Case Of Cauda Equina Syndrome Research Articles

A prospective review of Cauda Equina Syndrome referrals received by an on-call orthopaedic department at a major trauma unit.

Cauda Equina Syndrome (CES) is one of the genuine orthopaedic emergencies. Diagnosis of acute CES is challenging and may be missed, resulting in considerable medicolegal claims. In Ireland, nearly €21 million in compensation has been paid out over a 10-year period due to the diagnosis being missed. As a result, defensive practices have resulted in an increased number of referrals for CES to the on-call orthopaedic service in a major trauma unit. A prospective data-capturing exercise was carried out of all referrals for acute CES to the orthopaedic on-call department in a tertiary-level university-affiliated teaching hospital between August and November 2023. Qualitative data was captured including referral source, referring clinician grade, in-hours or out-of-hours referral, MRI on referral, red flags as identified by the referring team, red flags as identified by the orthopaedic team, and outcome. Forty referrals for CES were made over the duration of this audit. Seventeen (42.5%) referrals were made in-hours, and 23 (57.5%) were referred out-of-hours. Only five (12.5%) of these referrals had an MRI done at the time of the referral. No patients were transferred for an out-of-hours MRI to another hospital. Only five (12.5%) patients required surgical decompression-none of these patients required an out-of-hours emergent decompression. There is a lack of understanding as to what exactly is being referred-resulting in a referral volume which is over ten times the expected number of CES cases being made to our unit. The lack of out-of-hours MRI access poses a significant concern for patient outcomes.

Direct epidural metastasis of breast cancer mimicking a large lumbar disc sequestrum: A case report and review of literature

We report a case of cauda equina syndrome (CES) caused by an epidural metastasis of breast cancer, which oddly mimicked a large disc sequestrum leading to misdiagnosis. To our knowledge, it is the first report of a metastatic epidural breast cancer lesion mimicking a disc sequestrum.

Characteristics and clinical features of cauda equina syndrome: insights from a study on 256 patients.

To determine the frequency, clinical presentation, and etiological factors of cauda equina syndrome (CES). This retrospective study was done on 256 participants, and aimed to analyze the frequency and patterns of clinical presentation in suspected cases of CES. The inclusion criteria included participants aged 18 or older with medical records available for review and having red-flagged symptoms for CES. The study collected information on various factors such as age, gender, confirmation of CES on MRI, neurological deficits, etiological factors, duration of symptoms, and more. The data collected was analyzed using descriptive statistics and logistic regression to identify significant variables between MRI-proven CES and suspected CES. The mean age was 58.05±19.26years, with 151 females (58.98%) and 105 males (41.02%). The majority (50.78%) had a neurological deficit, while other symptoms included difficulty initiating micturition or impaired sensation of urinary flow (17.58%), loss of sensation of rectal fullness (3.12%), urinary or faecal incontinence (35.16%), bilateral sciatica (21.88%), neurological symptoms in the lower limbs (25.00%), anaesthesia or any leg weakness (24.22%), and bilateral sciatica as the predominant symptom (21.88%). Symptoms were chronic in 47.27% and acute in 21.88%. The odds of MRI-proven CES increase by 3% per year of age. Neurological deficit was strongly associated with MRI-proven CES (OR=14.97), while loss of sensation of rectal fullness increased the odds by 10-fold (OR=10.62). CES can present with various symptoms, including the bilateral neurological deficit, urinary and faecal incontinence, and bilateral sciatica, with age, severe bilateral neurological deficit, and loss of sensation of rectal fullness being associated with MRI-proven CES. Early diagnosis and treatment are crucial for better outcomes.

Lumbar Giant Disk Herniations Treated With a Unilateral Approach for Bilateral Decompression.

