Case study highlighting cauda equina syndrome and the effects on bladder management.

Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, where all the nerves in the lower back suddenly become severely compressed. It is a serious medical emergency, and compression of the nerves in the lower portion of the spinal canal can lead to permanent loss of bowel and bladder control, paraesthesia, and paralysis of the legs if left untreated. Causes of CES include: trauma, spinal stenosis, herniated discs, spinal tumour, cancerous tumour, inflammatory and infectious conditions or due to an accidental medical intervention. CES patients typically present with symptoms of: saddle anaesthesia, pain, incontinence and numbness. Any of these are red flag symptoms and require immediate investigation and treatment.

Cauda equina syndrome.

Cauda equina syndrome is an uncommon but serious cause of lower back pain resulting from compression of the cauda equina nerve roots, most commonly by lumbar disc herniation. Red flag symptoms, such as bladder dysfunction, saddle anaesthesia and sciatica, should lead to high clinical suspicion of cauda equina syndrome. The British Association of Spinal Surgeons has published an updated standard of care for these patients because of the potentially debilitating effects of missed cases of cauda equina syndrome. This review summarises these standards and provides a framework to support quick triage of at-risk patients. Immediate magnetic resonance imaging, within 1 hour of presentation to the emergency department, is crucial in patients with suspected cauda equina syndrome to allow prompt diagnosis and treatment. Urgent decompressive surgery is usually recommended for the best outcomes, to reduce morbidity and complication rates.

A service evaluation of the management of patients with suspected cauda equina syndrome from an outpatient physiotherapy service in the United Kingdom.

BACKGROUND: The expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources. AIM: To evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome. DESIGN: Service evaluation with an embedded case series of patients with radiological CES. METHOD: The records of patients who were identified by their outpatient physiotherapists as having suspected CES (n-231) over a 27-month period were included. Data was extracted from patients' medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series. RESULTS: In 79% of cases, it was decided that emergency referral was not required. The remaining 21% of patients were referred to the emergency department and 49% of these had an emergency MRI. In the case series of seven patients with cauda equina compression on MRI, four patients had a disc bulge and underwent emergency surgery. One patient had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis. Two patients had stenosis and decided against surgical intervention. CONCLUSIONS: Findings from this service evaluation suggest support for the use of safety netting and an effective communication chain to facilitate effective management of patients with suspected CES.

Spinal cord stimulation and cauda equina syndrome: Could it be a valid option? A report of two cases / Estimulación medular y síndrome de cauda equina. ¿Podría ser una opción válida? Reporte de dos casos

Spinal cord stimulation (SCS) consists of the application of electrical stimuli to the dorsal columns of the spinal cord or to the posterior nerve roots in order to modulate the pain signals carried by the ascending pain pathways to the brain. Two cases of SCS in patients with cauda equina syndrome after lumbar surgery are presented. They were treated for persistent neuropathic pain but also experienced improvement in their motor and urinary symptoms after this treatment. Although the primary indication for SCS is neuropathic pain control, its application can also lead to improvement of motor deficits, sensory disorders, and urinary incontinence, as shown in these two cases. SCS will likely play a fundamental role in rehabilitative therapies in different neurological diseases. Further investigation in the field is needed (AU)

La estimulación medular (SCS) consiste en la aplicación de estímulos eléctricos a las columnas dorsales de la médula espinal o a las raíces nerviosas para modular las señales de dolor en su vía ascendente hacia el cerebro. Se presentan dos casos del síndrome de cauda equina, secundario a cirugías lumbares. Estos fueron tratados por dolor neuropático persistente, pero también experimentaron mejoría de sus síntomas motores y urológicos con la SCS. La principal indicación de la SCS es el control del dolor neuropático; sin embargo, su uso también podría mejorar déficits neurológicos, alteraciones de la sensibilidad y la incontinencia urinaria, como se muestra en estos dos casos. La SCS probablemente jugará un rol importante en las terapias rehabilitadoras en algunas enfermedades neurológicas, aunque se necesita más investigación en este campo para estudiar dichos efectos (AU)

Spinal cord stimulation and cauda equina syndrome: Could it be a valid option? A report of two cases.

Spinal cord stimulation (SCS) consists of the application of electrical stimuli to the dorsal columns of the spinal cord or to the posterior nerve roots in order to modulate the pain signals carried by the ascending pain pathways to the brain. Two cases of SCS in patients with cauda equina syndrome after lumbar surgery are presented. They were treated for persistent neuropathic pain but also experienced improvement in their motor and urinary symptoms after this treatment. Although the primary indication for SCS is neuropathic pain control, its application can also lead to improvement of motor deficits, sensory disorders, and urinary incontinence, as shown in these two cases. SCS will likely play a fundamental role in rehabilitative therapies in different neurological diseases. Further investigation in the field is needed.

