Evaluation and management of cauda equina syndrome in the emergency department

The experience and need of patients with cauda equina syndrome caused by lumbar disc herniation: a phenomenological qualitative study

OBJECTIVE

Cauda equina syndrome (CES) is an emergency disease that can lead to serious sequelae. The purpose of this study was to deeply understand the experience and need of patients with CES caused by lumbar disc herniation (LDH).

METHODS

Sixteen patients diagnosed as CES caused by LDH were enrolled. Descriptive phenomenology was used to collect data through semistructured face-to-face interviews. Colaizzi7's seven-step analysis method was used to sort out and code the original interview data to form the thematic framework.

RESULTS

Four themes were extracted from the interviews. The theme 1 was difficulty of disease recognition and doctor selection, the subtheme were Poor knowledge of the disease and the difficulty of choosing a hospital and department. The theme 2 was lacking of specialized information and misleading by misinformation, the subtheme were desire for information related to surgery and rehabilitation and misinformation affected the patients' decision-making. The theme 3 was coordination and process issues within health system, the subtheme were the sharing or mutual recognition of examination results and not clear about the medical insurance policy. The theme 4 was emotional response and psychological need, the subtheme were preoperative inner conflict, worry about the prognosis and desire for family and external support.

CONCLUSION

This study demonstrated that CES patients faced complex challenges throughout the treatment process. These issues should be studied and solved in the future.

A case of spinal epidural abscess, cauda equina syndrome, retroperitoneal abscess, aortic graft infection and aortoenteric fistula

Low back pain is a common complaint in those presenting to the emergency department (ED), but only a small fraction of patients will have an emergent pathology. Specific features such as immunocompromised status, injection drug use, preexisting infection, fever, urinary or fecal retention or incontinence, perineal sensory changes, or lower extremity weakness should prompt the emergency physician to consider emergent pathology. We discuss the case of a 61-year-old male with extensive past medical history including thoracoabdominal aneurysm repair, aortoenteric fistula with chronic infection, and severe lumbar neural foraminal narrowing who presented with complaints of low back pain, fecal incontinence, and motor weakness of the left lower extremity. Subsequent magnetic resonance imaging and computed tomography scan demonstrated multiple pathologies including spinal epidural abscess, cauda equina syndrome, retroperitoneal abscess, and aortic graft infection with aortoenteric fistula, conditions associated with significant morbidity and mortality.

Causal Association Between Inflammatory Proteins, Inflammatory Cells, and Cauda Equina Syndrome: A Two-Sample Mendelian Randomization

BACKGROUND

Recent studies have shown that inflammation plays a crucial role in the progression of cauda equina syndrome (CES). However, the exact cause-and-effect relationship between them is still unclear.

METHODS

We used CES data from the FinnGen genome-wide association study (GWAS), containing 329 cases and 408,351 control patients. Inflammatory proteins data were obtained from a large scale GWAS of 14,828 European ancestry participants, and inflammatory cells data were obtained from a GWAS summary of 3757 Sardinians. We chose inverse variance weighted as the main method and the Cochrane Q test to assess heterogeneity in the results. The MR-Egger intercept test and MR pleiotropy residual sum and outliers test were used to evaluate the horizontal pleiotropy, and sensitivity analysis was performed by leave-one-out analysis.

RESULTS

We examined robust associations between inflammatory proteins, inflammatory cells, and CES using Mendelian randomization. Two inflammatory proteins and 12 inflammatory cells were found as risk factors for CES: IL-8 and PD-L1; and basophil plasmacytoid dendritic cell, CD86+plasmacytoid dendritic cell, CD62L-plasmacytoid dendritic cell, CD39+secreting Treg, IgD+CD38-B cell, switched memory B cell, IgD+CD24+B cell, CD62L+dendritic cell, CD4+T cell, γδ T cell, and CD33dim HLA DR-myeloid cell. Two inflammatory proteins and 7 inflammatory cells were found as protective factors for CES: IL-10RA and CCL25; and transitional B cell, terminal differentiation double negative T cell, CD28-CD127-CD25++CD8br T cell, IgD+CD38br B cell, CD28+CD45RA-CD8br Treg, IgD+CD38-naive B cell, and granulocyte. Heterogeneity and pleiotropy analysis confirmed the reliability of the results. Our study reveals the causal relationship between inflammatory proteins, inflammatory cells, and CES, offering new insights for the development of future therapeutic drugs and early warning indicators.

CONCLUSIONS

Our findings extend genetic research to causal analysis between inflammatory proteins, cells, and CES. We found 2 proteins and 12 cells as risk factors and 2 proteins and 7 cells as protective factors. Further investigations are needed to verify whether these inflammation markers can be used to prevent or treat CES.

An emergency medicine review: Multiple myeloma and its complications

INTRODUCTION

Multiple myeloma (MM) and its complications carry a high rate of morbidity and mortality.