Disk herniations that obstruct the spinal canal by more than 50% are named "giant disk herniations" (GDHs). GDHs are challenging to treat from a surgical perspective because of their size and the risk of iatrogenic manipulation during resection resulting in additional neurological compromise. As a result, the appropriateness of minimally invasive tubular approaches for the treatment of lumbar GDHs remains controversial. To report our experience in treating lumbar GDHs using tubular minimally invasive surgery. A total number of 228 disk herniations were evaluated for the criteria of GDH. In addition, the presence of neurological deficits such as cauda equina syndrome, pain as measured by a visual analog scale, operating time, complications, estimated intraoperative blood loss, and number of surgical revisions were assessed. The standard tubular diskectomy technique was modified to include unilateral laminectomy for bilateral decompression before the diskectomy to create a sufficient working space for removal of the disk fragments. Twenty-three (10%) patients met the criteria for GDH. Clinically significant motor weakness was present in 21 patients (91.3%) before surgery, and 3 patients (13%) presented with cauda equina syndrome. The average mean visual analog scale (±SD) for the preoperative pain score was 8.3 and decreased to 2.4 at follow-up after surgery. All cases of cauda equina syndrome resolved postoperatively. Unilateral tubular minimally invasive surgery diskectomy seems to be a safe and effective treatment alternative for lumbar GDHs, combined with the "over-the-top" decompression, which provides bilateral decompression and working space.

Effectiveness of Pelvic Floor Exercises Along with Faradic Stimulation on Bladder Retention and Quality of Life in Post-operative Case of Cauda Equina Syndrome. Case Report

Effectiveness of Pelvic Floor Exercises Along with Faradic Stimulation on Bladder Retention and Quality of Life in Post-operative Case of Cauda Equina Syndrome. Case Report

Post-void bladder ultrasound in suspected cauda equina syndrome—data from medicolegal cases and relevance to magnetic resonance imaging scanning

ObjectivePost-void residual (PVR) scans of less than 200 ml are increasingly being used to rule out the likelihood of cauda equina syndrome (CES) and to delay emergency MRI scanning in suspected cases. This study was done to review a series of 50 MRI confirmed cases of CES and to test the hypothesis that a PVR of less than 200 ml was unlikely to be present.MethodsFifty consecutive medicolegal cases involving CES were audited. Records were reviewed to see if PVR scans were done. MRI scans were reviewed, clinical and radiological diagnosis reviewed, and treatment recorded.ResultsOut of 50 CES cases, 26 had had PVR scans. In 14/26 (54%) the PVR scan was ≤ 200 ml. In one case, the CES diagnosis was in question leaving 13/26 (50%) cases where there was a clear clinical and MRI diagnosis of CES despite the PVR being ≤ 200 ml. All 13 were classified as incomplete cauda equina syndrome (CESI) and all proceeded to emergency decompression.ConclusionsThis study is the first in the literature to demonstrate that there is a significant group of CES patients who require emergency decompression but have PVRs ≤ 200 ml.The results demonstrate the existence of a significant group of CESI patients whose bladder function may be deteriorating, but they have not yet reached the point where the PVR is over 200 ml. Given the accepted understanding that CESI is best treated with emergency decompression, such patients are likely to have worse outcomes if MRI scanning and therefore surgery is delayed. We recommend the following:PVR is recommended as an assessment tool in suspected CES.A PVR of ≤ 200 reduces the likelihood of having CES but does not exclude it; clinical suspicion of CES should always lead to an MRI scan.Further investigation of PVR as a prognostic tool is recommended.

Cauda Equina Syndrome Caused by a Sacral Insufficiency Fracture in the Lower Part of Zones 2 and 3: A Case Report

Sacral insufficiency fractures (SIFs) often cause referred low back pain, and are rarely accompanied by cauda equina syndrome (CES). We report a case of CES caused by SIF in the lower part of zones 2 and 3, which is not a typical location. A postmenopausal woman often sat on a chair for long periods, and pain in the coccyx and perianal area occurred. After 4 years, during which time the pain worsened and she developed urinary and fecal incontinence, magnetic resonance imaging showed a SIF involving the S3-S5 vertebrae. Prolonged latency of the bulbocavernosus reflex was confirmed through an electrodiagnostic study, and detrusor underactivity was confirmed through a urodynamic study, leading to a CES diagnosis. Unlike typical cases of osteoporotic SIF, the fracture occurred at an atypical location. We believe that long periods of sitting caused a different weight-bearing pattern of the sacrum from that found in typical cases. Keywords: Fractures, stress; Cauda equina syndrome; Osteoporosis

Acute cauda equina syndrome due to lumbar spinal stenosis caused by prolonged supine position during cardiac catheterization: a case report

