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

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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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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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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Cauda Equina Syndrome in a Pregnant Woman Referred to Physical Therapy for Low Back Pain

Journal of Orthopaedic and Sports Physical Therapy ◽

10.2519/jospt.2008.0411 ◽

2008 ◽

Vol 38 (11) ◽

pp. 721-721 ◽

Cited By ~ 5

Author(s):

Shaun J. O'Laughlin ◽

Eileen Kokosinski

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Pregnant Woman ◽

Physical Therapy ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Low Back

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BET 2: Is sexual dysfunction a recognised sign of cauda equina syndrome in the ED?

Emergency Medicine Journal ◽

10.1136/emermed-2019-208777.2 ◽

2019 ◽

Vol 36 (8) ◽

pp. 508-510

Author(s):

Michelle Angus ◽

Daniel Horner

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Sexual Dysfunction ◽

Cauda Equina Syndrome ◽

Search Strategy ◽

Cauda Equina ◽

Low Back ◽

Red Flag ◽

Study Type ◽

New Onset

A shortcut review of the literature was carried out to examine the association of sexual dysfunction in the context of new-onset low back pain, with cauda equina syndrome (CES). Five papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that clinicians appear to be poor at recording this feature during assessment, but between 12% and 96%, patients with confirmed CES will report the presence of new-onset sexual dysfunction at presentation when asked. It appears that this can also be a single isolated red flag feature in the context of low back pain and as such should be a mandatory part of any clinical assessment that seeks to evaluate the risk of impending CES.

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Atypical variant of Baastrup’s disease with lumbar stenosis and cauda equina syndrome

Surgical Neurology International ◽

10.25259/sni_467_2019 ◽

2019 ◽

Vol 10 ◽

pp. 198

Author(s):

Kartikeya Shukla ◽

Jaskaran Singh Gosal ◽

Mayank Garg ◽

Suryanarayanan Bhaskar ◽

Deepak Kumar Jha ◽

...

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Neurological Deficits ◽

Low Back ◽

Canal Stenosis ◽

Baastrup’S Disease ◽

Degenerative Disorder ◽

Lumbar Spinal

Background: Classical Baastrup’s disease is a degenerative disorder of the lumbar spine characterized by the approximation of adjacent spinous processes due to excessive lordosis. This results in edema, sclerosis, cyst, bursitis, and midline epidural fibrosis and is often overlooked as a cause of low back pain. Here, we report a patient with atypical Baastrup’s disease and lumbar spinal stenosis who presented with a cauda equina syndrome. Case Description: A 67-year-old male presented with low back pain of 1 year’s duration. This exacerbated over the past 3 weeks, becoming associated with the left lower limb numbness/weakness and bladder dysfunction. The lumbar magnetic resonance (MR) showed atypical Baastrup’s disease characterized by multiple ill-defined areas of contrast enhancement in the paraspinal region in conjunction with lumbar canal stenosis. The patient underwent lumbar decompression and exhibited improvement in his neurological deficits postoperatively. Conclusion: This case highlights the atypical MR features of lumbar Baastrup’s disease in conjunction with stenosis. Atypical Baastrup’s disease should be differentiated from classical Baastrup’s disease or other infectious pathologies (e.g., Pott’s disease of the spine) and appropriately treated with timely spinal decompression.

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Guillain-Barré syndrome and Low back pain: two cases and literature review

Open Medicine ◽

10.1515/med-2018-0074 ◽

2018 ◽

Vol 13 (1) ◽

pp. 503-508

Author(s):

