1
|
Gavin L, Curran MG, McCabe JP. A comparison of available guidelines for the detection of cauda equina syndrome and assessing the need for further clinical guidance in Ireland. Ir J Med Sci 2024; 193:1865-1872. [PMID: 38504069 PMCID: PMC11294425 DOI: 10.1007/s11845-024-03633-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/12/2024] [Indexed: 03/21/2024]
Abstract
The cauda equina syndrome (CES) is a rare but critical disorder, which can result in devastating motor weakness and sensory deficit, alongside often irreversible bladder, bowel and sexual dysfunction. In addition to the clinical burden of disease, this syndrome results in a disproportionately high medicolegal strain due to missed or delayed diagnoses. Despite being an emergency diagnosis, often necessitating urgent surgical decompression to treat, we believe there is a lack of clarity for clinicians in the current literature, with no published Irish guideline concerning screening or detection. The current study aims to identify and analyse appropriate guidelines in relation to CES screening which are available to clinicians in Ireland. The study design included a comprehensive literature review and comparison of existing guidelines. The review identified 13 sources of appropriate guidance for clinicians working in Ireland. These resources included textbooks, websites and guidelines developed in the UK. No Irish guidelines or advice were available on CES screening/treatment at the time of review. This review demonstrated the lack of consensus and guidance for clinicians in Ireland on how to effectively screen for CES, judge who requires further imaging and investigations and how to rule out the condition. A national consensus on thorough screening and prompt investigation for CES is necessary, and the formulation of new CES guidelines would be a welcome addition to what is available to clinicians currently.
Collapse
Affiliation(s)
- Lorcan Gavin
- University of Galway, University Road, Co Galway, Ireland.
| | | | - John P McCabe
- Department of Trauma and Orthopaedics, Bon Secours Hospital, Renmore, Galway, Ireland
| |
Collapse
|
2
|
Jentzsch T, Cadotte DW, Wilson JR, Jiang F, Badhiwala JH, Akbar MA, Rocos B, Grossman RG, Aarabi B, Harrop JS, Fehlings MG. Spinal Cord Signal Change on Magnetic Resonance Imaging May Predict Worse Clinical In- and Outpatient Outcomes in Patients with Spinal Cord Injury: A Prospective Multicenter Study in 459 Patients. J Clin Med 2021; 10:4778. [PMID: 34682902 PMCID: PMC8537526 DOI: 10.3390/jcm10204778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/22/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022] Open
Abstract
Prognostic factors for clinical outcome after spinal cord (SC) injury (SCI) are limited but important in patient management and education. There is a lack of evidence regarding magnetic resonance imaging (MRI) and clinical outcomes in SCI patients. Therefore, we aimed to investigate whether baseline MRI features predicted the clinical course of the disease. This study is an ancillary to the prospective North American Clinical Trials Network (NACTN) registry. Patients were enrolled from 2005-2017. MRI within 72 h of injury and a minimum follow-up of one year were available for 459 patients. Patients with American Spinal Injury Association impairment scale (AIS) E were excluded. Patients were grouped into those with (n = 354) versus without (n = 105) SC signal change on MRI T2-weighted images. Logistic regression analysis adjusted for commonly known a priori confounders (age and baseline AIS). Main outcomes and measures: The primary outcome was any adverse event. Secondary outcomes were AIS at the baseline and final follow-up, length of hospital stay (LOS), and mortality. A regression model adjusted for age and baseline AIS. Patients with intrinsic SC signal change were younger (46.0 (interquartile range (IQR) 29.0 vs. 50.0 (IQR 20.5) years, p = 0.039). There were no significant differences in the other baseline variables, gender, body mass index, comorbidities, and injury location. There were more adverse events in patients with SC signal change (230 (65.0%) vs. 47 (44.8%), p < 0.001; odds ratio (OR) = 2.09 (95% confidence interval (CI) 1.31-3.35), p = 0.002). The most common adverse event was cardiopulmonary (186 (40.5%)). Patients were less likely to be in the AIS D category with SC signal change at baseline (OR = 0.45 (95% CI 0.28-0.72), p = 0.001) and in the AIS D or E category at the final follow-up (OR = 0.36 (95% CI 0.16-0.82), p = 0.015). The length of stay was longer in patients with SC signal change (13.0 (IQR 17.0) vs. 11.0 (IQR 14.0), p = 0.049). There was no difference between the groups in mortality (11 (3.2%) vs. 4 (3.9%)). MRI SC signal change may predict adverse events and overall LOS in the SCI population. If present, patients are more likely to have a worse baseline clinical presentation (i.e., AIS) and in- or outpatient clinical outcome after one year. Patients with SC signal change may benefit from earlier, more aggressive treatment strategies and need to be educated about an unfavorable prognosis.
