Bladder ultrasonography in the assessment of cauda equina syndrome in the emergency department: a literature review.

For cauda equina syndrome (CES), current clinical assessment in the emergency department usually involves perianal sensation (PAS) and anal tone (AT). Neither reliably predict magnetic resonance imaging (MRI) demonstrating a large central disc prolapse (MRI+). Other clinical examination findings increase the probability of MRI+. Other tests of sacral nerve root function include anal squeeze (AS) and the bulbocavernosus reflex (BCR). If BCR, PAS and AT, and AS are combined and they are all normal, CES can be excluded in almost all cases. Portable bladder ultrasonography is now commonly used to assess bladder function, particularly in measuring the post-void residual urinary volume (PVR). PVR is deemed normal at <50ml. If the PVR is <200ml and there are no objective signs, MRI+ is rare. If the PVR is >200ml, MRI+ is found in 43% of cases. The combined assessment of PAS, AT and AS (and BCR in selected cases) and PVR increases the specificity and sensitivity of a clinical diagnosis of CES (i.e. maximising MRI+ and minimising MRI-). Recommendations for when to perform MRI are made.

Spinal reperfusion syndrome. A literature review and medicolegal implications.

Aim. To consider the diagnosis of spinal reperfusion syndrome (SRS) and its medicolegal implications.Materials and Methods. . A PRISMA guided PubMed search was performed to identify cases of possible SRS following spinal surgery.Result. Fourteen papers suggested that SRS might be the cause of neurological deterioration. In patients undergoing surgery for cervical degenerative disorders there were 7 patients who had new deficits immediately on awakening from the anaesthetic. There were 6 patients who had no new deficit immediately post-surgery with new deficits occurring within hours, or up to 3 days post-surgery.Conclusion. There is no agreed clinical definition of the SRS and the radiological abnormalities are not defined. The diagnosis of SRS can potentially be made by exclusion or inclusion. If there is a known cause of new neurological deficits intra- or immediately post-operatively, such as for example intraoperative cord injury, inadequate decompression or a haematoma, that is the probable diagnosis, not SRS. If a patient awakes with new deficits the most likely cause (if no other cause is identified) is intraoperative injury to the cord. If there is delayed deterioration with no cause identified SRS is a possible explanation. New deficits occur in 0.5 to 1.0% of patients undergoing anterior cervical spine surgery i.e. overall this is common whereas SRS is rare. The medicolegal implications are discussed.

Informed consent in spinal surgery.

Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery. Cite this article: Bone Joint J 2019;101-B:355-360.

The surgical treatment of non-specific low back pain.

The National Institute for Health and Care Excellence has issued guidelines that state fusion for non-specific low back pain should only be performed as part of a randomised controlled trial, and that lumbar disc replacement should not be performed. Thus, spinal fusion and disc replacement will no longer be routine forms of treatment for patients with low back pain. This annotation considers the evidence upon which these guidelines are based. Cite this article: Bone Joint J 2017;99-B:1003-1005.

Standards of care in cauda equina syndrome.

What constitutes cauda equina syndrome (CES), how it should be subclassified and how urgently to image and operate on patients with CES are all matters of debate. A structured review of the literature has led us to evaluate the science and to propose evidence-based guidelines for the management of CES. Our conclusions include this guidance: pain only; MRI negative - recommend: analgesia, ensure imaging complete (not just lumbar spine) adequate follow-up. Bilateral radiculopathy (CESS) with a large central disc prolapse - recommend: discuss with the patient and if for surgery, the next day (unless deteriorates to CESI in which case emergency surgery); CESI - recommend: the true emergency for surgery by day or night; a large central PLID with uncertainty as to whether CESI or CESR (e.g. catheterised prior to CESR) or where there is residual cauda equina nerve root function or early CESR - recommend: treat as an emergency by day or night. Where there has been prolonged CESR and/or no residual sacral nerve root function - recommend: treat on the following day's list.

Cauda equina syndrome: is the current management of patients presenting to district general hospitals fit for purpose? A personal view based on a review of the literature and a medicolegal experience.

