Stone J. A practical review of functional neurological disorder (FND) for the general physician. Clin Med (Lond) 2021; 21:28-36. [PMID: 33479065 PMCID: PMC7850207 DOI: 10.7861/clinmed.2020-0987] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We present a practical overview of functional neurological disorder (FND), its epidemiology, assessment and diagnosis, diagnostic pitfalls, treatment, aetiology and mechanism. We present an update on functional limb weakness, tremor, dystonia and other abnormal movements, dissociative seizures, functional cognitive symptoms and urinary retention, and 'scan-negative' cauda equina syndrome. The diagnosis of FND should rest on clear positive evidence, typically from a combination of physical signs on examination or the nature of seizures. In treatment of FND, clear communication of the diagnosis and the involvement of the multidisciplinary team is beneficial. We recommend that patients with FND are referred to specialists with expertise in neurological diagnosis. FND is a common presentation in emergency and acute medical settings and there are many practical elements to making a positive diagnosis and communication which are useful for all physicians to be familiar with.
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Affiliation(s)
| | | | | | | | | | - Alan Carson
- Centre for Clinical Brain Services, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Services, Edinburgh, UK
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Hoeritzauer I, Carson A, Statham P, Panicker JN, Granitsiotis V, Eugenicos M, Summers D, Demetriades AK, Stone J. Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study. Neurology 2020; 96:e433-e447. [PMID: 33177221 DOI: 10.1212/wnl.0000000000011154] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 09/04/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe clinical features relevant to diagnosis, mechanism, and etiology in patients with "scan-negative" cauda equina syndrome (CES). METHODS We carried out a prospective study of consecutive patients presenting with the clinical features of CES to a regional neurosurgery center comprising semi-structured interview and questionnaires investigating presenting symptoms, neurologic examination, psychiatric and functional disorder comorbidity, bladder/bowel/sexual function, distress, and disability. RESULTS A total of 198 patients presented consecutively over 28 months. A total of 47 were diagnosed with scan-positive CES (mean age 48 years, 43% female). A total of 76 mixed category patients had nerve root compression/displacement without CES compression (mean age 46 years, 71% female) and 61 patients had scan-negative CES (mean age 40 years, 77% female). An alternative neurologic cause of CES emerged in 14/198 patients during admission and 4/151 patients with mean duration 25 months follow-up. Patients with scan-negative CES had more positive clinical signs of a functional neurologic disorder (11% scan-positive CES vs 34% mixed and 68% scan-negative, p < 0.0001), were more likely to describe their current back pain as worst ever (41% vs 46% and 70%, p = 0.005), and were more likely to have symptoms of a panic attack at onset (37% vs 57% and 70%, p = 0.001). Patients with scan-positive CES were more likely to have reduced/absent bilateral ankle jerks (78% vs 30% and 12%, p < 0.0001). There was no significant difference between groups in the frequency of reduced anal tone and urinary retention. CONCLUSION The first well-phenotyped, prospective study of scan-negative CES supports a model in which acute pain, medication, and mechanisms overlapping with functional neurologic disorders may be relevant.
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Affiliation(s)
- Ingrid Hoeritzauer
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
| | - Alan Carson
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
| | - Patrick Statham
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
| | - Jalesh N Panicker
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
| | - Voula Granitsiotis
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
| | - Maria Eugenicos
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
| | - David Summers
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
| | - Andreas K Demetriades
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
| | - Jon Stone
- From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of EdinburghDepartments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General HospitalDepartment of Rehabilitation Medicine (A.C.), NHS Lothian, EdinburghDepartment of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, LondonEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK
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Lidstone SC, Nassif W, Juncos J, Factor SA, Lang AE. Diagnosing functional neurological disorder: seeing the whole picture. CNS Spectr 2020; 26:1-8. [PMID: 33161935 DOI: 10.1017/s1092852920001996] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Functional neurological disorder (FND) is a complex neuropsychiatric syndrome with many phenotypes that are commonly encountered in clinical practice. Despite the heterogeneity of FND, the rate of misidentification is consistently low. For the more common motor subtypes, there are clear positive clinical, electrophysiological, and rarely imaging criteria that can establish the diagnosis in the traditional sense. For nonmotor subtypes, the characterization may be less clear. Here, we argue that the current diagnostic criteria are not reflective of the current shared neuropsychiatric understanding of FND, and, as a result, provide an incomplete picture of the diagnosis. We propose a three-step diagnostic triad for FND, in which the traditional neurological diagnosis is only the first element. Other steps include psychiatric/psychological formulation, integration, and follow-up. We advocate that this diagnostic approach should be the shared responsibility of neurology and mental health professionals. Finally, a research agenda is proposed to address the missing factors in the field.