OBJECTIVE

This review evaluates MM and its complications, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

MM is the second most common hematologic cancer and associated with monoclonal plasma cell proliferation. The presentation of MM varies, ranging from few symptoms to end organ injury and failure. The most common presenting findings include anemia, bone pain, renal injury, fatigue, hypercalcemia, and weight loss. While clinical outcomes have improved with known therapies, a variety of complications may occur. Anemia is the most common hematologic complication, though hyperviscosity syndrome, bleeding, and coagulopathy may occur. Renal injury is common, and hypercalcemia is the result of bone demineralization. Infection is a major cause of morbidity and mortality. Osteolytic bone disease is a significant feature of MM, present in 70 % of patients, which may result in pathologic and insufficiency fractures. The most serious neurologic complication includes spinal cord compression, and other neurologic complications include peripheral neuropathy and intracranial involvement. Cardiac toxicity may occur with MM therapies, and there is also increased risk of venous thromboembolism. Endocrine complications may also occur, including adrenal insufficiency and thyroid dysfunction.

CONCLUSIONS

An understanding of the complications of MM can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

COVID-19 and Spontaneous Resolution of Lumbar Disk Prolapse: A Retrospective Cohort Study of Patients Awaiting Microdiscectomy

BACKGROUND

 Between individual patients with lumbar disk prolapse (LDP), the natural course of disease is significantly variable. Spontaneous resolution is reported to occur in up to 70% of cases. However, we currently cannot predict for whom and when this will occur. Neurosurgical intervention is indicated for LDP patients with nontolerable pain after at least 8 to 12 weeks of conservative management, or significant neurologic deficit. Channeling essential resources in the National Health Service (NHS) to fight the COVID-19 pandemic led to the postponement of most elective operations, including microdiskectomy. This left many LDP patients previously considered to be surgical candidates with conservative-only options in the interim. To our knowledge, we are the first center to report the specific impact of the peri- and postpandemic period on waiting list times, delayed elective microdiskectomy, and the incidence of spontaneous LDP resolution.

METHODS

 Retrospective case series of a prospectively collected electronic departmental database identified LDP patients who would have been impacted by the COVID-19 pandemic at some point in their care pathway (March 2020-February 2022). Further information was obtained from electronic patient records.

RESULTS

 In total, 139 LDP patients were listed for elective microdiskectomy at the time of postponement of elective surgery. Over a third of LDP patients (n = 47, 33.8%), in shared decision with the responsible neurosurgeon, had their rescheduled microdiskectomy canceled due to clinical improvement (14.1%), radiologic regression (6.5%), or both (12.2%).

CONCLUSION

 Our single-center retrospective analysis revealed that for over a third of LDP patients, the prolonged postpandemic waiting list times for elective microdiskectomy resulted in their surgery not taking place either due to spontaneous clinical improvement or proven radiologic regression. Considering this, a prolonged conservative approach to LDP may be appropriate in some patients, allowing time for natural resolution, while avoiding perioperative risks.

Health care disparities in complication and mortality rates following surgical management of cauda equina syndrome in New York State

CONTEXT

While healthcare disparities related to race and ethnicity are well reported for non-emergent conditions, the literature on disparities in outcomes of emergent spinal conditions such as cauda equina syndrome (CES) remains sparse.

OBJECTIVE

To evaluate racial disparities in complication, mortality, and readmission rates following surgical intervention for CES.

METHODS

This retrospective analysis of The Statewide Planning and Research Cooperative System (SPARCS) database demonstrates that among patients surgically treated for CES in New York between 2015 and 2020. Bivariate and multivariate logistic regression analysis was performed to analyze the association of race and outcome variables after controlling for age, sex, comorbidities, length of stay, insurance, and hospital characteristics.

RESULTS

Overall, 2,114 patients who underwent lumbar surgery for CES were identified. The study population was comprised of Black patients (177, 8%), White patients (79%, 1680), and Asian patients (257, 12%). Options for surgery included lumbar decompression (821, 38.8%), fusion (746, 35.3%), or both (547, 25.9%). On multivariate analysis, the odds of 30-day mortality were 2.98-fold greater in Black patients than in other patients (P = 0.029). By 180 and 360 days, the odds of mortality were 4.27 and 3.05-fold greater in Black patients than in other patients, respectively (P < 0.001 each). Thirty-day readmissions were 1.87-fold greater in Black patients than others (P = 0.004). No difference in overall complication rate was found between Black patients and all other race groups (P = 0.306).

CONCLUSIONS

Black patients surgically treated for CES face significantly higher rates of mortality and readmission than their non-Black counterparts.

What Degree of Radiological Compression Predicts Cauda Equina Syndrome: A Retrospective Study at a National Tertiary Center

OBJECTIVE

Cauda equina syndrome (CES) is diagnosed both clinically and radiologically. However, it's unclear if a specific degree of cauda equina compression on imaging can confirm the diagnosis. This study aimed to identify an optimal percentage of prolapse to canal ratio (PCR) on magnetic resonance imaging that correlates with cauda equina compression, facilitating reliable decision-making for CES symptoms.

METHODS

A single-center retrospective case series analysis was conducted from 2020 to 2021. Sixty-one patients who underwent emergency lumbar discectomy within 48 hours of presentation were included, divided into a CES group and a disc prolapse group. CES cases were identified using International Classification of Diseases, 10th Revision code G83.4. PCR was calculated by dividing the width of the disc herniation by the total width of the spinal canal at the level of the herniation on single mid-sagittal T2 magnetic resonance imaging scans, using the IC Measure software on Windows.

