Diagnosis of cauda equina syndrome in the emergency department

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.

787 Evaluation of the role of anal tone and perianal sensation examination in the assessment of suspected cauda equina syndrome

Aims/Objectives/Background

Cauda equina syndrome (CES) can present with a varied constellation of clinical signs and symptoms, which together with the time sensitive nature of the condition and risk of catastrophic clinical outcome, presents a significant challenge to those assessing patients with this suspected diagnosis. Anal tone is commonly tested during initial assessment using a digital rectal examination (DRE). This study aims to evaluate the diagnostic value of anal tone and perianal sensation assessment in patients with suspected CES and report modern prevalence data on CES within a neurosciences centre.

Methods/Design

Consecutive patients with suspected CES presenting over a three-year period to the Emergency Department (ED) of a busy tertiary centre were included in the study. History and examination findings, documented in the ED notes, were assessed and these variables were correlated with the presence or absence of cauda equina compression on subsequent magnetic resonance imaging (MRI).

Results/Conclusions

Out of 1005 patients with suspected CES, 117 (11.6%) had MRI confirmed cauda equina compression (MRI +ve CES). 35% of MRI +ve patients and 31% of MRI -ve patients had reduced anal tone. Using univariate and multivariable logistic regression analyses, no associations were found between abnormal anal tone and MRI +ve CES for patients of all ages. The univariate logistic regression analysis identified altered perianal sensation to be significantly associated with MRI +ve CES in patients ≤ 42 years old. This association was no longer present when an adjusted multivariable logistic regression was performed.

The prevalence of MRI +ve CES was 11.6%. Our findings suggest that the clinical finding of reduced anal tone has no demonstrable diagnostic value for those with suspected CES, either in itself or in combination with other clinical findings. Further studies are needed to confirm the diagnostic efficacy of assessing perianal sensation in this context.

Evaluation of the role of anal tone and perianal sensation examination in the assessment of suspected cauda equina syndrome

PURPOSE

Cauda equina syndrome (CES) can present with a varied constellation of clinical signs and symptoms, which together with the time-sensitive nature of the condition and risk of catastrophic clinical outcome, presents a significant challenge to those assessing patients with this suspected diagnosis. Anal tone is commonly tested during initial assessment using a digital rectal examination (DRE). This study aims to evaluate the diagnostic value of anal tone and perianal sensation assessment in patients with suspected CES and report modern prevalence data on CES within a neurosciences centre.

MATERIALS AND METHODS

Consecutive patients with suspected CES presenting over three years to the Emergency Department (ED) of a busy tertiary centre were included in the study. History and examination findings, documented in the ED notes, were assessed and these variables were correlated with the presence or absence of cauda equina compression on subsequent magnetic resonance imaging (MRI).

RESULTS

Out of 1005 patients with suspected CES, 117 (11.6%) had MRI confirmed cauda equina compression (MRI + ve CES). 35% of MRI + ve patients and 31% of MRI -ve patients had reduced anal tone. Using univariate and multivariable logistic regression analyses, no associations were found between abnormal anal tone and MRI + ve CES for patients of all ages. The univariate logistic regression analysis identified altered perianal sensation to be significantly associated with MRI + ve CES in patients ≤42 years old. This association was no longer present when an adjusted multivariable logistic regression was performed.

CONCLUSION

The prevalence of MRI + ve CES was 11.6%. Our findings suggest that the clinical finding of reduced anal tone has no demonstrable diagnostic value for those with suspected CES, either in itself or in combination with other clinical findings. Further studies are needed to confirm the diagnostic efficacy of assessing perianal sensation in this context.

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

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.

The Cauda Scale - Validation for Clinical Practice

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.

BET 2: Is sexual dysfunction a recognised sign of cauda equina syndrome in the ED?

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.

The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery

Background

This paper aims to review the introduction of an enhanced recovery after surgery (ERAS) service within complex spinal surgery, with an aim to assess if this is a cost effective way to improve the overall experience of such complex surgery.

Methods

The ERAS model was defined and followed within a regional centre for complex spinal surgery in the UK. Outcomes such as length of stay (LOS) and satisfaction were measured before and after implementation of the service.

Results

LOS was reduced and both patient and staff satisfaction improved following the implementation of the ERAS service.

Conclusions

The ERAS model can successfully be implemented within complex spinal surgery, to help improve satisfaction and reduce cost.

