Determination of potential risk characteristics for cauda equina compression in emergency department patients presenting with atraumatic back pain: a 4-year retrospective cohort analysis within a tertiary referral neurosciences centre

2021 ◽  
pp. emermed-2020-210540
Author(s):  
Michelle Angus ◽  
Carlos M Curtis-Lopez ◽  
Roberto Carrasco ◽  
Vicki Currie ◽  
Irfan Siddique ◽  
...  
Keyword(s):  
Back Pain ◽  
Cohort Analysis ◽  
Cauda Equina ◽  
Digital Rectal Examination ◽  
Leg Pain ◽  
Sensory Loss ◽  
Reference Standard ◽  
Rectal Examination ◽  
Presenting Symptoms ◽  
Cauda Equina Compression

ObjectiveAtraumatic back pain is an increasingly common presentation to the ED. A minority of these cases will have significant structural pathology, resulting in acute cauda equina compression (CEC). Although clinicians often look for ‘red flags’ to identify potential CEC, the prognostic accuracy of these presenting symptoms and clinical examination findings is unclear. We sought to evaluate the accuracy of individual clinical features in a large cohort of ED patients with atraumatic backpain and reference standard imaging, for the diagnosis of CEC.MethodsA retrospective case note review from 2014 to 2018 within an established ED atraumatic back pain pathway, undertaken at the largest tertiary spinal referral centre in the UK. We analysed routine data, collected prospectively by treating clinicians within a structured electronic health record clinical proforma. Data on signs and symptoms in 996 patients with suspected CEC referred for definitive MRI over a 4-year study period were extracted and compared against a final reference standard diagnosis.ResultsWe identified 111 patients with radiological evidence of CEC within the cohort referred for definitive imaging (111/996, 11.1%), of whom 109 (98.2%) underwent operative intervention. Patients with CEC were more likely to present with bilateral leg pain (OR=2.2), dermatomal sensory loss (OR 1.8) and bilateral absent ankle or ankle and knee jerks (OR=2.9). Subjective weakness was found to be associated with CEC on univariate but not multivariate analysis. We found no relationship between digital rectal examination findings and the diagnosis of CEC.ConclusionsIn our cohort, factors independently associated with CEC diagnosis on MRI included bilateral leg pain, dermatomal sensory loss. Loss of lower limb reflexes was strongly suggestive of CES (likelihood ratio 3.4 on multivariate logistic regression). Our findings raise questions about the diagnostic utility of invasive digital rectal examination.

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

CJEM ◽  
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?

scholarly journals Thoracic myelopathy secondary to multi-level ossification of the ligamentum flavum in an Asian patient

2017 ◽  
Vol 4 (3) ◽  
pp. 46
Author(s):  
Chiara J Chong ◽  
Wan Tin Lim
Keyword(s):  
Back Pain ◽  
Ligamentum Flavum ◽  
Cauda Equina ◽  
Central Canal ◽  
Sensory Function ◽  
Lower Limbs ◽  
Sensory Loss ◽  
Thoracic Myelopathy ◽  
Limb Weakness ◽  
Canal Stenosis

Thoracic myelopathy occurs less frequently than lumbar myelopathy. There are several causes of thoracic myelopathy of which ossification of the ligamentum flavum (OLF) is one. OLF has several unique features, arising posteriorly and causing proprioceptive issues first before extending to cause motor and sensory loss. We present a case of a 58-year-old gentleman with a six-month history of progressive lower limb weakness, numbness, back pain and recurrent falls due to OLF. Magnetic resonance and computed tomography imaging revealed extensive thoracic OLF and concomitant facet hypertrophy involving T6-7, T7-8, T9-10, T10-11 and L1-2. Severe central canal stenosis and L1-2 cauda equina root compression were also seen on radiological imaging. The patient developed sphincter disturbance during his admission and had difficulty passing urine. He underwent physiotherapy but was only able to sit and stand with the help of a walking frame at best. He did not regain motor or sensory function in his lower limbs although his back pain improved. Surgical decompression is associated with good neurological outcomes in OLF. Despite this, our patient declined surgery and opted for conservative therapy instead. We wish to highlight a rare case of thoracic myelopathy and the potentially irreversible neurological deterioration that occurs if there is no early surgical intervention.

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

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.

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

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.

Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience

2000 ◽  
Vol 93 (1) ◽  
pp. 53-57 ◽  
Author(s):  
Mark K. Lyons ◽  
John L. D. Atkinson ◽  
Robert E. Wharen ◽  
H. Gordon Deen ◽  
Richard S. Zimmerman ◽  
...  
Keyword(s):  
Mayo Clinic ◽  
Cauda Equina ◽  
Sensory Loss ◽  
Spinal Instability ◽  
Surgical Removal ◽  
Motor Weakness ◽  
Content Type ◽  
Presenting Symptoms ◽  
Synovial Cysts ◽  
Fine Print

Object. The authors report a retrospective analysis of 194 patients surgically treated at their institutions for symptomatic lumbar synovial cysts from January 1974 to January 1996. Methods. Patient characteristics including age, sex, symptoms, signs, and preoperative neuroimaging studies were reviewed. Surgical procedures, complications, results, and pathological findings were correlated with preoperative assessment. One hundred ninety-four patients were surgically treated for symptomatic lumbar synovial cysts. Eighty percent were diagnosed and treated between 1987 and 1996. There were 100 men and 94 women with an average age of 66 years (range 28–94 years). The most common symptoms were painful radiculopathy (85%) and neurogenic single or multiroot claudication (44%). However, sensory loss (43%) and motor weakness (27%) were also presenting symptoms. Eleven percent of patients had undergone previous lumbar surgery prior to being referred to the Mayo Clinic. Preoperative neurological examination demonstrated motor weakness (40%), sensory loss (45%), reflex changes (57%), and variants of cauda equina syndrome (13%). In 19% of patients, normal neurological status was demonstrated. There was equal left/right-sided laterality, and eight patients presented with bilateral synovial cysts. The most commonly affected level was L4–5 (64%). All patients underwent laminectomy and resection of the cyst. Concomitant fusion was performed in 18 patients in whom clinical evidence of instability had been observed. However, subsequent fusion was required in only four patients who developed symptomatic spondylolisthesis. Surgery-related complications included cerebrospinal fluid leak (three patients), discitis (one patient), epidural hematoma (one patient), seroma (one patient), and deep vein thrombosis (one patient). One patient died 3 days after surgery of cardiac dysrhythmia. Follow-up data obtained for at least 6 months postoperatively were available in 147 patients. Of these, 134 (91%) reported good relief of their pain and 82% experienced improvement in their motor deficits. Conclusions. Lumbar synovial cysts are a more common cause of lumbar radicular pain than previously thought. Surgical removal of the cyst is a safe and effective treatment for symptomatic relief in patients with lumbar synovial cysts. A concomitant fusion procedure may be performed in select cases. In this study, only a few patients developed symptomatic spinal instability requiring a second operation.

scholarly journals Clinical and radiographically/neuroimaging documented outcome in transforaminal lumbar interbody fusion

2006 ◽  
Vol 20 (3) ◽  
pp. 1-5 ◽  
Author(s):  
John K. Houten ◽  
Nicholas H. Post ◽  
Joseph W. Dryer ◽  
Thomas J. Errico
Keyword(s):  
Back Pain ◽  
Disc Herniation ◽  
Interbody Fusion ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Leg Pain ◽  
Sensory Loss ◽  
Symptom Duration ◽  
Lumbar Interbody Fusion ◽  
Disc Space ◽  
Recurrent Disc Herniation

Object Although transforaminal lumbar interbody fusion (TLIF) is an increasingly popular surgical technique, there are a limited number of studies in which investigators have stratified outcome data with respect to surgical indications or documented radiographically proven and clinical results with respect to disc space height (DSH). The authors conducted a study to evaluate the long-term outcomes after TLIF with respect to surgical indication and radiographic/neuroimaging results. Methods Thirty-three consecutive TLIF-treated patients underwent follow-up investigation for a mean of 37 months. Isthmic spondylolysis was present in eight patients, recurrent disc herniation in 14, and degenerative disc disease (DDD) in 11. The operative technique involved the placement of interbody structural allograft, pedicle screw instrumentation, and morcellized autograft in the anterior interbody space and the contralateral intertransverse gutter. Surgery was performed at L4–5 in 16 patients, L5–S1 in 14, L3–4 in two, and both L4–5 and L5–S1 in one patient. Preoperative symptoms were back pain (in 91% of cases), leg pain (in 94%), sensory loss (in 67%), and motor deficits (in 30%). Postoperatively, back pain was improved in 67% of the patients, unchanged in 27%, and worsened in 7%. Leg pain improved in 80% of patients, was unchanged in 10%, and worsened in 10%. Outcome, as measured using the Prolo Functional and Economic Scales, improved from a score of 4.9 to 7. In patients with spondylolysis and recurrent disc herniation outcomes were better than in those with DDD only. There was no correlation of outcome with symptom duration, patient age, or level of surgery. In an independent review of pre- and late postoperative radiographs no significant differences in lordosis angles, Cobb angles, or DSHs were found. Fusion occurred in all cases. Conclusions The TLIF procedure was associated with good clinical outcomes and a high fusion rate but no change in the DSH. Patients who present with spondylolysis and recurrent herniations experience better outcome than those with degenerative disease alone.

