Testing For Cauda Equina Syndrome

TESTING for CAUDA EQUINA SYNDROME

You may want to follow the following pages with a good coffee as the image

shows and understand the motto it is saying. Those of us with

CAUDA EQUINA SYNDROME,

have to follow this motto everyday, whether we want to or not.

      HOW DOES DIAGNOSTIC IMAGING SHOW

CAUDA EQUINA SYNDROME ?

Cauda Equina Syndrome is caused by filum terminale lipoma:  Magnetic Resonance Imaging (MRI) features

and surgical treatment. The adult spinal cord terminates at the level of the L1–L2 vertebrae, with the terminal

lumbar and sacral nerve roots within the spinal canal.  

The lower distal part of the spinal cord is known as the conus medullaris, and its tapered end forms the filum

terminale. Distal to this area is a gathering of nerve roots (horsetail-like) forming the cauda equina distally.

The squeezing of multiple lumbosacral nerve roots below the Conus Medullaris causes specific symptoms.

These symptoms consist of low back pain, sciatica, saddle sensory problems, bladder and bowel problems,

and lower extremity motor and sensory loss.

Cauda Equina Syndrome (CES) is most commonly caused by herniation of a lumbar disc and presents as a

complication in 2-5% of lumbar disc herniation cases. Clinical features of CES include perineal anaesthesia

and other lumbosacral root sensory deficits, lower extremity weakness, difficulty with bladder and bowel

control, sexual dysfunction, low back pain, and unilateral or bilateral sciatica. CES could be of two types, as

discussed in the Section "What Is Cauda Equina Syndrome"  they being Complete or Incomplete. Complete

CES patients usually have saddle anaesthesia and bladder or bowel retention/incontinence, while incomplete

CES patients have saddle anaesthesia but with minor bladder and bowel dysfunction like loss of urgency or

altered urinary sensorium.  

A thorough neurological examination (including an assessment of perineal sensation and anal sphincter

tone) should be performed. Patients with back pain and urinary incontinence should have a urinary post-void

residual volume measured; greater than 100–200 ml indicates urinary retention and mandates further 

evaluation. Magnetic Resonance Imaging (MRI) should be urgently obtained when a diagnosis of CES is

suspected. Treatment with high-dose steroids (dexamethasone 4–100 mg intravenously (IV)) may provide pain

relief and improved neurological function (by reducing oedema) while awaiting diagnostic studies and surgical

decompression. CES is an absolute indication for emergency surgical decompression; laminectomy with

gentle traction of the Cauda Equina and discectomy is the technique of choice.

The outcome for patients with CES is determined primarily by their symptoms at presentation. Patients who

can ambulate at presentation will generally remain ambulatory. Patients who present with paresis but are

ambulatory with assistance have approximately a 50% chance of walking again, and as many as 79% of

patients presenting with urinary retention will continue to require a urinary catheter after treatment. 

Other modes of surgical treatment have also been commonly used if the lumbar disc herniation is involved,

like microsurgery for lumbar disc herniation that requires surgical intervention. Discectomy and minimally

invasive techniques have also been adopted by many surgeons. Some patients, however, need emergency

surgery.

The primary aims of this study were to look at our recent experience at the Royal Alexandra Hospital, Paisley,

United Kingdom (UK) along with a private research study being conducted in New Zealand, and to determine

how many of the patients who warranted MRI for CES possessed the above clinical findings and how many of

them had positive MRI for established CES.  As a secondary objective, we aimed to determine whether any

clinical feature(s) could accurately predict the presence of structural abnormality on MRI and what the main

radiological findings are for these patients. We aimed also to support a larger study to develop a more

universal assessment tool for acute lower back pain.

