Diagnosis of cauda equina syndrome in the emergency department

Best Evidence Topic report: Is a CT head required for patients who present to the emergency department with a first seizure?

A short systematic review was undertaken to assess whether adult patients presenting to the ED with a first seizure require a CT head scan to rule out emergent intracranial pathology. MEDLINE, EMBASE, Cochrane and Google Scholar databases were searched. Seven relevant papers were identified. Study information, patient characteristics, key results and methodological weaknesses were tabulated. Our results indicate that adults presenting with a first seizure are a high-yield group for CT with a number needed to scan (NNS) between 10 and 19 for findings that would change management in ED, such as haemorrhage, infarction and tumours. We believe that this NNS is sufficiently low to justify the routine use of neuroimaging for these patients in emergency care.

A novel approach to expedite emergency investigation for suspected cauda equina syndrome referrals from community and primary care services: A service evaluation

INTRODUCTION

Although a rare spinal emergency, cauda equina syndrome (CES) can result in significant physical, emotional, and psychological sequalae. Introducing a CES pathway enhances diagnosis but may increase Radiology and Orthopaedic workload. To address this, one NHS hospital in England introduced a novel CES pathway. Utilising a criteria-led pathway, patients were referred directly from community/primary care, via the Emergency Department, for an emergency MRI scan.

OBJECTIVE

To compare the outcomes of patients referred via an original and redesigned Community and Primary Care CES pathway.

DESIGN

A retrospective service evaluation was undertaken of all emergency MRI scans investigating suspected CES via either pathway.

METHODS

Two 3-month time periods were analysed; pre-(original) and post-implementation of the redesigned pathway; time to surgery was reviewed over two 12-month periods.

RESULTS

Increased MRI scan utilisation was seen following the implementation of the redesigned pathway: original n = 50, redesigned n = 128, increasing Radiology workload. However, the redesigned pathway resulted in a reduction in time to MRI from 3h:01m to 1h:02m; reduction in time spent in ED 4h:55m to 3h:24m; reduction in time to surgery 18h:05m to 13h:38m; reduction in out-of-hour scanning from 10 to 2 patients during the evaluation period; and a reduction in on-call Orthopaedic involvement by 38%.

CONCLUSION

All timed outcomes were improved with the implementation of this novel pathway. This suggests expediting MRI scans can result in substantial downstream benefits; albeit while increasing MRI scan utilisation. This pathway aligns with the emergency management of suspected CES under the new national CES pathway in England.

Recovery with posterior decompression and dural suturing in a patient with cauda equina syndrome caused by lamina entrapment in an unstable burst fracture: A case report

INTRODUCTION

This report investigates Cauda Equina Syndrome (CES), a critical neurological condition from lumbar and sacral nerve root compression that arises from trauma, such as unstable burst fractures leading to interlaminar entrapment. This study highlights the effective management and recovery of a young woman with CES following a traumatic fall, offering new insights into the condition's treatment and recovery process.

CASE PRESENTATION

A 24-year-old female experienced severe lower back pain, bilateral lower limb weakness, saddle anesthesia, and bladder dysfunction after a 3-m fall. The neurological assessment showed reduced sensation and motor function in the lower extremities. Diagnostic imaging revealed an unstable L2 burst fracture with cauda equina entrapment. She underwent emergency posterior decompression and dural repair, followed by a tailored rehabilitation program, which is a novel aspect of this study.

DISCUSSION

This report underscores the critical need for immediate surgical intervention in CES to avert lasting neurological damage. The case represents the significance of early decompression for improving prognosis and explores the complexities of managing CES with unstable spinal fractures and dural tears. It demonstrates the challenges in surgical intervention and postoperative rehabilitation, offering a new perspective on the integrative approach to treatment.

CONCLUSION

This case exemplifies the imperative CES management post-spinal trauma. Despite severe initial deficits, an innovative multidisciplinary approach involving surgery and early rehabilitation resulted in remarkable functional recovery. This study contributes to a new understanding of CES management in acute trauma settings and calls for further research to advance treatment protocols and enhance predictive outcomes.