Unique Presentation of Hematometrocolpos Mimicking Cauda Equina Syndrome: Severe Back Pain and Urinary Incontinence in an Adolescent Girl

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?

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Low Back Pain in a Child Associated With Acute Onset Cauda Equina Syndrome

Journal of Pediatric Orthopaedics ◽

10.1097/bpo.0b013e318247195a ◽

2012 ◽

Vol 32 (3) ◽

pp. 271-276 ◽

Cited By ~ 10

Author(s):

Juan Pretell-Mazzini ◽

Kudakwashe R. Chikwava ◽

John Paul Dormans

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Acute Onset ◽

Low Back

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What is the incidence of cauda equina syndrome? A systematic review

Journal of Neurosurgery Spine ◽

10.3171/2019.12.spine19839 ◽

2020 ◽

Vol 32 (6) ◽

pp. 832-841 ◽

Cited By ~ 2

Author(s):

Ingrid Hoeritzauer ◽

Matthew Wood ◽

Phillip C. Copley ◽

Andreas K. Demetriades ◽

Julie Woodfield

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Cauda Equina Syndrome ◽

Small Sample Size ◽

Meta Analysis ◽

Adult Population ◽

Cauda Equina ◽

Small Sample ◽

Low Back ◽

Patient Pathways

OBJECTIVECauda equina syndrome (CES) is a surgical emergency requiring timely operative intervention to prevent symptom progression. Accurately establishing the incidence of CES is required to inform healthcare service design and delivery, including out-of-hours imaging arrangements.METHODSA systematic literature search of MEDLINE, EMBASE, and Scopus was undertaken to identify original studies stating the incidence of CES, and the estimates were combined in a meta-analysis as described in the protocol registered with PROSPERO (registration no. CRD42017065865) and reported using the PRISMA guidelines.RESULTSA total of 1281 studies were identified, and 26 studies were included in the review. Data about CES incidence were available from 3 different populations: asymptomatic community populations, patients with nontraumatic low-back pain, and patients presenting as an emergency with suspected CES. The incidence of CES was 0.3–0.5 per 100,000 per year in 2 asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working-age population. CES occurred in 0.08% of those with low-back pain presenting to primary care in 1 study, and a combined estimate of 0.27% was calculated for 4 studies of those with low-back pain presenting to secondary care. Across 18 studies of adults with suspected CES, 19% had radiological and clinical CES. Difficulties in comparison between studies resulted from the heterogeneous definitions of CES and lack of separation of more advanced CES with retention, which is unlikely to be reversible. In the studies of patients with suspected CES, the small sample size, the high number of single-center studies (18/18), the high number of studies from the United Kingdom (17/18), the retrospective nature of the studies, and the high number of abstracts rather than full texts (9/18) reduced the quality of the data.CONCLUSIONSFrom current studies, it appears that CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Determining accurate incidence figures and designing a bespoke service for investigation of patients with suspected CES would require a consensus clinical and radiological definition of CES and international multisite studies of patient pathways of investigation and management.

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1499 The Statistical Value of Different Clinical Characteristics in Evaluation of Suspected Cauda Equina Syndrome

British Journal of Surgery ◽

10.1093/bjs/znab259.1058 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

W Levitt ◽

B Kamalakannan ◽

Y Leung

Keyword(s):