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What we are showing on this page, is a cross section of the survey results as well as replicating and the differing and respective levels

of Cauda Equina. The results we have shown here are better shown in the Book/Manual as graphs and the results in more detail. We

felt to put it up on the website would be a mammoth task, as there are four whole chapters, some 123 pages just explaining and

showing how the analysis was completed and the results were calculated. What we are showing here is a just a glimpse of the full

report to give you an idea of not only the rarity of CES, but what the patient who is diagnosed with this hideous disorder has to

look forward to. If you wish to know more on the matter before the release of the Book/Manual, or how the calculations etc, are carried

out, please just send us an enquiry form with what information you require. But please remember the amount we can release is limited

at this point in time due, to the results being reviewed, and the Book/Manual still in the editing phase.

Thank you for your patience and understanding.

    ****************************************************************************

 Materials and Methods

Could It Be CES Hmmm ???

We conducted a retrospective analysis of consecutive patients for whom urgent spinal MRI was requested

over an eight-month period between August 2012 and March 2017. All scans were performed in the radiology

department of Royal Alexandra Hospital, Paisley. Criteria for inclusion into the study were the presence of

medical notes and images that had been reported by a radiologist. Medical notes were then reviewed to

identify the duration of symptoms, clinical features on examination, the result of the scan and the urgency and

type of treatment provided.

Clinical features were subdivided for analysis. Urinary symptoms were classified as acute incontinence,

retention, frequency and other. Bowel symptoms were divided into acute incontinence and change in bowel

habits. Perianal findings per rectal examination were divided into saddle anaesthesia, decreased anal tone or

the presence of both. The Kendall’s tau test was used for statistical analysis of all the data. A p value of less

than 0.05 was considered to be significant.

Results  

Based on inclusion criteria, 1,772 patients were eligible for the study in the UK and 775 in New Zealand. The

cohort in the UK consisted of 1,092 males and 680 females with a mean age of 52.5 years (range, 18–89 years;

median, 52 years).  MRI of the spine was performed within 24 hours of admission in 26 patients (32.9%). The

mean time interval between hospital admission and the scan was 149.17 hours/6.21 days (range, one hour to

nine weeks; median, four days), 71% of patients had scans within 24–48 hours of admission.

Only one MRI spine was performed out of hours during the five year period. The rest were performed beyond

48 hours of admission, the longest being 22 days.  68% patients who were admitted with questionable CES had

been reviewed and decided to have out-patient MRI scans. Among them, back pain with radiation down the

legs (sciatica) was found in 57% of patients; the other patients had moderate to severe bilateral lower limb

weakness. In 21% of the patients who had out-patient MRI spine ( 10-15 days from hospital presentation) were

found to have an established CES, they were urgently referred to spinal surgery and underwent primary

fenestration excision of the lumbar vertebra.   The range of duration of symptoms prior to hospitalization was

24 hours to six months.

Amongst a range of symptoms, acute onset of lower lumbar pain was the most commonly encountered

symptom among patients. Decreased power in the lower limbs was noted in 51% patients, making it the

most frequently encountered focal neurological deficit. Of these, 12% patients showed decreased power in one

leg (unilateral), while 39% of patients had both legs affected (bilateral). Sensory deficit in the lower limbs below

the knee was the second most common focal neurological deficit noted in 20% patients. Further details of

neurological signs specific to CES and population size percentages can be found within this book. 

The results from New Zealand were similar but the waiting time was over 16.3 to 29.9 days. Decreased ankle

and knee reflexes were found in 32% of patients , and foot drop was encountered in 41% of patients.

Patients with the decreased anal tone, faecal incontinence, urinary retention, saddle anaesthesia and urinary

incontinence had been scanned within 24 hours but they were not classed as acute. Patients with acute onset

of constipation were scanned within the range of four to seven days. MRI consistent with CES was found in

75% of patients. All of them confirmed to have CES on MRI scan had been referred to spinal surgery and

underwent surgical intervention: primary fenestration excision of the lumbar vertebral disc.

A total of 27.8% of patients were previously admitted to the hospital with lower lumbar back pain. Of these,

19% had a previous MRI spine. (Note: We are using the UK statistics only at this point). Lumbar disc prolapse

was the most common radiological finding on a previous MRI.  Patients who had an abnormal MRI spine for

back pain prior to this presentation showed a correlation with a newly diagnosed CES on MRI Only six patients

(7.6%) had a history of lumbar spinal surgery.  