Background: Cauda equina syndrome (CES) is a severe neurologic condition marked by progressive loss of function of the neurologic elements in the spinal canal below the termination of the spinal cord. This article reports an instructive case of CES with acute aggravation of neuropathy after catheter ablation for atrial fibrillation. Patient concerns: A 63-year-old Japanese man underwent catheter ablation for atrial fibrillation. Because he complained of severe low back pain and numbness in the posterior of both lower limbs while in the supine position, he was given analgesia with pentazocine and sedated with propofol, and the procedure continued. He was then forced to maintain lumbar extension while in the supine position for 13 hours. After the treatment, he noticed urination disor-der, numbness, and paralysis of both lower limbs. Diagnosis: Neurological findings included sensory impairment and motor deficit of L5 and below, including bowel/bladder dysfunction. Lumbar magnetic resonance imaging showed severe lumbar spinal stenosis at L4-L5. He was diagnosed with CES due to lumbar spinal stenosis. Interventions: The patient received emergency surgery for L4-L5 decompression. Decompression of the spinal canal was achieved 33 hours after the start of catheterization. Outcomes: The patient’s leg symptoms improved immediately after surgery, and he was able to walk with a walker. On postoperative day 6, the urinary catheter was removed. However, he experienced urinary retention and needed intermittent self-directed urination. Five months after surgery, he was able to urinate on his own, and completed the intermittent self-directed urination. Nine months after surgery, his muscle strength had recovered almost completely, and he was able to walk with a cane. However, bladder dysfunction such as frequent urination and residual urination remained 4 years after surgery. Lessons: If the supine position elicits low back pain and leg numbness, the presence of lumbar spinal stenosis should be considered. Forcing patients with such symptoms into a sustained posture can lead to CES.

Limited sequence MRI to improve standards of care for suspected cauda equina syndrome.

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform. In all, 188 patients with suspected CES underwent a LS lumbosacral MRI between the beginning of September 2017 and the end of July 2018. These images were read by a consultant musculoskeletal radiologist. All images took place on a 3T or 1.5T MRI scanner at Stoke Mandeville Hospital, Aylesbury, UK, and Royal Berkshire Hospital, Reading, UK. The 188 patients, all under the age of 55 years, underwent 196 LS lumbosacral MRI scans for suspected CES. Of these patients, 14 had cauda equina compression and underwent emergency decompression. No cases of CES were missed. Patients spent a mean 9.9 minutes (8 to 10) in the MRI scanner. Our results suggest that a LS lumbosacral MRI could be used to diagnose CES safely in patients under the age of 55 years, but that further research is needed to assess safety and efficacy of this technique before changes to existing protocols can be recommended. In addition, work is needed to assess if LS MRIs can be used throughout the spine and if alternative pathology is being considered. Cite this article: Bone Joint J 2020;102-B(4):501-505.

Modified Pedicle Subtraction Osteotomy for Osteoporotic Vertebral Compression Fractures.

ObjectiveTo evaluate the cases of osteoporotic compression fracture with kyphotic deformity treated with modified pedicle subtraction osteotomy and analyze the usefulness of this osteotomy.MethodsTwenty patients (nine men, 11 women; mean age, 66.4 years; mean follow‐up duration, 39.6 months) who underwent modified pedicle subtraction osteotomy at our hospital between November 2003 and July 2012 with a minimum follow‐up period of 2 years were included. All cases were injuries induced by a fall incurred while standing or lifting heavy objects without high‐energy trauma. The mean bone mineral density‐dual energy x‐ray absorptiometry (BMD‐DEXA) was 0.673 g/cm2 (0.571–0.740 g/cm2), which was ‐2SD below normal, indicating severe osteoporosis. The indications for surgery included gait disturbance due to severe pain with pseudarthrosis, increased kyphotic angle, and progressive neurological symptoms. We evaluated Japanese Orthopaedic Association scores, Oswestry Disability Index scores, bone union, change in kyphotic angle, estimated blood loss, complications, and the patient's overall clinical satisfaction.ResultsThe collapsed vertebrae were thoracic (T9, 11, 12) in 13 cases and lumbar (L1) in seven cases. The mean pre‐ and post‐operative kyphotic angles were 26.2 ± 9.9 degrees and 8.3 ± 8.1 degrees, showing an 18.3‐degree correction. Plain radiography at the last follow‐up showed a mean angle of 17.9 ± 12.6 degrees, indicating a 9.5‐degree correction loss. The overall correction was 8.2 degrees. Bony union was achieved at the last follow‐up in all cases. Clinical outcomes showed improvement in mean Japanese Orthopaedic Association score from 13.2 to 21.7 and mean Oswestry Disability Index score from 40.3 to 13.6. Overall clinical patient satisfaction showed 12 excellent results, five moderate results, and three poor results. Mean operation time was 4.2 h (range, 4–6 h). The overall mean estimated blood loss (EBL) was 1098 mL (range, 750–1370 mL). The mean hospital stay was 3.6 weeks (range, 2–6 weeks). There was one case of cauda equina syndrome at 2 days postoperatively, and two cases of screw loosening. There were no cases of distal junctional kyphosis, but there were two cases of proximal junctional kyphosis.ConclusionsDespite limited correction of kyphotic angle, our modified pedicle subtraction osteotomy technique resulted in satisfactory outcomes in our patients, who had persistent severe back pain, increased kyphotic angle with pseudarthrosis, and progressive neurologic deficits. Nevertheless, this procedure requires careful follow‐up and strict surgical indications because of the risk of neurological damage and technical problems.