There is no universally agreed definition of cauda equina syndrome (CES). Clinical signs of CES including direct rectal examination (DRE) do not reliably correlate with cauda equina (CE) compression on MRI. Clinical assessment only becomes reliable if there are symptoms/signs of late, often irreversible, CES. The only reliable way of including or excluding CES is to perform MRI on all patients with suspected CES. If the diagnosis is being considered, MRI should ideally be performed locally in the District General Hospitals within one hour of the question being raised irrespective of the hour or the day. Patients with symptoms and signs of CES and MRI confirmed CE compression should be referred to the local spinal service for emergency surgery. CES can be subdivided by the degree of neurological deficit (bilateral radiculopathy, incomplete CES or CES with retention of urine) and also by time to surgical treatment (12, 24, 48 or 72 hour). There is increasing understanding that damage to the cauda equina nerve roots occurs in a continuous and progressive fashion which implies that there are no safe time or deficit thresholds. Neurological deterioration can occur rapidly and is often associated with longterm poor outcomes. It is not possible to predict which patients with a large central disc prolapse compressing the CE nerve roots are going to deteriorate neurologically nor how rapidly. Consensus guidelines from the Society of British Neurological Surgeons and British Association of Spinal Surgeons recommend decompressive surgery as soon as practically possible which for many patients will be urgent/emergency surgery at any hour of the day or night.

Secondary neurological deterioration in traumatic spinal injury: data from medicolegal cases.

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

Postmortem findings in a case of variant Creutzfeldt-Jakob disease treated with intraventricular pentosan polysulfate.

BACKGROUND: A small number of patients with variant Creutzfeldt-Jakob disease (vCJD) have been treated with intraventicular pentosan polysulfate (iPPS) and extended survival has been reported in some cases. To date, there have been no reports on the findings of postmortem examination of the brain in treated patients and the reasons for the extended survival are uncertain. We report on the neuropathological findings in a case of vCJD treated with PPS. METHODS: Data on survival in vCJD is available from information held at the National CJD Research and Surveillance Unit and includes the duration of illness in 176 cases of vCJD, five of which were treated with iPPS. One of these individuals, who received iPPS for 8 years and lived for 105 months, underwent postmortem examination, including neuropathological examination of the brain. RESULTS: The mean survival in vCJD is 17 months, with 40 months the maximum survival in patients not treated with PPS. In the 5 patients treated with PPS survival was 16 months, 45 months, 84 months, 105 months and 114 months. The patient who survived 105 months underwent postmortem examination which confirmed the diagnosis of vCJD and showed severe, but typical, changes, including neuronal loss, astrocytic gliosis and extensive prion protein (PrP) deposition in the brain. The patient was also given PPS for a short period by peripheral infusion and there was limited PrP immunostaining in lymphoreticular tissues such as spleen and appendix. CONCLUSIONS: Treatment with iPPS did not reduce the overall neuropathological changes in the brain. The reduced peripheral immunostaining for PrP may reflect atrophy of these tissues in relation to chronic illness rather than a treatment effect. The reason for the long survival in patients treated with iPPS is unclear, but a treatment effect on the disease process cannot be excluded.

Cervical myelopathy in rheumatoid arthritis.

Involvement of the cervical spine is common in rheumatoid arthritis. Clinical presentation can be variable, and symptoms may be due to neck pain or compressive myeloradiculopathy. We discuss the pathology, grading systems, clinical presentation, indications for surgery and surgical management of cervical myelopathy related to rheumatoid arthritis in this paper. We describe our surgical technique and results. We recommend early consultation for surgical management when involvement of the cervical spine is suspected in rheumatoid arthritis. Even patients with advanced cervical myelopathy should be discussed for surgical treatment, since in our experience improvement in function after surgery is common.

Priapism in acute spinal cord injury.

STUDY DESIGN: Prospective literature review; search via Oldmedline (1958-1965), Medline (1966-2005) and Pubmed. OBJECTIVES: The objective of this study is to review the pathophysiology of priapism in acute traumatic spinal cord injury (SCI); to determine the incidence of priapism in traumatic SCI, whether or not priapism is associated with incomplete or only complete SCI and whether and what treatment might be required. METHODS: This is a review article based upon the available literature in this area. RESULTS AND CONCLUSIONS: Priapism that follows acute traumatic SCI is high-flow (non-ischaemic) priapism, that is, the blood within the corpus is arterial in nature. Priapism does not occur in all patients with acute SCI. The literature does not allow us to determine in what proportion of patients priapism occurs. Priapism has been reported following a wide variety of spinal cord pathologies including acute SCI, transverse myelitis and postoperative extradural haematoma. In all patients, priapism is associated with complete motor and sensory (American Spinal Injury Association A) paraplegia. Priapism has been reported following spinal shock. Following traumatic SCI, priapism usually settles rapidly without specific treatment being required. Priapism occurs at the moment of complete motor and sensory paraplegia, it does not occur following a delay. There are medicolegal implications: the presence/absence of priapism assists in determining when the complete spinal cord lesion occurred.

Coil embolisation of intercostal artery for operative localisation of spinal dural arterio-venous fistulae.

We describe a new method of intra-operative localisation of spinal dural arterio-venous fistulae, involving pre-operative embolisation of the appropriate intercostal artery. This method has significant advantages over other forms of spinal level localisation and has not previously been described.