A scoping review protocol: Investigating the extent and legal process of cauda equina syndrome claims for UK physiotherapists.

INTRODUCTION: Cauda equina syndrome (CES) is a condition where early identification and treatment is crucial to avoid potentially devastating effects. There is a high number of litigation cases linked with CES given it is a relatively rare condition. This scoping review protocol proposes to explore the extent and process of CES litigation in UK healthcare context cases amongst UK physiotherapists. METHODS AND ANALYSIS: The methodological framework recommended by Arksey and O'Malley, Levac et al. and the Joanna Briggs Institute will be used throughout this review to aid reporting and transparency. A patient and public involvement (PPI) group meeting was convened at the beginning of the review process in order to provide knowledge exchange to inform the search strategy and propose resources to be used during the scoping review. Two reviewers will independently review the literature in order to apply the inclusion and exclusion criteria. Once the studies to be included have been identified, the data from these studies will be extracted and charted. Results will show quantitative data of the studies included in the review and a narrative synthesis of the literature. DISSEMINATION: This scoping review will evaluate the existing knowledge relating to CES and litigation and will map the key concepts around this topic. Results will be disseminated to practitioners and policy-makers through peer-reviewed publications, conferences, reports and social media. This method may prove helpful to others who are investigating extent and processes relating to medicolegal cases involving healthcare practitioners. REGISTRATION: The current paper is registered with OSF registries (DOI 10.17605/OSF.IO/MP6Y3).

Cauda equina compression in metastatic prostate cancer.

A 67-year-old man presented to his general practitioner with intermittent episodes of unilateral sciatica over a 2-month period for which he was referred for an outpatient MRI of his spine. This evidenced a significant lumbar vertebral mass that showed tight canal stenosis and compression of the cauda equina. The patient was sent to the emergency department for management by orthopaedic surgeons. He was mobilising independently, pain free on arrival and without neurological deficit on assessment. Clinically, this patient presented with no red flag symptoms of cauda equina syndrome or reason to suspect malignancy. In these circumstances, National Institute for Health and Care Excellence guidelines do not support radiological investigation of the spine outside of specialist services. However, in this case, investigation helped deliver urgent care for cancer that otherwise may have been delayed. This leads to the question, do the current guidelines meet clinical requirements?

Transplantation of neural stem cells encapsulated in hydrogels improve functional recovery in a cauda equina lesion model.

This study explored the therapeutic effects of transplantation of neural stem cells (NSCs) encapsulated in hydrogels in a cauda equina lesion model. NSCs were isolated from neonatal dorsal root ganglion (nDRG) and cultured in three-dimensional porous hydrogel scaffolds. Immunohistochemistry, transmission electron microscopy and TUNEL assay were performed to detect the differentiation capability, ultrastructural and pathological changes, and apoptosis of NSCs. Furthermore, the functional recovery of sensorimotor reflexes was determined using the tail-flick test. NSCs derived from DRG were able to proliferate to form neurospheres and mainly differentiate into oligodendrocytes in the three-dimensional hydrogel culture system. After transplantation of NSCs encapsulated in hydrogels, NSCs differentiated into oligodendrocytes, neurons or astrocytes in vivo. Moreover, NSCs engrafted on the hydrogels decreased apoptosis and alleviated the ultrastructural and pathological changes of injured cauda equina. Behavioral analysis showed that transplanted hydrogel-encapsulated NSCs decreased the tail-flick latency and showed a neuroprotective role on injured cauda equina. Our results indicate transplantation of hydrogel-encapsulated NSCs promotes stem cell differentiation into oligodendrocytes, neurons or astrocytes and contributes to the functional recovery of injured cauda equina, suggesting that NSCs encapsulated in hydrogels may be applied for the treatment of cauda equina injury.

Cauda Equina Syndrome Core Outcome Set (CESCOS): An international patient and healthcare professional consensus for research studies.