Surgical outcome of intradural extramedullary spinal cord tumors - Our experience at a tertiary health care center

Introduction: To report the treatment results of 19 patients who underwent excision of intradural extramedullary (IDEM) spinal tumors.
 Materials & Methods: This is a retrospective study. Patients’ records were retrieved from the electronic database of Grande International Hospital. There were 19 IDEM spinal tumors excised over a period of 6 years between January 2013 and August 2019 by a single surgeon. There were 11 (57.9%) males and 8 (42.1%) females with an average age of 48.37±21.87 years (range, 5-79 years). The mean postoperative follow-up period was 12.87±14.88 months (range, 15 days - 60 months). The histopathological findings, locations of the tumors, and clinical results were analyzed. Neurological findings were evaluated using ASIA grading system and pain was evaluated using VAS score.
 Results: Histopathologically the tumors were: 8 meningioma (42.1%), 4 schwannoma (21.1%), 4 neurofibroma (21.1%), 1 dermoid cyst (5.3%), 1 lipoma (5.3%), and 1 myxopapillary ependymoma (5.3%). Tumor locations were: dorsal in 10 (52.6%), lumbar in 5 (26.3%), lumbosacral in 2 (10.5%), dorsolumbar in 1 (5.3%), and cervical in 1 (5.3%) patient. Neurologic status of 7 patients was normal and 12 had neurologic involvement with 3 patients having Cauda Equina Syndrome (CES) preoperatively. At the final follow-up, 3-grade, 2-grade and 1-grade improvement in ASIA score was observed in 1, 6 and 1 cases, respectively. There was no change in the ASIA grade in 1 case. All 3 cases of CES achieved full neural recovery. Preoperative VAS score was 9.21±1.08 and improved significantly to 0.74±1.62 after surgery. Neurological improvement was seen in 91.67% with complete recovery in 75% of the cases and not a single case deteriorated neurologically post-surgery.
 Conclusion: Most intradural-extramedullary spinal cord tumors are mostly benign and good clinical results can be obtained when adequately treated with surgery.

Management of cauda equina syndrome by Ayurveda: A case study

Cauda equina syndrome (CES) is a rare but potentially morbid condition which may cause permanent neurological disability in the form of motor and sensory dysfunctions of the lower extremities, impaired bladder, bowel, and sexual function. Different underlying pathological conditions may give rise to CES, of which a herniated lumbar intervertebral disc is the most common cause. In the present case study, a 62-year-old male patient who was diagnosed as a case of CES due to an extruded L4/L5 disc and refused to undergo surgery and wanted to go for Ayurveda treatment was admitted to the Panchakarma IPD, Ayurveda Hospital, NEIAH, Shillong. He was treated following the principles of Avarana Janya Vatavyadhi (diseases caused by Vata when vitiated due to obstruction in its normal flow) with oral medications and Panchakarma therapy. Improvement in the condition of the patient in terms of pain relief, bladder control, improvement of motor power, walking capacity, straight leg raising test (SLRT), etc. were observed after the completion of treatment and during the first follow-up after 1 month.

