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Metcalfe D, Hoeritzauer I, Angus M, Novak A, Hutton M, Woodfield J. Diagnosis of cauda equina syndrome in the emergency department. Emerg Med J 2023; 40:787-793. [PMID: 37669831 DOI: 10.1136/emermed-2023-213151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023]
Abstract
Cauda equina syndrome (CES) is a spinal emergency that can be challenging to identify from among the many patients presenting to EDs with low back and/or radicular leg pain. This article presents a practical guide to the assessment and early management of patients with suspected CES as well as an up-to-date review of the most important studies in this area that should inform clinical practice in the ED.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ingrid Hoeritzauer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Michelle Angus
- Complex Spinal Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Alex Novak
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mike Hutton
- Exeter Spinal Surgery Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Julie Woodfield
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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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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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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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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