BACKGROUND: Cauda Equina Syndrome (CES) is an emergency condition that requires acute intervention and can lead to permanent neurological deficit in working age adults. A Core Outcome Set (COS) is the minimum set of outcomes that should be reported by a research study within a specific disease area. There is significant heterogeneity in outcome reporting for CES, which does not allow data synthesis between studies. The hypothesis is that a COS for CES can be developed for future research studies using patients and healthcare professionals (HCPs) as key stakeholders. METHODS AND FINDINGS: Qualitative semi-structured interviews with CES patients were audio-recorded, transcribed and analysed using NVivo to identify the outcomes of importance. These were combined with the outcomes obtained from a published systematic literature review of CES patients. The outcomes were grouped into a list of 37, for rating through two rounds of an international Delphi survey according to pre-set criteria. The Delphi survey had an overall response rate of 63% and included 172 participants (104 patients, 68 HCPs) from 14 countries who completed both rounds. Thirteen outcomes reached consensus at the end of the Delphi survey and there was no attrition bias detected. The results were discussed at an international consensus meeting attended by 34 key stakeholders (16 patients and 18 HCPs) from 8 countries. A further three outcomes were agreed to be included. There was no selection bias detected at the consensus meeting. There are 16 outcomes in total in the CESCOS. DISCUSSION: This is the first study in the literature that has determined the core outcomes in CES using a transparent international consensus process involving healthcare professionals and CES patients as key stakeholders. This COS is recommended as the most important outcomes to be reported in any research study investigating CES outcomes and will allow evidence synthesis in CES.

SHADES of grey - The challenge of 'grumbling' cauda equina symptoms in older adults with lumbar spinal stenosis.

Diagnosing cauda equina syndrome is challenging in older adults with lumbar spinal stenosis. Understanding these challenges is vital for clinicians who are faced with difficult decisions about when to refer for investigation or surgical management. This is a growing clinical issue because of the escalating prevalence of lumbar spinal stenosis in our ageing population, and increasing demands on healthcare services including imaging and surgical services. This professional issue explores the challenges and evidence gaps relating to cauda equina syndrome in older adults with lumbar spinal stenosis. The degenerative patho-anatomical changes in the lumbar spine that are responsible for lumbar spinal stenosis also have the potential to lead to a gradual compromise of the cauda equina nerve roots. The clinical presentation may be unclear. As a result, there is a risk that slow-onset 'grumbling' cauda equina symptoms may be overlooked or dismissed in older patients with lumbar spinal stenosis. Furthermore, a lack of standardised diagnostic criteria and management pathways add to the challenges for clinicians diagnosing and managing potential cauda equina compromise associated with lumbar spinal stenosis. We recommend careful assessment, appropriate safety netting, and ongoing clinical monitoring and vigilance when assessing and managing this potentially vulnerable patient group.

[Spinal infection with spinal cord/cauda equina affection requires emergency handling]. / Spinal infektion med ryggmärgs­påverkan kräver snabba åtgärder - Genomgång av Ivo-anmälningar visar att fördröjd handläggning kan ge allvarliga restsymtom.

Seventeen cases of infections in spinal structures were reported 2010-2017 to the Swedish Health and Social Care Inspectorate (IVO), a government agency responsible for supervising health care, for missed or delayed diagnosis. All patient records were scrutinized in order to find underlying causes and common factors. The delayed diagnoses were equally found among men and women and most frequent in in the age-group 65 to 79 years of age. The diagnostic delay most probably in many cases led to patient harm and avoidable sequelae, many with severe impairment for daily life. Several of the patients had a locus minoris resistentiae in the spine and in several cases the entry port of infections were cutaneous wounds, for example leg ulcers. The most important finding was that in the majority of cases the clinical investigation was inadequate and the clinical follow-up - while in hospital! - was inferior, without documentation of muscular weakness and sensory loss. In several cases a too passive management was found, when the losses eventually had become apparent, delaying surgical interventions.

Management of Herniated Lumbar Disk Disease and Cauda Equina Syndrome in Pregnancy.

Lower back pain is a commonly reported symptom during pregnancy. However, herniated lumbar disk disease is an uncommon cause for such pain. Cauda equina syndrome (CES) during pregnancy is a rare clinical scenario. This review highlights the epidemiology, diagnostic and treatment strategies, and challenges encountered when managing herniated lumbar disk disease and CES in pregnancy. Magnetic resonance imaging is the diagnostic modality of choice. Nonoperative treatment strategies are successful in the vast majority of cases in patients with a herniated disk in the absence of CES. CES and progressive neurological deficits remain absolute indications for surgical intervention regardless of gestational age. For such patients or those with debilitating symptoms refractory to nonoperative treatment strategies, surgery has been demonstrated to be safe in the pregnant patient population. However, surgery should be performed with obstetric and midwifery support should complications occur to the fetus.

Protocol for the development of a core outcome set for cauda equina syndrome: systematic literature review, qualitative interviews, Delphi survey and consensus meeting.