RESULTS

CES most frequently occurred at the L4/5 level (37/61). The median PCR in CES cases was 76.19% (66.67-85.71), significantly higher than in disc prolapse cases, 48.08% (31.33-55.56) (P < 0.001). A PCR threshold of 40% maximized sensitivity at 100% but had a specificity of 45%. Conversely, a threshold of 75% maximized specificity at 100% with a sensitivity of 50%. The optimal PCR, determined by the Youden index, was 66%, yielding a sensitivity of 75% and specificity of 97%, with an area under the curve of 0.923.

CONCLUSIONS

Simple radiological measurements of PCR can potentially triage CES patients and guide their management. Future studies should correlate PCR with clinical signs and symptoms for a comprehensive assessment.

Patients returning to the emergency department with symptoms of cauda equina syndrome: do the symptoms differ with radiological cauda equina compression?

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.

Revolutionizing Bladder Health: Artificial-Intelligence-Powered Automatic Measurement of Bladder Volume Using Two-Dimensional Ultrasound

INTRODUCTION

Measuring elevated post-void residual volume is important for diagnosing urinary outflow tract obstruction and cauda equina syndrome. Catheter placement is exact but painful, invasive, and may cause infection, whereas an ultrasound is accurate, painless, and safe.

AIM

The purpose of this single-center study is to evaluate the accuracy of a module for artificial-intelligence (AI)-based fully automated bladder volume (BV) prospective measurement using two-dimensional ultrasound images, as compared with manual measurement by expert sonographers.

METHODS

Pairs of transverse and longitudinal bladder images were obtained from patients evaluated in an urgent care clinic. The scans were prospectively analyzed by the automated module using the prolate ellipsoid method. The same examinations were manually measured by a blinded expert sonographer. The two methods were compared using the Pearson correlation, kappa coefficients, and the Bland-Altman method.

RESULTS

A total of 111 pairs of transverse and longitudinal views were included. A very strong correlation was found between the manual BV measurements and the AI-based module with r = 0.97 [95% CI: 0.96-0.98]. The specificity and sensitivity for the diagnosis of an elevated post-void residual volume using a threshold ≥200 mL were 1.00 and 0.82, respectively. An almost-perfect agreement between manual and automated methods was obtained (kappa = 0.85). Perfect reproducibility was found for both inter- and intra-observer agreements.

CONCLUSION

This AI-based module provides an accurate automated measurement of the BV based on ultrasound images. This novel method demonstrates a very strong correlation with the gold standard, making it a potentially valuable decision-support tool for non-experts in acute settings.

Relationship between sarcopenia and fatty liver in middle-aged and elderly patients with type 2 diabetes mellitus

OBJECTIVE

In this study, we investigated the relationship between sarcopenia and fatty liver in middle-aged and elderly patients diagnosed with type 2 diabetes mellitus (T2DM) to provide a theoretical foundation for the prevention and treatment of sarcopenia.

METHODS

A total of 282 patients diagnosed with T2DM aged 50 and older and were admitted to the Endocrinology Department of Xin Medical University First Affiliated Hospital between December 2021 and February 2023, were selected. Body mass index (BMI), and limb and trunk muscle mass of the patients were measured, and data were collected. Patients were grouped based on the sarcopenia diagnostic criteria. All study participants underwent the same physical examinations and laboratory tests. The relationship between the onset of sarcopenia and fatty liver in middle-aged and elderly patients diagnosed with T2DM was then investigated using statistical analysis.

RESULTS

Comparing the sarcopenia group to the non-sarcopenia group revealed statistically significant variations in gender, BMI, fatty liver prevalence rate, uric acid (UA), alanine aminotransferase (ALT), blood glucose, blood lipid associated indicators, and limb skeletal muscle content. There were, however, no statistically significant differences in age, disease duration, hypertension, smoking, or alcohol intake. There was a positive correlation between BMI, UA, fasting c-peptide, and Appendicular Skeletal Muscle Index (ASMI). Higher levels of BMI, ASMI, and UA were identified as protective variables against sarcopenia by multifactorial logistic regression analysis.

CONCLUSION

Higher levels of BMI, ASMI, and UA can greatly reduce skeletal muscle atrophy in patients with T2DM. Patients with a fatty liver may be less vulnerable to sarcopenia. There is little evidence, however, that a fatty liver works as a preventive factor against sarcopenia.

Peripheral nervous system and neuromuscular disorders in the emergency department: A review

INTRODUCTION

Acute presentations and emergencies in neuromuscular disorders (NMDs) often challenge clinical acumen. The objective of this review is to refine the reader's approach to history taking, clinical localization and early diagnosis, as well as emergency management of neuromuscular emergencies.

METHODS

An extensive literature search was performed to identify relevant studies. We prioritized meta-analysis, systematic reviews, and position statements where possible to inform any recommendations.