New approaches to the restoration of shallow marginal peatlands

Globally, the historic and recent exploitation of peatlands through management practices such as agricultural reclamation, peat harvesting or forestry, have caused extensive damage to these ecosystems. Their value is now increasingly recognised, and restoration and rehabilitation programmes are underway to improve some of the ecosystem services provided by peatlands: blocking drainage ditches in deep peat has been shown to improve the storage of water, decrease carbon losses in the long-term, and improve biodiversity. However, whilst the restoration process has benefitted from experience and technical advice gained from restoration of deep peatlands, shallow peatlands have received less attention in the literature, despite being extensive in both uplands and lowlands. Using the experience gained from the restoration of the shallow peatlands of Exmoor National Park (UK), and two test catchments in particular, this paper provides technical guidance which can be applied to the restoration of other shallow peatlands worldwide. Experience showed that integrating knowledge of the historical environment at the planning stage of restoration was essential, as it enabled the effective mitigation of any threat to archaeological features and sites. The use of bales, commonly employed in other upland ecosystems, was found to be problematic. Instead, 'leaky dams' or wood and peat combination dams were used, which are both more efficient at reducing and diverting the flow, and longer lasting than bale dams. Finally, an average restoration cost (£306 ha(-1)) for Exmoor, below the median national value across the whole of the UK, demonstrates the cost-effectiveness of these techniques. However, local differences in peat depth and ditch characteristics (i.e. length, depth and width) between sites affect both the feasibility and the cost of restoration. Overall, the restoration of shallow peatlands is shown to be technically viable; this paper provides a template for such process over analogous landscapes.

Determination of the purity of valine by isocratic liquid chromatography coupled with charged aerosol detection (CAD)

A liquid chromatography coupled with charged aerosol detection (LC-CAD) procedure; capable of separating and quantifying the most common impurities of valine at levels as low as 0.05 per cent (m/m), has been developed. The procedure is simple (isocratic), rapid, linear, sensitive and repeatable. It employs a widely available and inexpensive stationary phase (C18).

Antimicrobial resistance of Salmonella enterica typhimurium DT104 isolates and investigation of strains with transferable apramycin resistance

An examination of salmonella isolates collected by the Scottish Agricultural College Veterinary Services Division from April 1994 to May 1995 was conducted to determine the extent to which Salmonella enterica serotype Typhimurium phage type 104 (DT104) occurred and to investigate the antimicrobial resistance patterns of isolates. Typhimurium DT104 was the predominant salmonella and was isolated from nine species of animal. All isolates of this phage type possessed resistance to at least one antimicrobial and 98% of the isolates were resistant to multiple antimicrobials with R-type ACTSp the predominant resistance pattern. Various other resistance patterns were identified and transferable resistance to the veterinary aminoglycoside antimicrobial apramycin was demonstrated in three strains. A retrospective study for gentamicin resistance in isolates from the Scottish Salmonella Reference Laboratory collection revealed a human isolate of Typhimurium DT104 resistant to gentamicin but sensitive to apramycin and a bovine isolate with apramycin and gentamicin resistance.

Abnormal clearance of immune complexes from the circulation of patients with primary sclerosing cholangitis

The ability of fixed macrophages of the reticuloendothelial system to clear circulating immune complexes was studied in 6 patients with primary sclerosing cholangitis, 5 patients with various other forms of chronic liver disease, and 12 normal control subjects. Autologous red cells were radiolabeled with 51Cr and sensitized with anti-Rh(D) immunoglobulin G in vitro. After intravenous infusion of the labeled antibody-coated red cells, the radioactivity content of timed blood specimens was measured. The time required by the reticuloendothelial system to clear one-half the labeled cells from the circulation (t1/2) was then determined. The t1/2 clearance times were significantly prolonged in all 6 patients with primary sclerosing cholangitis, whereas the clearance times in 4 of the 5 liver disease control patients were either normal or shortened. Serum immunoglobulin G and immunoglobulin M immune complex levels did not correlate with t1/2 clearance times. These results suggest that in primary sclerosing cholangitis there is a defect in the ability of fixed macrophages of the reticuloendothelial system to mediate clearance of circulating particles that have been opsonized with immunoglobulin G. This finding further supports recent data that incriminates the immune system in the pathogenesis of primary sclerosing cholangitis.