Using Kendall’s tau test, we tested the relationship between clinical manifestations and established CES on

MRI of the spine. We found that none of the clinical manifestations was closely related to a diagnosis of CES.

We also tried to test with non-urgent lumbar disc pathology. Further details of all variables examined with their

corresponding percentages and p values can be found in and other systemic factors like weight loss, previous

cancer, human immunodeficiency virus (HIV)/drug abusers and steroids had shown no correlation with CES

diagnosis. 

'MRI' - The Only True Way To Identify Cauda Equina Syndrome

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Sample of Results From Survey and Research Study

 In 78.5% of patients  showed evidence of lumbar disc pathology on MRI of the spine. Disc prolapse was the

most common pathology, noted in 57% patients. Of these, 69% occurred at L4–L5, making it the most common

level of disc prolapse found on MRI of the spine. Various shapes/types of disc prolapsed were found, including

annular, diffuse, circumferential, right lateral, left lateral, posterior and central. Of these, central and diffuse

disc prolapse was the most common shapes of prolapsed evidenced on MRI spine. The scans of patients

24.1% were characterised by degenerative changes including osteoarthritis, spinal stenosis and osteoporosis.

Disc desiccation was the third most common pathology noted in 8.9%. of these, four occurred at L4–

L5 and two at L5–S1, and some patients demonstrated widespread disc desiccation involving all the disc

space.  The neoplastic disease was found in 13.7%, of whom had a known primary lesion, which was

lung carcinoma with adrenal metastasis. Those patients had lumbar metastasis with significant compression

of the thoracic spine at T5 by a large spinal metastasis evident on the whole MRI spine and received

radiotherapy.

The remaining patients with spinal neoplastic disease presented with established CES on MRI of the spine. 

Of these patients they had a large L3–L4 superiorly migrated intra-canalicular sequestrated disc fragment in

an epidural space.  (That disc fragment was encroaching the right L3–L4 traversing nerve roots. Later, a

nuclear medicine whole-body bone scan demonstrated widespread osteoblastic skeletal malignancy arising

from the prostate.) There were patients who had a severe biconcave fracture at T10–T11 demonstrated on

whole MRI spine along with retropulsion of the posterior wall consistent with metastatic disease. They were

managed non-operatively and received specific oncological therapy, palliative care and medical management.

A further 6.3% had primary neoplastic lesions but had no evidence of spinal metastases.  Discitis

was demonstrated in 5.0%; of these, it was shown that it occurred at L5–S1 or at L2–L3 and L3–L4,

respectively. Other pathologies demonstrated on MRI spine included incidental haemangioma at L1–L2,

meningocele at L4–L5, Tarlov cyst in the sacral canal, small peri-neural cyst at S1–S2, fatty infiltration of

paraspinal muscles and Schmörl’s node at T10.

In our study, only 26 patients received an MRI scan within 24 hours of hospital admission. The remaining

patients, despite having urgent requests for MRI, were scanned only within a mean of 6.21 days, during which

time the majority remained as in-patients. 50% of those patients were found to have an established CES on

MRI and underwent surgical intervention; 1% of them had an out-patient MRI scan. 

This highlights the limitation of the clinical assessment tool given those patients who were initially thought to

have warranted MRI less urgently than others but still underwent surgery. As a primary objective, we examined

whether a single clinical feature could predict the presence of CES on MRI scan. This can help to propose a

more universal rule to study patients with lower back pain. A Canadian Computed Tomography (CT) rule for

patients after a minor or mild head injury has been developed, and our study can support a larger study to

develop a similar rule for acute lower back pain. We found that none of the single clinical features

could predict the presence of the syndrome. In contrast, Balasubramanian et al. found that the presence of

saddle sensory deficit has a higher predictive value than other clinical features in diagnosing CES. 