scholarly journals Coflex interspinous implant placement leading to synovial cyst development: case report

2018 ◽  
Vol 29 (3) ◽  
pp. 265-270 ◽  
Author(s):  
Seba Ramhmdani ◽  
Marc Comair ◽  
Camilo A. Molina ◽  
Daniel M. Sciubba ◽  
Ali Bydon
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Facet Joint ◽  
Cauda Equina ◽  
Synovial Cyst ◽  
Leg Pain ◽  
Segmental Motion ◽  
Low Back ◽  
The Right ◽  
Lumbar Spinal

Interspinous process devices (IPDs) have been developed as less-invasive alternatives to spinal fusion with the goal of decompressing the spinal canal and preserving segmental motion. IPD implantation is proposed to treat symptoms of lumbar spinal stenosis that improve during flexion. Recent indications of IPD include lumbar facet joint syndrome, which is seen in patients with mainly low-back pain. Long-term outcomes in this subset of patients are largely unknown. The authors present a previously unreported complication of coflex (IPD) placement: the development of a large compressive lumbar synovial cyst. A 64-year-old woman underwent IPD implantation (coflex) at L4–5 at an outside hospital for low-back pain that occasionally radiates to the right leg. Postoperatively, her back and right leg pain persisted and worsened. MRI was repeated and showed a new, large synovial cyst at the previously treated level, severely compressing the patient’s cauda equina. Four months later, she underwent removal of the interspinous process implant, bilateral laminectomy, facetectomy, synovial cyst resection, interbody fusion, and stabilization. At the 3-month follow-up, she reported significant back pain improvement with some residual leg pain. This case suggests that facet arthrosis may not be an appropriate indication for placement of coflex.

The Evaluation of Digital Rectal Examination for Assessment of Anal Tone in Suspected Cauda Equina Syndrome

Spine ◽  
2015 ◽  
Vol 40 (15) ◽  
pp. 1213-1218 ◽  
Author(s):  
Katrina Eve Sherlock ◽  
William Turner ◽  
Sherief Elsayed ◽  
M. Bagouri ◽  
L. Baha ◽  
...  
Keyword(s):  
Cauda Equina Syndrome ◽  
Cauda Equina ◽  
Digital Rectal Examination ◽  
Rectal Examination

Intact arch spondylolisthesis

1985 ◽  
Vol 63 (6) ◽  
pp. 840-844 ◽  
Author(s):  
Eben Alexander ◽  
David L. Kelly ◽  
Courtland H. Davis ◽  
Joe M. McWhorter ◽  
William Brown
Keyword(s):  
Intervertebral Disc ◽  
Cauda Equina ◽  
Leg Pain ◽  
Low Back ◽  
Content Type ◽  
The Past ◽  
Cauda Equina Compression ◽  
Male Patients ◽  
Almost All

✓ Over the past 11 years, the authors have treated 50 cases of intact arch spondylolisthesis. There were 38 female and 12 male patients, and all but 11 were older than 60 years of age. Almost all had severe low-back pain made worse by standing or walking. Other common manifestations were unilateral leg pain, numbness or weakness of the leg, and evidence of mild cauda equina compression. Severe cauda equina compression was rare. Myelography invariably showed an extradural dorsal compression. A waist deformity was characteristic in many patients, but 12 had a complete block. In 15 patients (30%) the myelographic impression was that of a herniated intervertebral disc. Most subluxations were of L-4 on L-5. At operation, the facets were found to be thickened, distorted, and irregular. All patients were treated with a wide decompression and laminectomy, which included a medial facetectomy of the inferior and superior facets. An intervertebral disc was removed in 10 patients. Follow-up monitoring of 41 patients (for an average period of 36 months) showed that 26 (63%) were pain-free, 11 had less pain, and four were unimproved. Five other patients with short follow-up periods (average 5 months) were all improved.

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