Cauda Equina Syndrome: A Rare Presentation in Burkitt Lymphoma

NOTICE: THIS ARTICLE HAS BEEN RETRACTED Cauda equina syndrome (CES) is a serious neurological condition in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. The most common cause is central disc protrusion at L5 - S1 level. Diagnosis usually requires imaging studies including magnetic resonance imaging (MRI) or computed tomography (CT) myelogram. We present a very rare case of CES due to extensive Burkitt lymphoma involving spinal cord. J Med Cases. 2019;10(6):168-170 doi: https://doi.org/10.14740/jmc3308

Cauda Equina Syndrome: A Rare Presentation in Burkitt Lymphoma

NOTICE: THIS ARTICLE HAS BEEN RETRACTED Cauda equina syndrome (CES) is a serious neurological condition in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. The most common cause is central disc protrusion at L5 - S1 level. Diagnosis usually requires imaging studies including magnetic resonance imaging (MRI) or computed tomography (CT) myelogram. We present a very rare case of CES due to extensive Burkitt lymphoma involving spinal cord. J Med Cases. 2019;10(6):168-170 doi: https://doi.org/10.14740/jmc3308

Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals

Introduction: Cauda equina syndrome (CES) is a condition with significant implications and medico-legal profile. The literature still lacks large primary studies to provide strong evidence for a robust management pathway. Statements from Neurosurgical and Spinal societies support early diagnosis and imaging but this has not resulted in any noticeable shift in referral pattern. We strongly feel the need for a nationally agreed, evidence-based referral pathway in practice. We present our large series and in-depth analysis of the referral pathway to provide strong evidence for more robust referrals and management.Methods: We reviewed 250 referrals of suspected CES (sCES) to the regional neurosurgical unit, evaluating the importance of clinical findings and the imaging pathway.Results: After clinico-radiological evaluation only 32 (13%) had confirmed CES requiring urgent surgery. There was no significant difference in terms of clinical presentation between these true cases of CES (tCES) and false cases (fCES). Imaging was therefore the key rate-limiting step. MRI was the most common investigation used. 73 patients presented without imaging out of hours (OOH). In this group, investigation was delayed to the next day in 60/73 (82%) patients while only 13 (18%) patients underwent OOH MRI. Only 2 (3%) were able to have this at their local hospital.Conclusions: As with previous studies we conclude that signs/symptoms are insufficient to identify tCES. Taking into consideration the improved outcome with early diagnosis, the importance of early scanning in diagnosing tCES, and the poor availability of OOH MRI scanning outside of neurosurgical units, we recommend a national policy of 24/7 MRI availability for cases of sCES at all hospitals with MRI scanners. This would remove the 87% of patients not requiring urgent surgery from an unnecessary and distracting referral process.

Clinical and imaging characteristics in patients undergoing surgery for lumbar epidural lipomatosis

BackgroundLumbar epidural lipomatosis (LEL) is characterized by abnormal accumulation of unencapsulated adipose tissue in the spinal epidural space. Such accumulation compresses the dural sac and nerve roots, and results in various neurological findings. However, the pathophysiology of LEL remains unclear. This study examined the associations between imaging and clinical findings in detail, and investigated the mechanisms underlying symptom onset by measuring intraoperative epidural pressures in LEL.MethodsSixteen patients (all men; mean age, 68.8 years) were enrolled between 2011 and 2015. Mean body mass index was 26.5 kg/m2. Four cases were steroid-induced, and the remaining 12 cases were idiopathic. All patients presented with neurological deficits in the lower extremities. Cauda equina syndrome (CES) alone was seen in 8 patients, radiculopathy alone in 4, and both radiculopathy and CES (mixed CES) in 4. All patients subsequently underwent laminectomy with epidural lipomatosis resection and were followed-up for more than 1 year. We investigated the clinical course and imaging and measured epidural pressures during surgery.ResultsSubjective symptoms improved within 1 week after surgery. Mean Japanese Orthopaedic Association (JOA) score was 15.2 ± 2.8 before surgery, improving to 25.4 ± 2.5 at 1 year after surgery. On magnetic resonance imaging, all lipomatosis lesions included the L4–5 level. On preoperative computed tomography, saucerization of the laminae was not observed in radiculopathy cases, whereas saucerization of the posterior vertebral body was observed in all radiculopathy or mixed CES cases. Intraoperative epidural pressures were significantly higher than preoperative subarachnoid pressures. The results suggest that high epidural pressure resulting from the proliferation of adipose tissue leads to saucerization of the lumbar spine and subsequent symptoms.ConclusionsClinical courses were satisfactory after laminectomy. In LEL, epidural pressure increases and symptoms develop through the abnormal proliferation of adipose tissue. Higher epidural pressures induce saucerization of the laminae and/or posterior vertebral body. Furthermore, the direction of proliferative adipose tissue (i.e., site of saucerization) might be related to the types of neurological symptoms.

