Diagnosis of cauda equina syndrome in the emergency department.

Cauda equina syndrome (CES) is a spinal emergency that can be challenging to identify from among the many patients presenting to EDs with low back and/or radicular leg pain. This article presents a practical guide to the assessment and early management of patients with suspected CES as well as an up-to-date review of the most important studies in this area that should inform clinical practice in the ED.

Evaluation of the role of anal tone and perianal sensation examination in the assessment of suspected cauda equina syndrome.

PURPOSE: Cauda equina syndrome (CES) can present with a varied constellation of clinical signs and symptoms, which together with the time-sensitive nature of the condition and risk of catastrophic clinical outcome, presents a significant challenge to those assessing patients with this suspected diagnosis. Anal tone is commonly tested during initial assessment using a digital rectal examination (DRE). This study aims to evaluate the diagnostic value of anal tone and perianal sensation assessment in patients with suspected CES and report modern prevalence data on CES within a neurosciences centre. MATERIALS AND METHODS: Consecutive patients with suspected CES presenting over three years to the Emergency Department (ED) of a busy tertiary centre were included in the study. History and examination findings, documented in the ED notes, were assessed and these variables were correlated with the presence or absence of cauda equina compression on subsequent magnetic resonance imaging (MRI). RESULTS: Out of 1005 patients with suspected CES, 117 (11.6%) had MRI confirmed cauda equina compression (MRI + ve CES). 35% of MRI + ve patients and 31% of MRI -ve patients had reduced anal tone. Using univariate and multivariable logistic regression analyses, no associations were found between abnormal anal tone and MRI + ve CES for patients of all ages. The univariate logistic regression analysis identified altered perianal sensation to be significantly associated with MRI + ve CES in patients ≤42 years old. This association was no longer present when an adjusted multivariable logistic regression was performed. CONCLUSION: The prevalence of MRI + ve CES was 11.6%. Our findings suggest that the clinical finding of reduced anal tone has no demonstrable diagnostic value for those with suspected CES, either in itself or in combination with other clinical findings. Further studies are needed to confirm the diagnostic efficacy of assessing perianal sensation in this context.

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.

OBJECTIVE: Atraumatic 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. METHODS: A 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. RESULTS: We 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. CONCLUSIONS: In 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.

The Cauda Scale - Validation for Clinical Practice.

Purpose: The purpose of this study was to validate the cauda scale (TCS) in an external population. TCS was proposed as a tool to be used to predict the likelihood of cauda equina compression.Methods: We analysed the presenting condition of consecutive patients attending the emergency department undergoing a magnetic resonance scan with a clinical suspicion of cauda equina syndrome (CES). The findings were graded according to TCS for those with and without radiological compression of the cauda equina. Logistic regression was applied to the data in accordance with the original paper.Results: Patients were included over a 14 month period (n = 313), subsequent imaging revealed CES compression in 34 cases and no CES compression in 279. The TCS proposed that small values meant a more likely diagnosis of CES, the data showed the opposite of this with the highest number of patients with CES scoring a maximal 9 on TCS (mildest symptoms).Conclusions: Our data suggests that TCS has potential limitations in identifying patients with CES and needs further work prior to implementation.

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

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.

An analysis of the utility, effectiveness and scope of advanced physiotherapy practitioners in an urgent treatment centre pilot.

BACKGROUND: The NHS Five Year Forward View explored the requirement to redesign emergency departments in England. It suggested that by December 2019, all emergency departments should aim to develop urgent treatment centres primarily led by primary care services opposed to the traditional model of being emergency physician led. This redesign aims to improve patient care by "helping people who need urgent care to get the right advice in the right place, first time". AIM: One aim was to quantify the proportional presentations of patients attending the emergency department who were suitable for management by advanced physiotherapy practitioners (APPs). A second aim was to analyse patient care delivered by APPs in comparison to other members of the multidisciplinary team. METHODS: A retrospective service evaluation was undertaken reviewing a pilot urgent treatment centre at a busy major trauma centre. Data was collected to assess number of patients seen by all multidisciplinary cohort members. This was to assess presentation patterns and compare workload delivery. RESULTS: The pilot found that APPs could assess and treat a wide range of conditions within the urgent treatment centre. APPs saw 30% of the caseload, organised similar numbers of investigations than GPs and had fewer 30 days re-attendances. CONCLUSION: The service review highlighted APP can assess, treat, discharge and appropriately refer similar numbers of patients compared to multidisciplinary colleagues. This would suggest that APPs are likely to be highly cost effective within an urgent treatment centre environment, but further study is warranted to assess clinical and cost effectiveness.

The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery.

BACKGROUND: This paper aims to review the introduction of an enhanced recovery after surgery (ERAS) service within complex spinal surgery, with an aim to assess if this is a cost effective way to improve the overall experience of such complex surgery. METHODS: The ERAS model was defined and followed within a regional centre for complex spinal surgery in the UK. Outcomes such as length of stay (LOS) and satisfaction were measured before and after implementation of the service. RESULTS: LOS was reduced and both patient and staff satisfaction improved following the implementation of the ERAS service. CONCLUSIONS: The ERAS model can successfully be implemented within complex spinal surgery, to help improve satisfaction and reduce cost.