Interestingly, one more study, by Gooding et al., found that digital rectal examination has no significant value

in the acute diagnosis of CES.  To explain the disparity, Rooney et al. postulated that an abnormally persistent

physiological response to acute back pain may lead to apparent neurological symptoms in the absence of an

organic cause.  Visceral dysfunction too may occur as a result of acute back pain and may, therefore, be

regarded as functional symptoms. Functional paralysis, for instance, has an incidence of 3 per 2,600,000

and has been known to mimic CES.  Despite both history and clinical examination suggesting CES, MRI of

the spine was still completely normal in our study disc prolapse was the most common

cause of sciatica/symptoms, most often involving L4–L5. Levis also found that L4– L5 is the most common

site for herniation. 

Due to the small sample size, it is beyond the scope of this study to provide greater

in-depth analysis of individual symptoms or combination of symptoms. This is the main limitation of

the results we have resented. Other weaknesses are predominantly due to the method of data collection and

study design. Due to the retrospective nature of this study, it is conceivable that data may not have been

recorded as diligently as they would have been in a prospective study and thus important findings may have

been omitted.

Physical Examination and Clinical Assessment of

Cauda Equina Syndrome  

 

The assessment of patients with suspected Cauda Equina Syndrome (CES) is usually undertaken by GPs or by

A&E staff. The suggestion that the bulbocavernosus reflex is used in diagnosing CES is impractical.

Whilst a rectal examination is acceptable (although unpalatable) to the majority of patients, eliciting the

bulbocavernosus reflex may be less well tolerated. I have never asked a patient if she minds if I stimulate her clitoris

whilst I perform a rectal examination and if I did I would expect prompt refusal, a formal complaint and a harrowing

few months of GMC enthusiasm.

Suggesting that this should be used for the diagnosis of CES may be potentially unproductive since the majority

of medical practitioners involved in the review of patients with suspected CES are most probably unskilled in eliciting

the bulbocavernosus reflex, which is a problem since failure to elicit the reflex will be construed as it is absent. I

suspect that many doctors, both male and female, will fail to even find the clitoris whilst performing a rectal examination

and reaching around a patient lying in the lateral position on a hospital trolley with her hips bent and knees firmly

together. The authors fail to mention that urinary retention is painless. This is because the bladder is totally denervated

and once it reaches its maximum capacity (up to 1500ml) urine will then dribble out as overflow incontinence, which

they will not be aware of either. The patient may find it easier to pass urine sitting down (increasing abdominal

pressure).  Painless urinary retention is the cardinal sign of CES and a patient without painless urinary retention has

only a 1 in 1,381,000 chance of not having CES.

 It must be stressed that the patient will not complain of urinary retention hence any patient in whom CES is suspected

should have at least a post micturition bladder scan or urinary catheter. 

A painless residual volume of 750-1000ml has a 90% specificity for CES. Since many of these patients have chronic

back pain, they will usually be on regular codeine (at least) and will be constipated. Without CES, this (along with pain)

can also result in urinary retention but the residual volume will be less since the bladder is not atomic. The S2/3/4

sensory supply can easily be tested by asking the patient if they can feel discomfort on the gentle traction of a urinary

catheter with the balloon inflated.

 Another point not stressed is a time of presentation and the availability of MRI in the UK. Most patients do not realise

that they are in urinary retention and overflow incontinence until mid-morning or lunchtime when they present

to A&E. 4 hours later a referral is made to a specialist with the usual plea that an MRI cannot be performed at 4:45

pm. Neurosurgeons often have to decide which patients to perform an out of hours MRI scan on (if it is available) on

the basis of a telephone referral. The authors classify CES into CES with or without urinary retention however a more

pertinent classification (essentially the same thing) is evolving CES or established CES. Evolving CES (diagnosed from

history) is a true surgical emergency and warrants a comprehensive out-of-hours service including MRI and surgery.

Fixed CES (fixed for 48 hours) can usually wait. 