SUMMARY

The spectrum of clinical presentations and etiologies ranges from neurotoxic envenomation or infection to autoimmune disease such as Guillain-Barré Syndrome (GBS) and myasthenia gravis (MG). Delayed diagnosis is not uncommon when presentations occur "de novo," respiratory failure is dominant or isolated, or in the case of atypical scenarios such as GBS variants, severe autonomic dysfunction, or rhabdomyolysis. Diseases of the central nervous system, systemic and musculoskeletal disorders can mimic presentations in neuromuscular disorders.

CONCLUSIONS

Fortunately, early diagnosis and management can improve prognosis. This article provides a comprehensive review of acute presentations in neuromuscular disorders relevant for the emergency physician.

Aortoiliac occlusion mimicking cauda equina syndrome, a diagnostic dilemma: A case report and review of the literature

Background

Cauda equina syndrome (CES) is a consequence of a variety of etiologies. CES is most commonly due to compression of the thecal sac and nerve roots by a massive disc herniation. However, it rarely presents secondary to aortic occlusion. Aortoiliac occlusive disorder is usually associated with chronic claudication, erectile dysfunction, and diminished lower limb pulses. Acute aortic occlusion, however, is associated with serious complications such as spinal cord infarction and ischemia. It is also associated with a high risk of morbidity and mortality. Moreover, it poses a diagnostic challenge and may be overlooked. This report emphasizes the importance of considering vascular etiology as a differential diagnosis for CES.

Case Description

This case report describes a unique case of aortic occlusion mimicking CES in a 56-year-old female patient.

Conclusion

For patients presenting with cauda equina symptomatology, it is critical to consider vascular etiology, especially for those with cardiovascular risk factors. Spine surgeons and emergency physicians should maintain a high index of suspicion for vascular etiologies and consider appropriate imaging studies to promote early diagnosis and intervention to prevent subsequent neurological and life-threatening consequences.

Cauda equina syndrome

Cauda equina syndrome is an uncommon but serious cause of lower back pain resulting from compression of the cauda equina nerve roots, most commonly by lumbar disc herniation. Red flag symptoms, such as bladder dysfunction, saddle anaesthesia and sciatica, should lead to high clinical suspicion of cauda equina syndrome. The British Association of Spinal Surgeons has published an updated standard of care for these patients because of the potentially debilitating effects of missed cases of cauda equina syndrome. This review summarises these standards and provides a framework to support quick triage of at-risk patients. Immediate magnetic resonance imaging, within 1 hour of presentation to the emergency department, is crucial in patients with suspected cauda equina syndrome to allow prompt diagnosis and treatment. Urgent decompressive surgery is usually recommended for the best outcomes, to reduce morbidity and complication rates.

High risk and low prevalence diseases: Acute limb ischemia

INTRODUCTION

Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization.

CONCLUSIONS

An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Acupuncture treatment of acute urinary retention caused by varicella-zoster virus through by combining the mechanism of sacral neuromodulation: A rare case report

RATIONALE

Urinary dysfunction triggered by varicella-zoster virus (VZV) attacking the nervous system seriously affects the quality of life of patients and may even cause irreversible damage to the urinary system. This a 62-year-old man with acute urinary retention triggered by VZV, who was cured after acupuncture treatment. The rational application of acupuncture therapy to promote the recovery of bladder contraction function can effectively relieve the symptoms of dysuria, shorten the course of the disease.

PATIENT CONCERNS

Symptoms included dysuria and distension of the bladder area secondary to postherpetic herpes zoster, with significant pressure and pain in his lower abdomen, accompanied by cutaneous herpes distributed over the sacral region.

DIAGNOSES

The case was diagnosed as acute urinary retention (Neurogenic Bladder). Ancillary tests include urodynamic examination, Doppler ultrasound, urodynamic tests are the preferred diagnostic method and suggest: no contraction of the detrusor muscle is seen during voiding, and voiding occurs in an The absence of abdominal pressure-assisted micturition and repeated attempts to pass urine suggests detrusor weakness; residual urine suggests a severe bladder emptying disorder. Doppler ultrasound suggested overfilling of the bladder, and 1153 mL of residual urine was seen in the bladder after voiding.

INTERVENTIONS

The patient developed sacral herpes and dysuria and was treated with oral antiviral drugs on the 12th day of illness. But his urinary difficulty did not improve but gradually worsened, resulting in acute urinary retention, and he then turned to the acupuncture treatment, innovative approach combined the mechanism of action of sacral neuromodulation with traditional Chinese medicine theory.

OUTCOMES

The duration of acupuncture treatment totaled 12 weeks; he was able to urinate on her own and her symptoms completely disappeared. No other adverse and unintended events occurred during treatment.

LESSONS

This study demonstrates that acupuncture is safe and effective in the treatment of acute urinary retention caused by VZV, which is worth recommending as a conservative treatment. Moreover, we found that the early intervention and full-term treatment with acupuncture is particularly important, provided that the right key acupoints are selected.

A comparison of the safety and efficacy of minimally invasive surgery versus open surgery in treating cauda equina syndrome: A systematic review and meta-analysis

PURPOSE

To compare the safety and efficacy of minimally invasive surgery (MIS) and open surgery (OS) in treating cauda equina syndrome (CES).

METHODS

A systematic literature search was conducted, searching relevant databases for studies investigating MIS and/or OS in treating CES. Pooled outcomes and their 95% confidence intervals (CIs) were meta-analyzed via random-effects models.