Xianjun Ding ◽

Hong Jiang ◽

Xingyue Hu ◽

Hong Ren ◽

Huaying Cai

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Cauda Equina ◽

Guillain Barre Syndrome ◽

Low Back ◽

Mri Features ◽

Prominent Symptom ◽

Guillain Barré Syndrome ◽

Lumbar Mri ◽

Guillain Barré

AbstractPurpose. To describe the clinical, electrophysiological, and lumbar magnetic resonance imaging (MRI) features of two cases of atypical Guillain-Barré syndrome (GBS). Methods We reported two GBS variant cases with initial and prominent symptoms of low back pain. We analysed their clinical, electrophysiological, and lumbar MRI features. Results Two patients with GBS reported low back pain as the initial and prominent symptom, which was not accompanied by limb weakness. The electrophysiological study showed abnormal F-waves in the common peroneal and tibial nerves, and acute polyradiculoneuropathy in the cauda equina. Examination of the cerebrospinal fluid (CSF) showed albuminocytologic dissociation. Serum was positive for GQ1b-IgM antibodies. Lumbar MRI showed gadolinium enhancement of the nerve roots and cauda equina. A standard regime of intravenous immunoglobulin markedly alleviated the low back pain. Conclusions Low back pain caused by GBS should be differentiated from other diseases. This initial or early prominent symptom may delay the diagnosis of GBS; therefore, it is important to conduct a detailed electrophysiological, CSF, and gadolinium-enhanced lumbar MRI analysis.

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Dermoid tumors of the spinal cord

Journal of Neurosurgery ◽

10.3171/jns.1970.33.6.0676 ◽

1970 ◽

Vol 33 (6) ◽

pp. 676-681 ◽

Cited By ~ 27

Author(s):

Ian C. Bailey

Keyword(s):

Spinal Cord ◽

Low Back Pain ◽

Back Pain ◽

Cauda Equina ◽

Complete Removal ◽

Cord Compression ◽

Conus Medullaris ◽

Low Back ◽

Content Type ◽

Fine Print

✓ This is an analysis of 10 cases of dermoid tumor occurring in the spinal canal (8 lumbar and 2 thoracic). Low-back pain was the commonest presenting symptom, especially if the tumor was adherent to the conus medullaris. Other complaints included urinary dysfunction and motor and sensory disturbances of the legs. Clinical and radiological evidence of spina bifida was found in about half of the cases and suggested the diagnosis of a developmental type of tumor when patients presented with progressive spinal cord compression. At operation, the tumors were often found embedded in the conus medullaris or firmly adherent to the cauda equina, thus precluding complete removal. Evacuation of the cystic contents, however, gave lasting relief of the low-back pain and did not cause any deterioration in neurological function. In a follow-up study, ranging from 1 to 15 years, virtually no improvement in the neurological signs was observed. On the other hand, only one case has deteriorated due to recurrence of tumor growth.

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Appropriateness of Imaging Decisions for Low Back Pain Presenting to the Emergency Department: A Retrospective Chart Review Study

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzab103 ◽

2021 ◽

Author(s):

Adrian Traeger ◽

Gustavo C Machado ◽

Sally Bath ◽

Martin Tran ◽

Lucinda Roper ◽

...

Keyword(s):

Emergency Department ◽

Low Back Pain ◽

Back Pain ◽

Chart Review ◽

Imaging Modality ◽

Cauda Equina ◽

Retrospective Chart Review ◽

Low Back ◽

Review Study ◽

Hospital Emergency Departments

ABSTRACT Background Imaging for low back pain is widely regarded as a target for efforts to reduce low value care. We aimed to estimate the prevalence of overuse and underuse of lumbar imaging in the Emergency Department. Methods Retrospective chart review study of five public hospital Emergency Departments in Sydney, Australia, in 2019/20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse). Results 649 patients presented with a complaint of low back pain of which 158 (24.3%) were referred for imaging. 79 (12.2%) had a combination of features suggesting lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95%CI 6.8% to 11.2%) and 4.3% (28 of 649 cases, 95%CI 3.0% to 6.1%), respectively. 13 cases were classified as underuse because the patient was referred for an uninformative imaging modality (e.g. referred for radiography for suspected cauda equina syndrome). Conclusion In this study of emergency care there was evidence of overuse of lumbar imaging, but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse.

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

CJEM ◽

10.1017/cem.2020.382 ◽

2020 ◽

Vol 22 (5) ◽

pp. 652-654

Author(s):

Zoe Polsky ◽

Margriet Greidanus ◽

Anjali Pandya ◽

W. Bradley Jacobs

Keyword(s):

Emergency Department ◽

Back Pain ◽

Cauda Equina Syndrome ◽

Bowel Movement ◽

Chronic Back Pain ◽

Cauda Equina ◽

Digital Rectal Examination ◽

Acute Onset ◽

Clinical Exam ◽

History Of

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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