Things to find out before referring to a specialist, or things that a specialist may reasonably ask you to ascertain are:

1:  Exact timing of onset of symptoms (nearest hour). Factor in time to get an MRI and transfer the patient to

     theatre and operate – allow at least 6 hours in reality- so to hit a 24-hour window refer the patient within 18 hours of

     the onset of symptoms.

2:  Post micturition (Bladder Incontinance) residual volume and can the patient feel you pulling the catheter: 750-     

      1000ml with no sensation on pulling the  catheter is virtually diagnostic of CES.

3: Is there saddle anaesthesia? and

4: What is the anal tone? It should be reduced. I also find it useful to ask the patient if they can feel that they 

     are going to pass flatus and if they can stop it. A patient who knows that they are going to pass flatus and can 

     stop themselves must have fairly normal anal sphincter sensation and power.

NB: Many CES patients have no back pain and no leg weakness. The main problem for CES patients is TIME, the

longer the wait the worst the result becomes.

 Cauda Equina Syndrome (CES) is a rare and dangerous as well as very serious neurological condition affecting the

bundle of nerve roots at the lower end of the spinal cord. The CE provides innervation to the lower limbs, and 

sphincter controls the function of the bladder and distal bowel and sensation to the skin around the bottom and back

passage.  CES occurs when the nerves below the spinal cord are compressed causing compromise to the bladder and

bowel. The most common cause of CES is a prolapse of a lumbar disc but other conditions such as metastatic spinal

cord compression can also cause CES. There is no agreed definition of CES but the British Association of  Spinal

Surgeons (BASS) present a definition that is useful in clinical practice; A patient presenting with acute back pain and/or

leg pain...... with a suggestion of a disturbance of their bladder or bowel function and/or saddle sensory disturbance

should be suspected of having a CES. Most of these patients will not have critical compression of the cauda equina.

However, in the absence of reliably predictive symptoms and signs, there should be a low threshold for investigation

with an emergency scan.

    Cross Section of the Nerve Endings before and after diagnosis of CES.

       Before                        After

   

 

Classification

 

 5 groups of patients we have found to be classified according to their presentation:

 CESS- Suspected: 

Patients who do not have CES symptoms but who may go on to develop CES. It is 

important  that patients understand the gravity of the condition and the importance of the time   

frame to seeking urgent medical attention. The use of a *credit card style patient information or a             

leaflet explaining what to look for and what to do should they develop symptoms is recommended.

CESI- Incomplete: 

Patients who present with urinary difficulties with a neurogenic origin, including loss of desire to void, poor stream,

needing to strain to empty their bladder, and loss of urinary sensation. These patients could develop CESR and are a

medical emergency and should have a surgical opinion urgently.  

CESR-Retention: 

Patients who present with painless urinary retention and overflow incontinence; the bladder is no longer under

executive control. An urgent surgical opinion is necessary .

CESC-Complete: 

Patients who have an objective loss of the cauda equina function, absent perineal sensation, a loose anus and

paralysed bladder and bowel.  

CESA - Actual: 

This is where the patient has suffered severe damage which has all the characteristics of  all the above including

CES-C, but presents also has numbness or "Pins and Needles" effect in one or both legs and a loss of full or partial

reflexes. The spinal cord ends around L1, consequently, the caudal nerve roots below the first lumbar root, form the

Cauda EquinaThe roots descend at an  almost vertical angle to reach their corresponding foramina, gathered around

the filum terminale within the spinal theca. The proximal portion of the Cauda Equina is said to be hypo vascular hence

more vulnerable if compressed.

 

 

 

 The spinal cord ends around L1, consequently, the caudal nerve roots below the first lumbar root, form the Cauda

Equina.  The roots descend at an  almost vertical angle to reach their corresponding foramina, gathered around the

filum terminale within the spinal theca. The proximal portion of the cauda equina is said to be hypo vascular hence

more vulnerable if compressed.   