RESULTS

Ten studies were included in the meta-analysis. Pooled mean operation times were shorter for MIS (75.4 min; 95 %CI: 40.8, 110.0) than OS (155.1 min; 121.3, 188.9). Similarly, mean hospital stay was shorter for MIS (4.08 days; 2.77, 5.39 vs. 8.85 days; 6.56, 11.13). Mean blood loss was smaller for MIS (71.7 mL; 0, 154.5 vs. 366.5; 119.1, 614.0). Mean post-op lumbar/back visual analogue scale (VAS) score was lower for MIS (3.65; 2.75, 4.56 vs. 5.80; 4.55, 7.05). Mean post-op leg VAS score was 1.27 (0.41, 21.4) for MIS and 1.29 (0.47, 2.12) for OS. Mean complete bladder recovery rate was 81.0% (55.0%, 94.0%) for MIS and 75.0% (44.0%, 92.0%) for OS. Mean complete motor recovery rate was larger for MIS (70.0%; 48.0, 85.0 vs. 42.0%; 34.0, 51.0). Mean percentages of "excellent" patient outcomes were equal for MIS (64.0%; 48.0%, 77.0%) and OS (64.0%; 22.0%, 92.0%).

CONCLUSION

MIS for CES was associated with reduced operative time, length of stay, and blood loss, compared to OS. MIS was also associated with better post-operative lumbar/back and leg VAS scores and complete motor and bladder recovery rates. MIS and OS produced an equal average percentage of "excellent" patient outcomes.

Case study highlighting cauda equina syndrome and the effects on bladder management

Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, where all the nerves in the lower back suddenly become severely compressed. It is a serious medical emergency, and compression of the nerves in the lower portion of the spinal canal can lead to permanent loss of bowel and bladder control, paraesthesia, and paralysis of the legs if left untreated. Causes of CES include: trauma, spinal stenosis, herniated discs, spinal tumour, cancerous tumour, inflammatory and infectious conditions or due to an accidental medical intervention. CES patients typically present with symptoms of: saddle anaesthesia, pain, incontinence and numbness. Any of these are red flag symptoms and require immediate investigation and treatment.

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?

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.

Publication Trends and Hot Spots in Cauda Equina Syndrome: A Bibliometric Analysis and Visualization of Current Research

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.

Minimally invasive decompression alone versus fusion surgery for acute lumbar disk herniation combined incomplete cauda equina syndrome

STUDY DESIGN

Retrospective single center study.

BACKGROUND

Cauda equine syndrome (CES), which caused by acute lumbar disc herniation (LDH), often requires urgent surgical treatment. Currently, there is no standard defining the type of surgery, and approaches to the treatment of patients are based on the experience of the surgeon.

PURPOSE

to compare the clinical efficacy of minimally invasive decompression alone (Decompression alone group) and transforaminal lumbar interbody fusion (Fusion group) in the treatment of the incomplete CES, caused by acute LDH.

PATIENTS AND METHODS

89 patients with acute incomplete CES associated with LDH either underwent decompression alone and fusion surgery from January 2005 to January 2020 in single-center, and data were collected and retrospectively analyzed. The patients were divided into 2 groups according to the operation technics: the Decompression alone group (n = 46) and the Fusion group (n = 43). The perioperative clinical data (neurological deficit, control of the urinary bladder sphincter, ODI scale, SF-36) was used to assess the efficacy of the respective surgical methods before operation and with a minimum follow-up 24 months.

RESULTS

Verified statistical significance more bleeding, longer surgery time and hospital stay, in the Fusion group than in the Decompression alone group. The postoperative clinical data dramatic improved after Decompression alone and Fusion surgery. At early postoperative period registered better clinical outcomes according to ODI, SF-36 after Decompression alone surgery, but at minimum follow-up 24 months verified better in the Fusion group. The number of revision interventions in the Decompression alone group was 28.3% (n = 13), in Fusion group - 9.3% (n = 4) (p = 0.02).

CONCLUSIONS

The prevalence of acute incomplete CES due to LDH in our series was registered in 1.02% of patients (124 of 12087). In the Fusion group, in the long-term period, there were better clinical outcomes and fewer revision surgical interventions compared with Decompression alone.

A Penetrating Lumbar Spine Injury With Misleading Neurological Symptoms

Penetrating spinal injuries require specific neurosurgical attention. To date, there are no guidelines regarding emergency neurosurgical management of such injuries and the decision whether to operate is made individually, based on the neurological examination and the analysis of any imaging available. We report the case of a 22-year-old patient who sustained two gunshots in the thighs and one in the lumbar spine. Clinical examination revealed neurological deficit in both legs prevailing on the right side. Discussion between the radiologist and the neurosurgeon concluded to an injury to the left S1 nerve root within the spinal canal, and to the right sciatic nerve. Thus, there was no need for a decompressive laminectomy. In the light of the current literature, penetrating spinal injuries rarely require an extensive surgical exploration; indications for such a procedure include incomplete neurological deficit with persistent neurological compression, cerebrospinal fluid leakage, and obvious instability. Furthermore, penetrating spinal injuries are rarely encountered, even for military neurosurgeons. Their surgical management and especially the need for laminectomy, stabilization, and dural sac watertight closure are still a matter of debate. An expert consensus statement would give food to surgeons facing penetrating spinal injuries.