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Affiliation(s)
- Sarah C Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Walid Nassif
- Department of Psychiatry, Emory University, and the Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Jorge Juncos
- Department of Neurology, Jean and Paul Amos Parkinson's Disease and Movement Disorders Program, Emory University, Atlanta, Georgia, USA
| | - Stewart A Factor
- Department of Neurology, Jean and Paul Amos Parkinson's Disease and Movement Disorders Program, Emory University, Atlanta, Georgia, USA
| | - Anthony E Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
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Stone J, Warlow C, Deary I, Sharpe M. Predisposing Risk Factors for Functional Limb Weakness: A Case-Control Study. J Neuropsychiatry Clin Neurosci 2020; 32:50-57. [PMID: 31466514 DOI: 10.1176/appi.neuropsych.19050109] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Functional limb weakness is a common symptom of functional neurological disorder. Few controlled studies have examined possible predisposing factors to determine their specificity for this symptom. METHODS In this prospective case-control study, patients with functional limb weakness (<2 years duration, N=107) were compared with a control group (comprising patients with weakness attributable to neurological disease, N=46, and healthy individuals, N=39). A structured clinical interview and questionnaires assessed potential predisposing factors, including family structure and childhood abuse and neglect (Childhood Trauma Questionnaire [CTQ]), personality traits (NEO Five-Factor Inventory), medical and surgical comorbidity, and exposure to a symptom model. RESULTS The patients with functional limb weakness and the control subjects were similar in gender and age. Self-reported childhood sexual abuse (15% versus 5%, p<0.01), and physical abuse (18% versus 7%, p<0.01; CTQ "moderate or above") were more common in the functional limb weakness group, although the absolute frequency was lower than anticipated. In the functional limb weakness group, there were modest differences in two personality traits, compared with the control group: higher neuroticism (p=0.02) and lower openness (p=0.01). Medical comorbidity, including appendectomy (33% versus 5%), irritable bowel syndrome (36% versus 18%), and chronic back pain (40% versus 16%), was more frequent in the functional limb weakness group. There were no differences in birth order or exposure to a symptom model. CONCLUSIONS Medical and surgical comorbidity and adverse childhood experience are risk factors, but not essential, for the development of functional limb weakness. However, evidence for personality traits or exposure to a symptom model is less robust.
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Affiliation(s)
- Jon Stone
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
| | - Charles Warlow
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
| | - Ian Deary
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
| | - Michael Sharpe
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
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31
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Hoeritzauer I, Wood M, Copley PC, Demetriades AK, Woodfield J. What is the incidence of cauda equina syndrome? A systematic review. J Neurosurg Spine 2020; 32:832-841. [PMID: 32059184 DOI: 10.3171/2019.12.spine19839] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cauda equina syndrome (CES) is a surgical emergency requiring timely operative intervention to prevent symptom progression. Accurately establishing the incidence of CES is required to inform healthcare service design and delivery, including out-of-hours imaging arrangements. METHODS A systematic literature search of MEDLINE, EMBASE, and Scopus was undertaken to identify original studies stating the incidence of CES, and the estimates were combined in a meta-analysis as described in the protocol registered with PROSPERO (registration no. CRD42017065865) and reported using the PRISMA guidelines. RESULTS A total of 1281 studies were identified, and 26 studies were included in the review. Data about CES incidence were available from 3 different populations: asymptomatic community populations, patients with nontraumatic low-back pain, and patients presenting as an emergency with suspected CES. The incidence of CES was 0.3-0.5 per 100,000 per year in 2 asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working-age population. CES occurred in 0.08% of those with low-back pain presenting to primary care in 1 study, and a combined estimate of 0.27% was calculated for 4 studies of those with low-back pain presenting to secondary care. Across 18 studies of adults with suspected CES, 19% had radiological and clinical CES. Difficulties in comparison between studies resulted from the heterogeneous definitions of CES and lack of separation of more advanced CES with retention, which is unlikely to be reversible. In the studies of patients with suspected CES, the small sample size, the high number of single-center studies (18/18), the high number of studies from the United Kingdom (17/18), the retrospective nature of the studies, and the high number of abstracts rather than full texts (9/18) reduced the quality of the data. CONCLUSIONS From current studies, it appears that CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Determining accurate incidence figures and designing a bespoke service for investigation of patients with suspected CES would require a consensus clinical and radiological definition of CES and international multisite studies of patient pathways of investigation and management.