     

The Cauda Equina roots have both a dorsal and ventral root. The ventral root provides motor fibres for the efferent

pathway along with sympathetic fibres. The dorsal root is composed of afferent fibres for the transmission of

sensation.

The functions of those nerves are:

-  Sensory and motor fibres to the lower limbs. 

-  Sensory innervation to the saddle area.

-  Voluntary control of the external anal and urinary sphincters.

- Aspects of anatomical features relating to saddle sensation, bladder, bowel and sexual function are discussed 

   below;

 The first three sacral nerves, S1,2 and 3 supply multifidus and lateral cutaneous branches to the skin and fascia over

the sacrum and part of the gluteal region. The 4th and 5th sacral nerves, S4 and 5, along with posterior primary ramus 

of the coccygeal nerve supply the skin and fascia around the coccyx. The pelvic splenic nerves to the pelvic viscera 

composed of parasympathetic fibres travel in the ventral rami of S2,3 and 4. They then leave these nerves as they exit 

the anterior sacral foramina and pass to the pre-sacral tissue. Some pass to the pelvic viscera alongside the pelvic 

sympathetic supply and supply the urogenital organs and distal aspect of the large intestine. Others pass immediately 

into retroperitoneal tissue and into the mesentery of the sigmoid and descending colon. The pudendal nerve supplies 

the perineum and arises from S2,3 and 4 with its terminal branches including the dorsal nerve of the penis or clitoris.

 Epidemiology

CES occurs as a consequence of compression of the Cauda Equina and can be caused by a number of pathologies. 

The prevalence among the general population has been estimated between 1:28,000,000 and 1:46,000,000  Globally. 

The most common cause of CES is herniation of a lumbar intervertebral disc and accounts for 2% of all herniated 

lumbar discs.  It commonly affects the discs at the L4/5 and L5/S1 level. However, disc prolapse at any lumbar level 

can cause CES. Patients may be predisposed to CES if they have a congenitally narrow spinal canal or have acquired 

spinal stenosis.  The prevalence among patients with low back pain is approximately 4 in 300,000. CES affects males 

and females equally and can occur at any age but primarily in adulthood. 

Other pathologies which can cause CES to include spinal stenosis, haematoma, trauma tumour, infection, fracture and

inflammatory conditions. Other rare causes such as abdominal aortic dissection, and complications after surgery, 

anaesthetic procedures, spinal manipulation or epidural injections are possible causes of CES

 Clinical Presentation

5 characteristic features of CES are consistently described in the literature and should form the basis of questions

related to diagnosis;

-   Bilateral neurogenic sciatica - Pain associated with the back and/ or unilateral/bilateral leg symptoms may              

     be present.

-   Reduced perineal sensation - Sensation loss in the perineum and saddle region is the most commonlyreported   

    symptom.

-   Altered bladder function leading to painless retention.

-   Bladder dysfunction is the most commonlyreported symptom and can range from increased frequency, difficulty in   

    micturition Urinary Incontinence), change in the stream,incontinence and retention.

-   Loss of anal tone - loss or reduced anal tone may be evident if a patient reports bowel dysfunction.

-   Boweldysfunction may include incontinence, inability to control motions, inability to feel when the bowel is full

    andconsequently overflow.

-  Loss of sexual function.  Sexual dysfunction is not widely mentioned in the literature but is an important aspect that

   should be discussed with patients. Although rare it is reported to be between 2% but less than 5%, but again,

    reporting is not always accurate as  it is a hard and embarrassing subject to discuss even with your surgeon or 

   Doctor.

 

Examination

Subjective Examination

 

 

The difficulty with diagnosing serious spinal conditions early and the catastrophic outcomes of delayed diagnosis are

widely documented. The subjective history is the most important aspect of the exam early in the disease process as the

subtle and vague symptoms related to early Cauda Equina Syndrome need to be identified using clear methods of

communication. Good communication skills allow us to gain an understanding of the patient’s world by achieving an

understanding of what patients perceive is happening to them.

