Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study

Ultrasound-guided needle aspiration of immediate postoperative symptomatic spinal epidural hematoma after lumbar stenosis surgical decompression in the elderly: a proof-of-concept case

BACKGROUND

Symptomatic spinal epidural hematoma (SSEH) is one of the most feared complications and source of litigation in spine surgery. Its occurrence rises up to 2% in minimally invasive spine surgery. In parts of the world where the population is aging, more fragile patients are expected to undergo degenerative spine surgery. Management of the SSEH includes emergent spine MRI, though some experts advocate for direct second-look surgery without imaging. Then, an urgent revision surgery under general anesthesia for hematoma evacuation is warranted. We report the case of a threatening SSEH in an 88-year-old patient after lumbar spine stenosis surgery. In order to spare a second general anesthesia for this fragile patient, we opted for a percutaneous ultra-sound guided drainage of the hematoma under local anesthesia as a first line treatment. The procedure was successful, we report an instant relief of his neurological deficit while performing the procedure.

CONCLUSION

Ultra-sound guided percutaneous drainage of hyperacute SSEH successfully avoided a revision surgery. It spared a second general anesthesia in a fragile patient. This procedure could be an alternative first-line treatment of SSEH for fragile patients.

Understanding Functional Neurological Disorder: Recent Insights and Diagnostic Challenges

Functional neurological disorder (FND), formerly called conversion disorder, is a condition characterized by neurological symptoms that lack an identifiable organic purpose. These signs, which can consist of motor, sensory, or cognitive disturbances, are not deliberately produced and often vary in severity. Its diagnosis is predicated on clinical evaluation and the exclusion of other medical or psychiatric situations. Its treatment typically involves a multidisciplinary technique addressing each of the neurological symptoms and underlying psychological factors via a mixture of medical management, psychotherapy, and supportive interventions. Recent advances in neuroimaging and a deeper exploration of its epidemiology, pathophysiology, and clinical presentation have shed new light on this disorder. This paper synthesizes the current knowledge on FND, focusing on its epidemiology and underlying mechanisms, neuroimaging insights, and the differentiation of FND from feigning or malingering. This review highlights the phenotypic heterogeneity of FND and the diagnostic challenges it presents. It also discusses the significant role of neuroimaging in unraveling the complex neural underpinnings of FND and its potential in predicting treatment response. This paper underscores the importance of a nuanced understanding of FND in informing clinical practice and guiding future research. With advancements in neuroimaging techniques and growing recognition of the disorder's multifaceted nature, the paper suggests a promising trajectory toward more effective, personalized treatment strategies and a better overall understanding of the disorder.

Cauda equina, conus medullaris and syndromes mimicking sciatic pain: WFNS spine committee recommendations

Introduction

Cauda equina syndrome (CES), conus medullaris syndrome (CMS), and sciatica-like syndromes or "sciatica mimics" (SM) may present as diagnostic and/or therapeutic dilemmas for the practicing spine surgeon. There is considerable controversy regarding the appropriate definition and diagnosis of these entities, as well as indications for and timing of surgery. Our goal is to formulate the most current, evidence-based recommendations for the definition, diagnosis, and management of CES, CMS, and SM syndromes.

Methods

We performed a systematic literature search in PubMed from 2012 to 2022 using the keywords "cauda equina syndrome", "conus medullaris syndrome", "sciatica", and "sciatica mimics". Standardized screening criteria yielded a total of 43 manuscripts, whose data was summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Utilizing the Delphi method, we generated seven final consensus statements.

Results and conclusion

s: We provide standardized definitions of cauda equina, cauda equina syndrome, conus medullaris, and conus medullaris syndrome. We advocate for the use of the Lavy et al classification system to categorize different types of CES, and recommend urgent MRI in all patients with suspected CES (CESS), considering the low sensitivity of clinical examination in excluding CES. Surgical decompression for CES and CMS is recommended within 48 h, preferably within less than 24 h. There is no data regarding the role of steroids in acute CES or CMS. The treating physician should be cognizant of a variety of other pathologies that may mimic sciatica, including piriformis syndrome, and how to manage these.

Bladder ultrasonography in the assessment of cauda equina syndrome in the emergency department: a literature review

For cauda equina syndrome (CES), current clinical assessment in the emergency department usually involves perianal sensation (PAS) and anal tone (AT). Neither reliably predict magnetic resonance imaging (MRI) demonstrating a large central disc prolapse (MRI+). Other clinical examination findings increase the probability of MRI+. Other tests of sacral nerve root function include anal squeeze (AS) and the bulbocavernosus reflex (BCR). If BCR, PAS and AT, and AS are combined and they are all normal, CES can be excluded in almost all cases. Portable bladder ultrasonography is now commonly used to assess bladder function, particularly in measuring the post-void residual urinary volume (PVR). PVR is deemed normal at <50ml. If the PVR is <200ml and there are no objective signs, MRI+ is rare. If the PVR is >200ml, MRI+ is found in 43% of cases. The combined assessment of PAS, AT and AS (and BCR in selected cases) and PVR increases the specificity and sensitivity of a clinical diagnosis of CES (i.e. maximising MRI+ and minimising MRI-). Recommendations for when to perform MRI are made.

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.

'Scan-negative' cauda equina syndrome: what to do when there is no neurosurgical cause

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.

Functional neurological disorder in the emergency department

We provide a narrative review of functional neurological disorder (FND, or conversion disorder) for the emergency department (ED). Diagnosis of FND has shifted from a "rule-out" disorder to one now based on the recognition of positive clinical signs, allowing the ED physician to make a suspected or likely diagnosis of FND. PubMed, Google Scholar, academic books, and a hand search through review article references were used to conduct a literature review. We review clinical features and diagnostic pitfalls for the most common functional neurologic presentations to the ED, including functional limb weakness, functional (nonepileptic) seizures, and functional movement disorders. We provide practical advice for discussing FND as a possible diagnosis and suggestions for initial steps in workup and management plans.

Suspected cauda equina syndrome: no reduction in investigation, referral and treatment during the COVID-19 pandemic

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.