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Affiliation(s)
- Ingrid Hoeritzauer
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
- 3Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, United Kingdom
| | - Matthew Wood
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
| | - Phillip C Copley
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
- 3Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, United Kingdom
| | - Andreas K Demetriades
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 3Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, United Kingdom
| | - Julie Woodfield
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
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32
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Angus M, Berg A, Carrasco R, Horner D, Leach J, Siddique I. The Cauda Scale - Validation for Clinical Practice. Br J Neurosurg 2020; 34:453-456. [PMID: 32310000 DOI: 10.1080/02688697.2020.1754337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose: The purpose of this study was to validate the cauda scale (TCS) in an external population. TCS was proposed as a tool to be used to predict the likelihood of cauda equina compression.Methods: We analysed the presenting condition of consecutive patients attending the emergency department undergoing a magnetic resonance scan with a clinical suspicion of cauda equina syndrome (CES). The findings were graded according to TCS for those with and without radiological compression of the cauda equina. Logistic regression was applied to the data in accordance with the original paper.Results: Patients were included over a 14 month period (n = 313), subsequent imaging revealed CES compression in 34 cases and no CES compression in 279. The TCS proposed that small values meant a more likely diagnosis of CES, the data showed the opposite of this with the highest number of patients with CES scoring a maximal 9 on TCS (mildest symptoms).Conclusions: Our data suggests that TCS has potential limitations in identifying patients with CES and needs further work prior to implementation.
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Affiliation(s)
- Michelle Angus
- Department of Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, UK
| | - Andrew Berg
- Department of Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, UK
| | - Roberto Carrasco
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Oxford, UK
| | - Daniel Horner
- Emergency Medicine Department, Salford Royal NHS Foundation Trust, Stott Lane, UK
| | - John Leach
- Department of Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, UK
| | - Irfan Siddique
- Department of Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, UK
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Gibson LL, Harborow L, Nicholson T, Bell D, David AS. Is scan-negative cauda equina syndrome a functional neurological disorder? A pilot study. Eur J Neurol 2020; 27:1336-1342. [PMID: 32073712 DOI: 10.1111/ene.14182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Cauda equina syndrome (CES) is a neurosurgical emergency which warrants lumbar magnetic resonance imaging (MRI). Many patients with suggestive symptoms of CES have no radiological correlate. A functional (non-organic) aetiology has been proposed in some, but currently little is known about this patient group and their clinical outcomes. METHODS At a tertiary referral centre, 155 adult patients underwent urgent lumbar MRI for suspected CES in 1 year from December 2014. Data regarding clinical symptoms and follow-up were obtained from records. Patients were divided into CES (n = 25), radiculopathy (n = 68) and scan-negative (SN) groups (n = 62) from scans. Up to 3 years post-discharge, postal questionnaires were sent to patients with Oswestry Disability Index, Pain Catastrophizing score, Patient Health Questionnaire (PHQ) 9, Generalized Anxiety Disorder (GAD) 7, PHQ 15 and Work and Social Adjustment Scale measures. RESULTS No clinical symptoms were found to differentiate CES from SN patients. Functional comorbidities were significantly more common in SN patients but mental health diagnosis frequency did not differ. Follow-up was variable with no consistent referral pathways, particularly for the SN group. 33% (n = 47) responded to the postal questionnaires; high levels of pain, symptom chronicity and disability were ubiquitous but self-reported mental health diagnoses and PHQ 15 were higher for SN patients. CONCLUSIONS Conflicting data suggest further research is needed to investigate the prevalence of mental illness and somatic symptoms in SN cases. SN patients have higher rates of comorbid functional disorders and inconsistent referral pathways. Self-report measures indicate impaired quality of life across all groups. The low response rate limits the generalizability of findings but neuropsychiatric assessment and care pathway optimization should be considered.
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Affiliation(s)
- L L Gibson
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - L Harborow
- South London and Maudsley NHS Foundation Trust, London, UK
| | - T Nicholson
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - D Bell
- Kings College Hospital NHS Foundation Trust, London, UK
| | - A S David
- Institute of Mental Health, University College London, London, UK
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McDonnell J, Ahern DP, Gibbons D, Dalton DM, Butler JS. A systematic review of the presentation of scan-negative suspected cauda equina syndrome. Surgeon 2020; 18:49-52. [DOI: 10.1016/j.surge.2019.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
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Kaiser R, Stokes OM, Mehdian H. In Reply: Time Factor and Disc Herniation Size: Are They Really Predictive for Outcome of Urinary Dysfunction in Patients With Cauda Equina Syndrome? Neurosurgery 2020; 86:E96-E97. [PMID: 31628749 DOI: 10.1093/neuros/nyz436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Radek Kaiser
- The Centre for Spinal Studies and Surgery, QMC Nottingham University Hospitals NHS Trust Nottingham, United Kingdom.,Department of Neurosurgery and Neurooncology First Faculty of Medicine Charles University and Military University Hospital Prague, Czech Republic
| | - Oliver M Stokes