The important items to screen within the subjective history are RED FLAGS. It is well recognized that the

presence of RED and YELLOW FLAGS are not mutually exclusive. The clinical reasoning process

essentially combines a biopsychosocial assessment alongside this Red Flag screening to get a full true picture of the

patient’s story and current clinical presentation.  Establishing the history of the present condition in detail is key as

timing is of paramount importance in this condition.  

When the back and or leg pain started is significant but precisely when symptoms relating to parasympathetic

supply began is vital; one hour, one day, one week, 15 years? There is no way of predicting who will progress from

CESS  to CESR or CESA and how quickly this may happen and so precise recording of the timing of chronology 

cannot be underestimated.   

Establish if things are changing, better, episodic, worse or the same. Improving pain does not necessarily mean the

condition is improving. Checking Red Flags and neurological status is important before this improved status can be

assumed. Constant pain and night pain must be viewed along with all Red Flags with  caution.   

Establish the pattern of pain through 24 hours. Reference of pain and precise area of pins and needles and numbness

must be identified and clearly documented. Aggravating and easing factors should be explored. Establish if these

symptoms have been experienced before or are, they different?   

Has an MRI been performed with these current symptoms? This seems so obvious but can help with the clinical

reasoning process.  What treatments have been tried including medication is helpful on a variety of levels.  Many

medications cause symptoms that masquerade as CES. This does not mean that symptoms can be ignored and

attributed to drugs, however, medication could be contributing to the bladder, bowel and sexual dysfunction. 

Similarly, pain can cause retention.   

Explore the patient’s medication regime and escalation up the analgesic ladder?  Is medication being used 

appropriately and titrated correctly?  This can give an indication of the severity of pain and its control. Establish the 

quality and intensity of pain e.g. VAS. 

What is the past medical history status; the previous diagnosis of disc pathology or spinal stenosis, for instance, may

be significant.  The previous history of serious conditions such as cancer must be noted and may be 

important. Similarly, many co-morbidities could masquerade as CES e.g. Diabetes, Multiple Sclerosis, Benign prostatic

hyperplasia, pregnancy. Has there been any recent or past spinal surgery and any history of osteoporosis; a retro

pulsed vertebral insufficiency fracture could cause CES?

If CES risk is suspected the subjective history must explore symptoms in even more detail. Tools and questions to 

use are covered in the next Research section. It is important that these questions are framed to highlight their gravity. 

The patient needs to recognise that the next questions are the vital and accurate response of the utmost importance.

Communication

 

A Qualitative research study in three major Emergency Departments conducted under the supervision of an Ethics

committee has identified that clear communication plays a pivotal role in identifying Cauda Equina Syndrome patient’s

early to facilitate bringing these patients to the surgical team in a timely manner. Through this study, it emerged that in

order to identify CES patients early in the disease process to facilitate a timely surgical opinion one of the key problems

was the use of language that reflected the patient’s own voice.  

The patient participants who were diagnosed by their own Doctor and agreed to be part of the survey, the Doctor

forwarding a documented request for a CT or MRI to be done to verify his conclusions. (Here we must say the hospitals

involved were NOT notified of the study, as it was to provide guidelines for future discussions).

The study emphasised the need for clinicians to use language that they could understand during a clinical

consultation, especially in the context of severe or chronic  pain. The worrying aspect of this was over 72% of the staff

who were tested without knowing they were in a survey showed Most Emergency Department staff will use the

excuse "they are to busy to listen to the circumstances of how the patient ended with the pain, or how long".  Give them

a couple of analgesics and send them on their way. In 64% of the patients in the study had serious back problems or

nerve damage. This was not investigated until the staff concerned were told what was happening, then the attitude

changed.

This is where  to the patient is so IMPORTANT, even if they do take a little longer to get to the

point. What are the symptoms and are too quick to just give analgesics for the pain and send them on their way,

instead of LISTENING to the patient who is feeling the pain, where he is feeling it and the intensity. 