Back Pain ◽

Cauda Equina Syndrome ◽

Pain Sensitivity ◽

Cauda Equina ◽

Leg Pain ◽

Statistical Association ◽

Mri Findings ◽

Leg Weakness ◽

Red Flag ◽

One Year

Abstract Introduction Cauda Equina Syndrome(CES) is a potentially disabling condition caused by compression of the thecal sac in the lumbar spine. Traditional teaching suggests red flags include back pain, sciatica, saddle anaesthesia and bladder disturbance. Current guidelines from the British Association of Spinal Surgeons recommend prompt investigation with MRI should these symptoms be present. Method A retrospective electronic case note review was undertaken from a one-year period to identify patients referred to the on call orthopaedic team with suspected CES and were investigated with MRI. Notes were reviewed for the presence of each clinical characteristic and correlated with MRI findings. Results 334 referrals underwent urgent MRI with 25 scans showing CES. Poor statistical association was observed with unilateral leg pain (sensitivity 0.28, specificity 0.48), back pain (sensitivity 0.92, specificity 0.13) and bladder dysfunction (sensitivity 0.72, specificity 0.36). Much closer statistical association was seen with bilateral leg pain (sensitivity 0.6, specificity 0.7, OR 5.03, 95% CI 2.16-11.68, p0.0002), leg weakness (sensitivity 0.68, specificity of 0.72, OR 5.35, 95% CI 2.23-12.85, p0.0002), leg sensory deficit (sensitivity 0.72, specificity 0.60, OR 3.79, 95% CI 1.54-9.36, p0.004) and altered perianal sensation (sensitivity 0.6, specificity 0.67, OR 3.03, 95% CI 1.31-6.99, p 0.009) Conclusions The diagnostic accuracy for some conventional red flag characteristics in CES is low. In our series back pain, unilateral sciatica and bladder disturbance showed low predictive value while bilateral sciatica, saddle anesthesia and lower limb sensorimotor deficits showed closer association and therefore should be closely evaluated for when reviewing such patients.

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Percutaneous Endoscopic Lumbar Discectomy for Treating Cauda Equina Syndrome Due To Lumbar Disc Herniation

10.21203/rs.3.rs-594596/v1 ◽

2021 ◽

Author(s):

Hai-Chao He ◽

Xiao-qiang LV ◽

Yong-Jin Zhang

Keyword(s):

Back Pain ◽

Lumbar Disc Herniation ◽

Disc Herniation ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Lumbar Discectomy ◽

Leg Pain ◽

Endoscopic Lumbar Discectomy

Abstract Background In recent decades, endoscopic techniques to treat lumbar disc herniation (LDH) have gained popularity in clinical practice. However, there is little literature on the use of percutaneous endoscopic lumbar discectomy (PELD) to treat cauda equina syndrome (CES) due to LDH. This study aims to evaluate the feasibility and clinical efficacy of PELD for treating CES caused by disc herniation, and as well as to report some technical strategies. Methods Between October 2012 and April 2018, 15 patients with CES caused by LDH at the early and intermediate stages of Shi’s classification were selected as the subjects of study, and underwent PELD. All patients were followed up for at least two years. The patients’ back pain and leg pain were evaluated using visual analogue scale (VAS) scores and the Oswestry Disability Index (ODI). Patient satisfaction was evaluated using the MacNab outcome scale. Clinical outcomes were measured preoperatively and at 3 days, 3 months, 6 months and the last follow-up. Results The VAS score for back pain, leg pain and ODI score significantly decreased from preoperatively scores of 6.67 ± 1.05, 7.13 ± 1.19 and 62.0 ± 6.85 respectively, to postoperatively cores of 1.80 ± 0.41, 1.47 ± 0.52 and 12.93 ± 1.03 at the last follow-up postoperatively. These postoperative scores were all significantly different compared with preoperative scores (P < 0.01). According to the modified MacNab outcome scale, 86.67% of these patients had excellent and good outcomes at the final follow-up. Complications included one patient with cerebrospinal fluid leakage and one patient who developed recurrent herniation; the latter patient finally achieved satisfactory results after reoperation. Conclusion PELD could be used as an alternative surgical method for the treatment of CES due to LDH in properly selected cases and appropriate patient selection. However, the operator should pay attention to foraminoplasty to enlarge the working space.

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Posterior epidural migration of a lumbar disc herniation

Surgical Neurology International ◽

10.25259/sni_67_2019 ◽

2020 ◽

Vol 11 ◽

pp. 4

Author(s):

Meryem Himmiche ◽

Khalid Chakour ◽

Mohammed El Faiz Chaoui ◽

Mohammed Benzagmout

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Low Back ◽

Case Description ◽

Disc Material ◽

Disc Herniations ◽

History Of

Background: Posterior epidural migration of a lumbar disc fragment (PEMLDF) refers to the dorsal migration of disc material around the thecal sac that can lead to radiculopathy and/or cause a cauda equina syndrome. It is rare and the diagnosis is often just established intraoperatively. Case Description: A 50-year-old male with a chronic history of low back pain and psychosis presented with PEMLDF originating at the L4–L5 level. Conclusion: Lumbar disc herniations rarely present as PEMLDF resulting in symptoms varying from radiculopathy to cauda equina syndrome. These should be included among the differential diagnostic considerations for dorsolateral epidural lesions.