- Exeter Spine Unit Princess Elizabeth Orthopaedic Centre Royal Devon and Exeter NHS Foundation Trust Exeter, United Kingdom
| | - Hossein Mehdian
- The Centre for Spinal Studies and Surgery, QMC Nottingham University Hospitals NHS Trust Nottingham, United Kingdom
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Pronin S, Woodfield J, Hoeritzauer I, Carson A, Stone J, Statham PF, Demetriades AK. Does a history of lumbar spine surgery predict radiological cauda equina compression in patients undergoing MRI for suspected cauda equina syndrome? Br J Neurosurg 2019; 34:76-79. [PMID: 31718292 DOI: 10.1080/02688697.2019.1687845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The clinical symptoms and signs of Cauda equina syndrome (CES) are non specific and poorly predictive of cauda equina compression on MRI. We aimed to establish whether a history of lumbar spine surgery predicts cauda equina compression on MRI in those presenting with suspected CES.Methods: A retrospective electronic record review was undertaken of 276 patients referred with clinically suspected CES who underwent a lumbosacral spine MRI. Those with a history of prior lumbar surgery were compared to those without. The likelihood of cauda equina compression was compared between the two groups.Results: About 78/276 (28%) patients with suspected CES had radiological compression of the cauda equina and went on to surgical decompression. A total of 54 (20%) patients had undergone prior lumbar surgery. Patients with a history of lumbar surgery were less likely to have cauda equina compression on MRI (χ2 - p = .035). Twenty six (9%) patients presented more than once with suspected CES. Patients with a history of lumbar surgery were more likely to re-present with suspected CES (χ2 - p = .002).Conclusions: Prior lumbar surgery was associated with a higher frequency of re-presentation with clinically suspected CES but a lower frequency of radiological cauda equina compression.
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Affiliation(s)
- Savva Pronin
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK.,Edinburgh Spinal Surgery Outcome Studies Group, The University of Edinburgh, Edinburgh, UK
| | - Julie Woodfield
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK.,Edinburgh Spinal Surgery Outcome Studies Group, The University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Ingrid Hoeritzauer
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK.,Edinburgh Spinal Surgery Outcome Studies Group, The University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Patrick F Statham
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK.,Edinburgh Spinal Surgery Outcome Studies Group, The University of Edinburgh, Edinburgh, UK
| | - Andreas K Demetriades
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK.,Edinburgh Spinal Surgery Outcome Studies Group, The University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Angus M, Horner D. BET 2: Is sexual dysfunction a recognised sign of cauda equina syndrome in the ED? Emerg Med J 2019; 36:508-510. [PMID: 31358554 DOI: 10.1136/emermed-2019-208777.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A shortcut review of the literature was carried out to examine the association of sexual dysfunction in the context of new-onset low back pain, with cauda equina syndrome (CES). Five papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that clinicians appear to be poor at recording this feature during assessment, but between 12% and 96%, patients with confirmed CES will report the presence of new-onset sexual dysfunction at presentation when asked. It appears that this can also be a single isolated red flag feature in the context of low back pain and as such should be a mandatory part of any clinical assessment that seeks to evaluate the risk of impending CES.
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Pronin S, Hoeritzauer I, Statham PF, Demetriades AK. Are we neglecting sexual function assessment in suspected cauda equina syndrome? Surgeon 2019; 18:8-11. [PMID: 31036485 DOI: 10.1016/j.surge.2019.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/22/2019] [Accepted: 03/26/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We assessed the documentation rates of signs and symptoms, including sexual function, in patients with suspected cauda equina syndrome and whether they can be improved by increasing local awareness. PATIENTS AND METHODS We reviewed all electronic records of patients referred with suspected CES who required urgent MRI to our regional service over a 2 month period. We recorded the documentation rates of clinical signs and symptoms. The results were presented locally to increase awareness. A further 2 month period was then re-audited. 120 patients in total were included across both time periods. Chi-squared was used to compare documentation rates between time periods. RESULTS 25 of 120 patients had radiological cauda equina compression. Lower limb neurology, urinary function and saddle sensation were almost universally documented. After the intervention, there was a significant increase (p < 0.05) in the documentation of bowel function and post-void residual but not sexual function. Sexual function was poorly documented with rates of 3% and 11% throughout the two audited periods. CONCLUSION Certain clinical features of CES are well documented. Increasing awareness may improve documentation of certain symptoms/signs in patients with suspected cauda equina syndrome. Sexual function was poorly documented and increasing awareness alone is an inadequate intervention.
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Affiliation(s)
- Savva Pronin
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK; Edinburgh Spinal Surgery Outcome Studies Group, UK.
| | - Ingrid Hoeritzauer
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK; Centre for Clinical Brain Sciences, The University of Edinburgh, UK; Edinburgh Spinal Surgery Outcome Studies Group, UK
| | - Patrick F Statham
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK; Edinburgh Spinal Surgery Outcome Studies Group, UK
| | - Andreas K Demetriades
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK; Centre for Clinical Brain Sciences, The University of Edinburgh, UK; Edinburgh Spinal Surgery Outcome Studies Group, UK
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