Obesity and spinal epidural lipomatosis in cauda equina syndrome

Background ContextAlthough lumbar disc herniations are common, only a small portion of these herniations lead to cauda equina syndrome (CES), which is an uncommon but debilitating disorder. Why some patients with herniation develop CES, when most do not, remains unknown. Preexisting subclinical epidural lipomatosis may limit canal space such that an otherwise benign herniation causes CES. PurposeThis study determines whether patients with an acute disc herniation and CES have a greater body mass index (BMI) and greater quantity of epidural fat compared with control subjects with non-CES symptomatic lumbar herniated discs. Study Design/SettingA retrospective case-control series at a university-based level-1 trauma center was carried out. Patient SampleThere were 33 CES and 66 control subjects identified from a prospectively maintained database of patients who underwent surgical management for a lumbar disc herniation between 2007 and 2012. Each CES case had two non-CES control patients matched by gender and age within 5 years except 5 CES cases that matched only one non-CES control. Outcome MeasuresThe outcome measures included weight, height, age, gender, and BMI. Radiographic outcome measures included the proportion of lumbar spinal canal occupied by fat and herniated disc on preoperative magnetic resonance imaging. MethodsPatient charts and preoperative radiographs were retrospectively reviewed. For each patient, a blinded reviewer determined the proportion of lumbar spinal canal occupied by fat, and the maximal proportion of the canal occupied by herniated material at the involved level. Patient demographics and radiographic measures were compared between CES and control groups using chi-square or Student t tests. A second blinded reviewer re-assessed a series of radiographs, and the intraobserver variability was determined by Spearman correlation. Logistic regression was used to model the preoperative factors associated with having an acute disc herniation and CES. ResultsThe CES cases had higher BMI (31.8 kg/m2, 95% confidence interval [CI] 29.5–34.0 vs. 28.1 kg/m2, 95% CI 26.7–29.5 in controls; p=.007), focally narrower canals (14.6 mm, 95% CI 13.8–15.3 mm vs. 16.4 mm, 95% CI 15.4–17.3 mm in controls; p=.003), and a greater percentage of spinal canal occupied by epidural fat (31.3%, 95% CI 26.1%–36.6% vs. 21.9%, 95% CI 18.7%–25.1% in controls; p=.003) and herniated disc material (54.5%, 95% CI 46.9%–62.0% vs. 34.4%, 95% CI 30.3%–38.5% in controls; p<.0001). Logistic regression confirmed canal width at the involved level, BMI, amount of canal occupied disc, and proportion of canal occupied by fat as independent predictors of having an acute disc herniation and CES. ConclusionsObesity is a risk factor for CES from disc herniation. The CES cases also had a greater amount of herniated material, focally narrower canal, and larger epidural fat deposits. The latter may be the mechanism linking obesity with CES.

A rare case report on cauda equina syndrome

Cauda Equina Syndrome (CES) is a rare but serious neurologic condition in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. CES is a clinical entity consisting of low back ache, bilateral leg pain with motor and sensory deficits, genitourinary dysfunction, saddle anaesthesia and faecal incontinence. It is a rare condition with a prevalence in the general population estimated between 1:100000 and 1:33000. The presentation of CES may vary, especially in the early stages of compression. Magnetic Resonance Imaging (MRI) is the accepted gold standard modality of choice for diagnosing CES which identifies potential mimics such as aortic dissection or spinal infarction. Here we discuss a rare and unique case of CES with atypical presentation, knowledge of which is essential for early diagnosis, treatment and prevention of permanent neurological dysfunction.