Definition and surgical timing in cauda equina syndrome-An updated systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To conduct a systematic review identifying existing definitions of cauda equina syndrome (CES) and time to surgery in the literature for patients with CES.

METHODS

A systematic review was conducted in accordance with the PRISMA statement. Ovid Medline, Embase, CINAHL Plus, and trial registries were searched from October 1st, 2016, to 30th December 2022, and combined with articles identified from a previous systematic review by the same authors (studies published 1990-2016).

RESULTS

A total of 110 studies (52,008 patients) were included. Of these only 16 (14.5%) used established definitions in defining CES, including Fraser criteria (n = 6), British Association of Spine Surgeons (BASS) (n = 5), Gleave and MacFarlane (n = 2), and other (n = 3). Most reported symptoms were urinary dysfunction (n = 44, 40%%), altered sensation in the perianal region (n = 28, 25.5%) and bowel dysfunction (n = 20, 18.2%). Sixty-eight (61.8%) studies included details on time to surgery. There was an increase in percentage of studies defining CES published in the last 5 years compared to ones from 1990-2016 (58.6% vs 77.5.%, P = .045).

CONCLUSIONS

Despite Fraser recommendations, substantial heterogeneity exists in reporting of CES definitions, and a start point for time to surgery, with most authors using self-defined criteria. A consensus is required to define CES and time to surgery, to allow consistency in reporting and study analysis.

[Long-term results and predictors of postoperative outcomes in patients with cauda equina syndrome following degenerative lumbar spine disease]

Cauda equina syndrome (CES) associated with acute disc extrusion or spinal stenosis often requires emergency surgery. Analysis of the Pubmed, Medline and eLibrary databases revealed a few studies devoted to long-term postoperative outcomes in patients with CES caused by degenerative spine disease.

OBJECTIVE

To evaluate long-term postoperative results and predictors of clinical and neurological outcomes in patients with CES caused by degenerative lumbar spine disease.

MATERIAL AND METHODS. D

Ecompressive and decompressive-stabilizing procedures were performed in 211 patients with CES caused by degenerative lumbar spine disease between 2000 and 2020. Long-term clinical parameters were available in 174 patients with mean follow-up period of 7 years. Sixty-eight patients had unsatisfactory postoperative outcomes. We assessed postoperative clinical and neurological outcomes in patients with CES and predictors of these outcomes.

RESULTS

We identified the following predictors of clinical and neurological outcomes using binary logistic regression model: period between clinical manifestation and surgery >48 hours, preoperative neurological impairment, spinal canal diameter, surgical procedure, dimension of herniated disc, ASA score and long-term postoperative analgesia with narcotic analgesics.

CONCLUSION

Preoperative planning and possible correction of the above-mentioned risk factors will potentially improve postoperative outcomes in patients with CES caused by degenerative lumbar spine disease.

Acute aortic occlusion leading to spinal cord ischemia in a 73-year-old: A case report

Background

Cauda equina syndrome (CES) is typically caused by a compressive etiology from a herniated disk, tumor, or fracture of the spine compressing the thecal sac. Here, we report a CES mimic - acute aortic occlusion (AAO), a rare disease that is associated with high morbidity and mortality. AAO can compromise spinal cord blood supply and leads to spinal cord ischemia.

Case Description

Our patient presented with an acute onset of bilateral lower extremity pain and weakness with bowel/bladder incontinence, a constellation of symptoms concerning for CES. However, on initial imaging, there was no compression of his thecal sac to explain his symptomology. Further, investigation revealed an AAO. The patient underwent an emergent aortic thrombectomy with resolution of symptoms.

Conclusion

AAO can mimic CES and should be considered in one's differential diagnosis when imaging is negative for any spinal compressive etiologies.

Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF) Compared with Open TLIF for Acute Cauda Equina Syndrome: A Retrospective Single-Center Study with Long-Term Follow-Up

OBJECTIVES

In a retrospective study, we sought to compare the clinical efficacy and postoperative magnetic resonance imaging (MRI) scans of minimally invasive (MI) and open (O) transforaminal lumbar interbody fusion (TLIF) in the treatment of cauda equina syndrome (CES) caused by lumbar disc herniation.

METHODS

In total, 116 patients with CES associated with disc herniation underwent decompression and stabilization surgery from January 2005 to January 2020 in a single-center study, and data were collected and retrospectively analyzed. The patients were divided into the O-TLIF and the MI-TLIF group. The perioperative clinical data and MRI assessment were used to assess the efficacy of the respective surgical methods preoperatively and with a minimum follow-up of 30 months.

RESULTS

As expected, the O-TLIF group had statistically significantly longer surgery times and hospital stay, more bleeding, and perioperative surgical complications than the MI-TLIF group. At a minimum follow-up period of 30 months, the MI-TLIF group had significantly better Oswestry Disability Index, visual analog scale, and Short-Form-36, and neurologic CES symptoms than the O-TLIF group. The postoperative MRIs revealed a statistically significant difference in the multifidus muscle area in MI group compared with the O group.