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Idiopathic Arachnoiditis of the Cauda Equina: A Case Report from Tanzania

Case Reports in Neurology ◽

10.1159/000518379 ◽

2021 ◽

pp. 535-540

Author(s):

Emmanuel V. Assey ◽

Abid M. Sadiq ◽

Magreth J. Swai ◽

Adnan M. Sadiq ◽

Marieke C.J. Dekker

Keyword(s):

Magnetic Resonance Imaging ◽

Back Pain ◽

Cauda Equina ◽

Imaging Modalities ◽

Rare Clinical Entity ◽

Resonance Imaging ◽

Cerebrospinal Fluid Analysis ◽

Fluid Analysis ◽

Lower Back ◽

Severe Back Pain

Arachnoiditis is a rare clinical entity that usually presents with severe debilitating radiating pain that can pose a challenge in diagnosis especially in areas without appropriate imaging modalities. We present a 26-year-old male with progressive lower back pain with radiation to the lower extremities, aggravated by movement and touch. We diagnosed idiopathic arachnoiditis based on cerebrospinal fluid analysis and magnetic resonance imaging. He was managed with a 5-day course of methylprednisolone and analgesics with a good outcome. Severe back pain without a specific cause in a young patient should be investigated with proper imaging modalities and lumbar puncture if warranted to evaluate the cause.

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703 The Impact of Introducing A Patient Information Leaflet on Patient Experience of Safety Netting for Cauda Equina Syndrome at Lister Hospital

British Journal of Surgery ◽

10.1093/bjs/znab134.473 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

S Sravanam ◽

M Vella-Baldacchino ◽

J Kitson

Keyword(s):

Back Pain ◽

Patient Information ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Patient Information Leaflet ◽

Medical Emergency ◽

Medical Attention ◽

Information Leaflet ◽

Red Flag ◽

Safety Netting

Abstract Introduction Cauda Equina Syndrome (CES) is a medical emergency. Patients with symptoms should seek medical attention immediately to prevent long-term neurological consequences. At our hospital, patients with back pain due to prolapsed vertebral discs are discharged with verbal advice about red-flag signs of CES. Studies have shown that patients retain only around half the information discussed in verbal consultations. Practice suggests that verbal advice combined with a patient information leaflet (PIL) allows for better safety-netting. Method In this study, we designed a new PIL reflecting latest British Association of Spinal Surgeons guidance. We then examined its impact on patient understanding and safety-netting of CES. Fifty patients who attended the Lister Hospital back pain service between September 2019 and August 2020 were randomly selected. Patients received a copy of the new PIL and were asked to complete a short questionnaire. Results Out of 26 respondents, over 86% (vs 59%) agreed/strongly agreed that the PIL helped them understand the red-flag signs of CES better. Furthermore, 81% said they felt better informed about CES than at the point of discharge from hospital. Conclusions This shows that the use of an effective way of educating patients about the red-flag signs of a medical emergency like CES.

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Development of a toolkit for early identification of cauda equina syndrome

Primary Health Care Research & Development ◽

10.1017/s1463423616000062 ◽

2016 ◽

Vol 17 (06) ◽

pp. 559-567 ◽

Cited By ~ 4

Author(s):

Sue Greenhalgh ◽

Carole Truman ◽

Valerie Webster ◽

James Selfe

Keyword(s):

At Risk ◽

Low Back Pain ◽

Back Pain ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Lower Limbs ◽

Motor Deficit ◽

Medical Setting ◽

Low Back ◽

Content Validation

AimTo develop a simple cauda equina syndrome (CES) toolkit to facilitate the subjective examination of low back pain patients potentially at risk of CES. To undertake preliminary validation of the content of the toolkit.BackgroundCES is a rare condition which can be very challenging to identify in a generalist medical setting.MethodA three phase iterative design with two stake holder groups; extended scope practitioners experienced in managing CES patients and CES sufferers.Toolkit developmentSynthesis of existing CES literature with CES patient data generated from in depth interviews.Toolkit validationContent validation of the draft toolkit with CES patients.Toolkit validationContent validation of the draft toolkit with extended scope physiotherapists.FindingsA three arm toolkit has been developed for use with patients considered by the clinician as at risk of developing CES (eg, worsening low back pain with symptoms/signs of progressive sensory-motor deficit in the lower limbs); patient expertise, clinical expertise, research and pathways. Uniquely, the toolkit drew upon the lived experiences of patients suffering from CES to inform the content.

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