INTRODUCTION: Cauda equina syndrome (CES) is a serious neurological condition most commonly due to compression of the lumbosacral nerve roots, which can result in significant disability. The evidence for acute intervention in CES is mainly from retrospective studies. There is heterogeneity in the outcomes chosen for analysis in these studies, which makes it difficult to synthesise the data across studies. This study will develop a core outcome set for use in future studies of CES, engaging with key stakeholders and using transparent methodology. This will help ensure that relevant outcomes are used in future and will facilitate attempts to summarise data across studies in systematic reviews. METHODS AND ANALYSIS: A systematic literature review will document all the outcomes for CES after surgery mentioned in the literature. The qualitative interviews with patients with CES will be semistructured, audio recorded, transcribed and thematically analysed with the use of NVivo V.10 to identify outcomes and determine the themes described. The outcomes from the literature review and patient interviews will be combined and prioritised to determine what the most important outcomes are in CES research studies to patients and healthcare professionals. The prioritisation will be done through a two-round iterative Delphi survey and a consensus meeting. This process will decide the core outcome set for patients with CES. ETHICS AND DISSEMINATION: REC and HRA approval was obtained on the 6/12/16 for the qualitative interviews from South Central-Hampshire A REC. REC reference 16/SC/0587. REC and HRA approval was obtained on 26/3/18 for the Delphi process and consensus meeting from North West-Greater Manchester Central REC. REC reference was 18/NW/0022. The final core outcome set will be published and freely available. TRIAL REGISTRATION NUMBER: This study is registered with the Core Outcome Measures in Effectiveness Trials database as study 824.

Cauda Equina Syndrome in Ankylosing Spondylitis: Challenges in Diagnosis, Management, and Pathogenesis.

OBJECTIVE: Cauda equina syndrome (CES) is a rare neurologic complication of longstanding ankylosing spondylitis (AS). It is unclear what causes CES, and no proven or effective therapy has been reported to date. We have encountered 6 patients with longstanding AS diagnosed with CES. We set about to study their features, review the literature, and generate hypotheses regarding pathophysiology, as well as to speculate on the possibilities of early recognition and prevention. METHODS: We obtained permission from 6 patients with longstanding AS and CES to access their medical records and imaging studies for research purposes related to this paper. We collected and reviewed each patient's medical history, imaging studies, disease duration, past therapies especially those that relate to AS, laboratory data, as well as any treatment they received for CES and followup results of each case to the present time. RESULTS: The 6 cases of CES with AS have remarkable similarity to each other in that several decades of the disease had passed before neurologic symptoms and later signs appeared. All cases have fused spines and facet joints without spinal fractures, spinal stenosis, or disc herniation. CONCLUSION: CES is a rare yet debilitating neurologic complication of longstanding AS. The pathophysiology and treatments are far from clear. We postulate that chronic enthesitis of the vertebral column initiates the process that results in dural stiffening and formation of ectasias, causing downstream nerve root damage.

Spinal Emergencies in Primary Care Practice.

Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Permanent neurologic sequela and even death can result if delays in appropriate treatment occur. A focused, critical review of 34 peer-reviewed articles was performed to identify current data about accurate diagnosis of spinal emergencies. This review highlights the key features of these 3 pathological entities with an emphasis on appropriate diagnostic strategy to intervene efficiently and minimize morbidity.

Assessment and management of cauda equina syndrome.

INTRODUCTION: Cauda equina syndrome (CES) is a rare condition that affects the nerves in the spine supplying the bladder, bowel and sexual function. Identification and subsequent urgent action is required to avoid permanent damage to these essential organs. Delays in diagnosis can have devastating and life changing consequences for patients and result in high cost negligence claims. PURPOSE: The purpose of this masterclass is to examine the current evidence and provide an evidence-based, clinically reasoned approach in the safe management of patients presenting with CES. It will include a focus on the importance of communication, documentation and a practical approach to safety netting those at risk. IMPLICATIONS FOR PRACTICE: CES has significant implications for patients and clinicians alike. Timely, effective diagnosis and management of patients with CES results in a better outcome.

Cauda equina syndrome secondary to neurolymphomatosis: Case report and literature review. / Síndrome de cauda equina secundario a neurolinfomatosis: presentación de un caso y revisión de la literatura.

Neurolymphomatosis is a rare disorder characterised by infiltration of neoplastic lymphocytes into the peripheral nervous system. A wide variety of symptoms can manifest depending on its nature and location, making its diagnosis a real challenge. Treatment is based on methotrexate, although various chemotherapy regimens are currently available for patients with systemic disease. We present the case of a male patient with neurolymphomatosis of the cauda equina, together with a review of all cases published to date.