CONCLUSIONS

In patients with acute CES caused by disc herniation, MI-TLIF, with decreased disruption of paravertebral tissues and postoperative pain syndrome, results in earlier mobilization and rehabilitation with better long-term clinical outcomes compared with O-TLIF.

Prediction of lower extremity strength by nerve conduction study in cauda equina syndrome

An electrodiagnostic test is more useful than the lower extremity isometric strength test for objectively determining the degree of nerve damage and prognosis in cauda equina syndromes (CES). This study evaluated the correlation between nerve conduction study (NCS) parameters and the lower extremity isometric strength and manual muscle test (MMT) grades. The isometric strengths of knee extension (KE), ankle dorsiflexion (ADF), and ankle plantarflexion (APF) were measured. NCS parameters, MMT, and isometric strength of femoral, peroneal, and tibial nerves were evaluated, including their correlations with each other. A regression equation between the isometric strength and compound muscle action potential (CMAP) amplitudes was derived and cutoff values were used to confirm boundary values of strength and amplitude between the MMT grades. KE isometric strength and femoral nerve CMAP amplitude were significantly correlated (r = 0.738, P < .001). ADF isometric strength and peroneal nerve CMAP amplitude were significantly correlated (tibialis anterior, r = 0.707, P < .001). KE (r = 0.713, P < .001), ADF (r = 0.744, P < .001), and APF (r = 0.698, P < .001) isometric strengths were correlated with the MMT grades. For the regression curve, the second-order curve was more reasonable than the first-order curve. Cutoff femoral nerve CMAP amplitude and isometric strength cutoff values were ≥2.05 mV and 17.3, respectively, for MMT grades 2 to 3 and 2.78 ± 1.08 and 20.8 ± 9.33, respectively, for grade 3. The isometric strengths of the KE, ADF, and APF and the CMAP amplitude of the electrophysiologic parameters were correlated in CES patients and a significant correlation with MMT grade was also identified. Accordingly, it is possible to identify the precise neurological condition, objectively evaluate the degree of paralysis and disability, and determine the quantitative muscle strength from MMT in order to establish an appropriate rehabilitation treatment plan.

Pudendal tumor mimicking cauda equina syndrome and acute radiculopathy: case report

INTRODUCTION

Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts.

CLINICAL PRESENTATION

A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved.

CONCLUSION

CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc.

Review/Perspective: Operations for Cauda Equina Syndromes - “The Sooner the Better”

Background:

Although most studies recommended that early surgery for cauda equina syndromes (CES) be performed within <48 h., the largest and most comprehensive Nationwide Inpatient Sample Database (NISC) series, involving over 25,000 CES patients recommended that time be shortened to 0–<24 h. In short, CES surgery performed “the sooner the better,” was best.

Methods:

The 2 major variants of CES include; incomplete/partial ICES, and those with urinary retention/bowel incontinence (RCES). Those with ICES often exhibit varying combinations of motor weakness, sensory loss (i.e. including perineal numbness), and urinary dysfunction, while RCES patients typically exhibit more severe paraparesis, sensory loss including saddle anesthesia, and urinary/bowel incontinence. The pathology responsible for ICES/RCES syndromes may include; acute disc herniations/stenosis, trauma (i.e. including iatrogenic/ surgical hematomas etc.), infections, abscesses, and other pathology. Surgery for either ICES/RCES may include decompressions to multilevel laminectomies/fusions.

Results:

Following early surgery, most studies showed that ICES and RCES patients exhibited improvement in motor weakness and sensory loss. However, recovery of sphincter function was more variable, being poorer for RCES patients with preoperative urinary retention/bowel incontinence.

Conclusions:

Although early CES surgery was defined in most studies as <48 h., two large NISC series involving over 25, 000 CES patients showed that CES surgery performed within 0 -< 24 h resulted in the best outcomes.

Bowel and Bladder Care in Patients With Spinal Cord Injury

Complete and incomplete spinal cord injuries affect between 250,000 and 500,000 people on an annual basis worldwide. In addition to sensory and motor dysfunction, spinal cord injury patients also suffer from associated conditions such as neurogenic bowel and bladder dysfunction. The degree of dysfunction varies on the level, degree, and type of spinal cord injury that occurs. In addition to the acute surgical treatment of these patients, spine surgeons should understand how to manage neurogenic bowel and bladder care on both a short- and long-term basis to minimize the risk for complications and optimize potential for rehabilitation.

Acute piriformis syndrome mimicking cauda equina syndrome: illustrative case

BACKGROUND

This report depicts a rare case of acutely developed urinary retention as well as sensory and motor disturbances caused by formation of a large hematoma within the piriformis muscle, which caused compression of nerves within the suprapiriform and infrapiriform foramina, thus imitating cauda equina syndrome. Although cases of acute lumbosacral plexopathy have been described, this case is the first time both urinary retention and sensory and motor disturbances were present.