During our Survey/Study, one question we asked was did the doctor ask specific questions concerning the problem and

we gave 21 example questions. The average of replies was 9. We also asked if they had an MRI, the average give was

5-12 hours, to be reviewed by Orthopeadic Registrar or Surgeon consult with them during this time, the average was 5.

Further to this we asked the period it took to see a Surgeon or Registrar was an average 6-9 hours and the

average time before surgery was implemented was 36-96+ hours.  By that time the problem had gone from  

CESS to CESRCESC or CESA

 A Cauda Equina Syndrome cue card for clinicians to use in the clinical consultation to enable the patient to focus on

important questions was had been developed. This was to enable clinicians to frame the questions as important. The

clinical cue card maps against a patient credit card using the same questions. This highlights symptoms to look out for

and crucially timely action to take should symptoms develop. The patient who would be in severe pain in certain

circumstances particularly in an emergency setting needs request immediate help to express the change in

embarrassing and sensitive symptoms.  In our study we found this was commonly ignored and some of the replies from

patients was that "The Pain Could Not Be That Bad" as expressed by the doctor.  If a doctor cannot see what is

causing the pain some are reluctant to take the patients word for the situation, we found 67% of replies had this

problem. In 7 cases the patients were told "They only wanted drugs", that is why they were there.

 

Physical Examination 

The physical examination should include a full neurological assessment to determine dermatomal sensory loss, 

myotome weakness and reflex change. Where a patient reports bilateral leg pain, signs of upper motor neuron

involvement should be examined (Babinski and Clones). For a comprehensive overview of neurological integrity

testing the reader is referred to the following book 'Neuromusculoskeletal examination and assessment.  Where a

patient reports sensory changes in the perineal area this should be tested to evaluate any sensory loss. A digital rectal

examination should be performed to assess any loss of anal sphincter tone. This should only be performed 

by an appropriately trained clinician. Reduced sensation of the perineum and/or anal tone is objective evidence of CESI

and CESR but are likely to be normal in CESS.

 

Diagnostic Procedures

The diagnosis of Cauda Equina Syndrome is based on the patients reported subjective history. Physical examination 

findings may help to confirm the diagnosis but should not be solely relied on.  If CES is even suspected the patient

must undergo a CT or  MRI urgently to confirm the diagnosis. It is important to understand your locally agreed pathway

to make sure there is no delay to diagnosis and where CES is confirmed, there is no delay to surgical intervention.

This should be carried out within 24 hours, 12 hours to be safe. While MRI, coupled with patient history and

examination, remains the diagnostic gold standard, it comes at a high cost with many patients demonstrating no

concordant pathology.

 

Key Evidence 

Cauda Equina Syndrome is a grey area and there is no consensus on which signs and symptoms should be acted on.

However, it can have life-changing consequences and it is important to act quickly if it is even suspected.

Although decisions to perform MRI were made by senior clinicians, these may have been influenced by the

clinical assessments conducted by more junior members of the medical team. Furthermore, with several

radiologists interpreting the images, there may be a degree of inter-observer variability. We were unable to

elucidate any clinical features that were able to predict the presence of an established CES on MRI. Our

findings included decreased anal tone 57.6%, faecal incontinence 43.8%, urinary retention 77.6%, bladder

incontinence 48.9%constipation 32.5%, saddle anaesthesia 48.9%Patients who had an abnormal MRI spine

for back pain prior to this presentation showed a correlation with a newly diagnosed CES on MRI

 

Which in conclusion when all the material is observed, there is a lack of knowledge on CES by

EmergencyRoom staff or House Doctors. The RED FLAGS  identifiers, should be an immediate diagnosis tool

if there is any doubt and an MRI urgently carried out within 6 hours of presentation. As the figures also show

the longer the patient is left with the symptoms,  and there is a significant delay longer than 12 -24 hours, then

CES is a major problem. Attentive General Practioners and ER doctors must play a huge role in identifying the

RED FLAG scenario. 

                                                                                              Ready For The Red Flags

     

 

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