Collapse
Affiliation(s)
- Thorsten Jentzsch
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - David W. Cadotte
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Combined Spine Program, Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, St. Michael’s Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
| | - Fan Jiang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Jetan H. Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Muhammad A. Akbar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Brett Rocos
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Robert G. Grossman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX 77030, USA;
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA;
| | - James S. Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| |
Collapse
|
3
|
McQuail PM, McCartney BS, Baker JF, Jaadan M, McCabe JP. Management of Metastatic Spinal Cord Compression in Ireland: Are Surgeons Overlooked? Int J Spine Surg 2018; 12:428-433. [PMID: 30276102 DOI: 10.14444/5051] [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: 11/20/2022] Open
Abstract
Background The National Institute of Health and Clinical Excellence (NICE) provide a framework of evidence-based guidelines for the management of metastatic spinal cord compression (MSCC). We aimed to compare our center's provision of service to these best practice guidelines and discuss key shortcomings with their implications for the spinal surgeon. Methods Patients with radiologic evidence of MSCC over a 30-month period were identified using the hospital electronic radiological database. A chart review was performed analyzing MSCC management. Results Forty-one patients were identified. Pain was the most common presenting complaint, occurring in 76% of patients. Radiotherapy alone was the most common therapy employed (93% of patients). A surgical opinion was sought for 51% of patients. Histological diagnosis of the causative lesion occurred in 5 patients from surgical specimens. Conclusions Incongruities between NICE guidelines and our practice exist. Early involvement of the spinal surgical services needs to be encouraged. Establishing a histological diagnosis of the spinal lesion should be seen as of therapeutic importance.
Collapse
Affiliation(s)
- Paula M McQuail
- Department of Trauma and Orthopaedic Surgery, Galway University Hospital Network, Ireland
| | - Ben S McCartney
- Royal College of Surgeons Ireland, Stephens Green, Dublin, Ireland
| | - Joseph F Baker
- Department of Trauma and Orthopaedic Surgery, Galway University Hospital Network, Ireland
| | - Mutaz Jaadan
- Department of Trauma and Orthopaedic Surgery, Galway University Hospital Network, Ireland
| | - John P McCabe
- Department of Trauma and Orthopaedic Surgery, Galway University Hospital Network, Ireland
| |
Collapse
|
4
|
Kepler CK, Vaccaro AR, Koerner JD, Dvorak MF, Kandziora F, Rajasekaran S, Aarabi B, Vialle LR, Fehlings MG, Schroeder GD, Reinhold M, Schnake KJ, Bellabarba C, Cumhur Öner F. Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1082-6. [PMID: 25599849 DOI: 10.1007/s00586-015-3765-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/08/2015] [Accepted: 01/09/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably. METHODS A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ). RESULTS The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility. CONCLUSION In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.
Collapse
Affiliation(s)
- Christopher K Kepler
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - John D Koerner
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | | | - Frank Kandziora
- Berufsgenossenschaftliche Unfallklinik Frankfurt, Center for Spinal Surgery and Neurotraumatology, Friedberger Landstrasse 430, 60389, Frankfurt, Germany
| | | | - Bizhan Aarabi
- University of Maryland Medical Center, College Park, MD, USA
| | | | - Michael G Fehlings
- University of Toronto Spine Program and Toronto Western Hospital, Toronto, ON, Canada
| | - Gregory D Schroeder
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Maximilian Reinhold
- Klinikum Suedstadt Rostock, Department of Orthopaedic and Trauma Surgery, Suedring 81, 18059, Rostock, Germany
| | - Klaus John Schnake
- Center for Spinal Surgery and Neurotraumatology, Berufsgenossenschaftliche Unfallklinik Frankfurt, Friedberger Landstrasse 430, 60389, Frankfurt/Main, Germany
| | - Carlo Bellabarba
- Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Box 359798, Seattle, WA, 98104, USA
| | - F Cumhur Öner
- School of Medicine, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| |
Collapse
|
5
|
Brooks FM, Ghatahora A, Brooks MC, Warren H, Price L, Brahmabhatt P, De Vauvert S, John C, Farnworth E, Sulaiman E, Ahuja S. Management of metastatic spinal cord compression: awareness of NICE guidance. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 24 Suppl 1:S255-9. [DOI: 10.1007/s00590-014-1438-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/25/2014] [Indexed: 11/30/2022]
|