OBSERVATIONS

The most useful tools for diagnosis of acute piriformis syndrome are detailed patient history, magnetic resonance imaging (MRI) of the pelvic region, and electrophysiological testing performed by an experienced electrophysiologist. As a result of diligent rehabilitation, including physiotherapy and electrostimulation, the patient was able to successfully recover, regardless of acute compression of the sacral plexus that lasted 6 days.

LESSONS

Clinicians should actively ask about previous pelvic trauma when taking a patient history in similar cases, especially if the patient is receiving anticoagulation treatment. If MRI of the lumbar spine does not reveal any pathologies, MRI of the pelvic region should be performed. Acute surgical decompression is crucial for preserving neurological function. In similar cases, it is possible to differentiate between spinal cord, cauda equina, and pelvic lesions using electrophysiological studies.

Lumbar disc herniation presenting with fecal incontinence without radiculopathy: A case report

Background:

Lumbar disc herniation (LDH) usually presents with lower extremity symptoms and signs, but rarely with bladder and bowel complaints. Here, we present a 61-year-old female who suffered solely from fecal incontinence (FI) attributed to a large LDH.

Case Description:

The patient presented with FI, but had a normal neurological examination. When the lumbar magnetic resonance imaging of showed a large central L5S1 LDH, the patient underwent an urgent diskectomy. Six months later, her symptoms had improved.

Conclusion:

Patients with large central LDHs may present with FI alone warranting urgent/emergent disc removal.

Spontaneous and rapid resolution of a massive lumbar disc herniation

Background

Most lumbar disc herniations can be successfully treated conservatively. However, massive lumbar disc herniations are often treated surgically to avoid permanent cauda equina syndromes/neurological deficits and potential litigation. Nevertheless, here, we present a 51-year-old female who refused lumbar surgery due to coronavirus disease 2019 (COVID-19) and sustained a full spontaneous recovery without surgical intervention.

Case Description

A 51-year-old female presented with a massive lumbar disc herniation at the L5S1 level. Despite refusing surgery for fear of getting COVID-19, she spontaneously neurologically improved without any residual neurological or radiographic sequelae.

Conclusion

Although the vast majority of patients with massive lumbar disc herniations are managed surgically, there are rare instances in which nonoperative management may be successful.

Spontaneous infarction of lumbar roots, vertebrae and paravertebral muscles

Ischemic injury to the lumbosacral nerve roots and plexus is a rare condition resulting from thrombosis of one or several lumbar arteries. As the arterial supply of the spine presents great variations between subjects, the clinical presentation of lumbar thrombosis is highly variable depending on the relative involvement of nerve roots, bones or muscles. Diagnosis can be challenging, especially in the acute phase, as different structures can be simultaneously involved. The identification of an enlarged vessel centered in the area of tissue damage can help with the final diagnosis. We present the case of a 59-year-old woman who presented with spontaneous incomplete cauda equina syndrome due to diffuse lumbar nerve root infarction. On imaging, acute lumbar artery thrombosis was confirmed, and in addition to nerve roots, adjacent vertebral and paraspinal muscle infarctions were also present.

Disorders of the Cauda Equina

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.

Vocal fold paralysis and cauda equina syndrome following spinal-epidural anesthesia: A case report

RATIONALE

Vocal fold paralysis and cauda equina syndrome are very rare neurologic deficits. This report describes the case of a patient who simultaneously developed both after uneventful spinal-epidural anesthesia with 0.5% hyperbaric bupivacaine.

PATIENT CONCERNS

We report the case of a 45-year-old female, who underwent surgery for bilateral hallux valgus developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered. There was no pain or paresthesia during needle placement or drug injection. Surgery was performed uneventfully.

DIAGNOSES

Right vocal fold paralysis was diagnosed with flexible laryngoscopy.

INTERVENTIONS

Patient was started on the treatment with a surgery for bilateral hallux valgus, who developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered.

OUTCOMES

Postoperatively, she had difficulty in urination and defecation. In addition, she developed unilateral vocal fold paralysis characterized by hoarseness, effortful voice production, and choking with liquids. Magnetic resonance imaging performed on the lumbosacral area and computed tomography of the neck, the chest, and the skull revealed entirely normal results. However, flexible laryngoscopy revealed a right vocal fold paralysis. Although cauda equina syndrome can occur due to neurotoxicity of local anesthetics, the exact etiology of vocal fold paralysis is uncertain.

LESSONS

The case highlights that 2 rare and serious complications of spinal-epidural anesthesia can even occur in the same patient after uneventful surgery and block performance.

Just the facts: Risk stratifying nontraumatic back pain for Cauda Equina Syndrome in the emergency department

A 43-year-old male, with a history of chronic back pain, presents to the emergency department (ED) with acute onset chronic pain. He states he “tweaked something” and has been debilitated by back pain, radiating down both his legs, for 24 hours. He has not had a bowel movement but denies noticing any “saddle anesthesia.” His clinical exam is limited by pain, and it is difficult to determine if he has objective weakness. His perineal sensation is intact, as is his sensation upon digital rectal examination. The patient has a post-void residual of 250 mL, but you are unsure how to interpret this value. As an emergency physician, when should you suspect, and how should you evaluate cauda equina syndrome?

International Framework for Red Flags for Potential Serious Spinal Pathologies

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.