Validation of the Calgary Spine Severity Score

Background contextThe Calgary Spine Severity Score (CSSS) is a published triage score reported in the Spine Journal in 2010. It separates spine referrals into four time categories of urgency. It stratifies patients according to clinical, radiologic, and pathologic findings. The CSSS however still requires external validation at another institution and in an unselected sample of patients. PurposeThe aim was to validate the CSSS. Study design/SettingThis was a validation study. Patient sampleThe sample included a total of 316 consecutive patients undergoing spinal surgery between April 2014 and September 2014 at a tertiary care hospital in Canada. Outcome measuresThe outcome was validity of the CSSS via its predicted time to operating room (OR) to predict actual time to OR. MethodsWe applied the CSSS to an unselected sample of consecutive patients from a tertiary care hospital between April 2014 and September 2014. Demographic and clinical data were collected. The CSSS was determined. We compared the time with OR predicted by the CSSS in one of four categories (routine >6 months=CSSS 3–5, priority <6 months=CSSS 6–8, urgent <1 month=CSSS 9–11, and emergent <1 week=CSSS 12–15) with the actual time to OR. We used Kaplan-Meier survival analysis to assess the CSSS predictive ability. Cox proportional hazard models were built and compared via analysis of variance to determine whether the models differed in their ability to fit the data. ResultsThree hundred sixteen patients were eligible. Two hundred eighty-nine had sufficient data. One hundred eighteen were a mismatch with the actual time to OR yielding an accuracy of 63%. The CSSS overestimated the urgency in 68 cases and underestimated it in 50 cases. Notably, seven cauda equina syndrome cases were classified as priority (<6 months) instead of emergent. The concordance was 0.70 and the R-square 0.33. We proposed several adjustments to the CSSS to increase its accuracy. The modified CSSS had an accuracy of 96%, overestimating nine cases and underestimating one case. The concordance was 0.77, and the R-square 0.70. ConclusionsThe modified CSSS is an easy-to-use triage score, which represents a substantial improvement as compared with the original CSSS. It now requires further external validation.

Cauda Equina Syndrome (CES) Secondary to Lumbar Disc Herniation: Retrospective Clinical Study in 13 Cases with in Progression Symptoms

Introduction A compression of nerve roots of cauda equina (CE) is responsible for cauda equina syndrome (CES). The nine pairs of CE nerve roots provide motor and sensory innervation to the lower extremity muscles, the pelvic floor, and the bowel and bladder sphincters. CES caused by a massive herniated lumbar disc, has rarely been described in literature. We report 13 cases of massive lumbar disc herniation causing CES which underwent surgical intervention after 48 hours or more from the trauma. Material and Methods Between September 2010 and June 2014, 13 cases of CES by lumbar disc herniation were treated in our department. In eight patients the herniated disc level was L4–L5, in one patient was L3–L4, and in four cases was L5–S1. The patients admitted to our hospital had lumbosciatic pain and worsening progressive: motor weakness (seven cases), hypoesthesia to lower limbs (nine cases), sexual dysfunction (two cases), hypo/areflexia (five cases). All the patients before surgery referred sphincter disorders (SD). The surgery was performed in a range from 48 hours to 8 days by the onset of symptomatology. Magnetic resonance imaging (MRI) of the lumbosacral region was performed in all cases before surgery; other postsurgical studies include electromyography (EMG), urodynamic study, RigiScan, and GSA. Results The MRI examinations showed a herniated lumbar disc determining a compression on CE. Of 13 patients, 11 had a complete recovery of sphincter disturbances and 8 had a recovery of neurological symptoms in the first day after surgery. Eight patients were discharged in the 3rd day after surgery and had a complete clinical recovery after 1 month from surgery. Conclusion CES is characterized by the following symptoms: low back pain, saddle anesthesia, hypo/areflexia, motor weakness or sensory disturbances to lower limbs, sphincter disorders, and sexual disorders. We classified CES according to the onset of symptoms in an acute (symptoms occur within 24 hours) and an in progression form (more than 24 hours). According to the clinical features CES can be classified in a complete (sphincter disorders plus at least four other criteria) and an incomplete form (sphincter disorders and three or less symptoms). Our study is aimed to elaborate a score to better define the preoperative symptomatology and give a prognostic evaluation about neurological recovery. In our experience, despite the fact that surgery has been performed at least 48 hours after the symptoms occurred, we had a complete neurological recovery in 10 out of 13 cases. In case of in progression CES, the surgical intervention, even if it is not performed within 12 hours, can allow a complete neurological recovery, depending on the severity of the clinical features at the time of surgery.