Cauda Equina Compression Research Articles

Can clinical presentation predict radiologically confirmed cauda equina syndrome: retrospective case review of 530 cases at a tertiary emergency department

PurposeCauda equina syndrome (CES) may have significant individual consequences if diagnostic delays occur. Our aim was to evaluate the presenting subjective and objective features of patients with suspected CES in comparison to those with radiologically confirmed cauda equina compression (CEC)..MethodsThis was a retrospective analysis of all cases presenting with suspected CES to a tertiary emergency care unit over a two-year period. CEC was defined as radiological confirmation of CEC by Consultant Musculoskeletal (MSK) Radiologist report (MSK-CEC) and by measured canal occupancy due to an acute disc extrusion (> 75%)[measured by a Senior Spinal Surgeon (SP-CEC)]. Routine data collection was compared between categories. Chi square, multivariate regression analyses and ROC analysis of multiple predictors was performed.Results530 patients were included in this analysis, 60 (11.3%) had MSK-CEC, and 470 had NO- CEC. Only 43/60 (71.7%) had emergent surgery. Those with MSK-CEC and SP-CEC were statistically more likely to present with bilateral leg pain [(MSK-CEC OR 2.6, 95%CI 1.2, 5.8; p = 0.02)(SP-CEC OR 4.7, 95%CI 1.7, 12.8; p = 0.003)]; and absent bilateral ankle reflexes [(MSK-CEC OR 4.3; 95% CI 2.0, 9.6; p < 0.001)(SP CEC OR 2.5; 95%CI 1.0, 6.19; p = 0.05)] on multivariate analysis. The ROC curve analysis acceptable diagnostic utility of having SP-CEC when both are present [Area under the curve 0.72 (95%CI 0.61, 0.83); p < 0.0001].ConclusionThis study suggests that in those presenting with CES symptoms, the presence of both bilateral leg pain and absent ankle reflexes pose an acceptable diagnostic tool to predict a large acute disc herniation on MRI scan..

What Degree of Radiological Compression Predicts Cauda Equina Syndrome: A Retrospective Study at a National Tertiary Center

ObjectiveCauda Equina Syndrome (CES) is diagnosed both clinically and radiologically. However, it's unclear if a specific degree of cauda equina compression (CEC) on imaging can confirm the diagnosis. This study aimed to identify an optimal percentage of prolapse to canal ratio (PCR) on MRI that correlates with CEC, facilitating reliable decision-making for CES symptoms. MethodsA single-center retrospective case series analysis was conducted from 2020 to 2021. Sixty-one patients who underwent emergency lumbar discectomy within 48 hours of presentation were included, divided into a CES group and a disc prolapse (DP) group. CES cases were identified using ICD-10 code G83.4. PCR was calculated by dividing the width of the disc herniation by the total width of the spinal canal at the level of the herniation on single mid-sagittal T2 MRI scans, using the IC Measure software on Windows. ResultsCES most frequently occurred at the L4/5 level (37/61). The median PCR in CES cases was 76.19% (66.67 – 85.71), significantly higher than in DP cases, 48.08% (31.33 – 55.56) (p<0.001). A PCR threshold of 40% maximized sensitivity at 100% but had a specificity of 45%. Conversely, a threshold of 75% maximized specificity at 100% with a sensitivity of 50%. The optimal PCR, determined by the Youden index, was 66%, yielding a sensitivity of 75% and specificity of 97%, with an area under the curve (AUC) of 0.923. ConclusionsSimple radiological measurements of PCR can potentially triage CES patients and guide their management. Future studies should correlate PCR with clinical signs and symptoms for a comprehensive assessment.

Patients returning to the emergency department with symptoms of cauda equina syndrome: do the symptoms differ with radiological cauda equina compression?

Background The guidance for clinicians on who requires further investigation when suspecting cauda equina syndrome has become clearer in England following the publication of the national recommendations. This does not have specific advice for those patients who have had recent imaging with no compression, returning to a healthcare provider with a change in symptoms. These cases can cause difficulty for clinicians with limited access to imaging who can often be reassured by previous imaging. Method This study presents a retrospective review of the case notes of 45 patients presenting on two occasions to the same Emergency Department who underwent magnetic resonance imaging due to the clinical diagnosis of cauda equina syndrome. Those with compression of the cauda equina on the second visit were compared to those without a compressive cause for their symptoms. Results Patients presenting with an increased number of clinical symptoms associated with cauda equina syndrome on their return visit were more likely to have compression of the cauda equina on imaging. Conclusion The small numbers in this study would suggest caution, however, if patients present with an increasing number of symptoms further imaging should be considered, even with previous reassuring scans.

An Optimized CT Protocol for Detecting Suspected Cauda Equina Syndrome: A Comparative Analysis with MRI.

Lumbar disc herniation, potentially leading to nerve root compression and cauda equina syndrome, is typically evaluated using MR imaging. However, the limited availability of MR imaging outside regular hours in certain health care systems poses considerable challenges. This purpose of this study was to prospectively evaluate the diagnostic accuracy of an optimized CT lumbar spine protocol as a potential alternative to MR imaging in assessing suspected neural compression. Patients presenting to the emergency department with suspected cauda equina syndrome or acute radicular symptoms secondary to lumbar disc herniation referred for MR imaging were prospectively enrolled for an additional CT optimized to assess spinal stenosis. An expert radiologist, blinded to clinical data, graded canal stenosis at each lumbar level on CT. The same grading process was applied to MR imaging after a 4-week interval to maintain blinding. Fifty-nine individuals were included in the final analysis. In 22 (39%) cases, no significant stenosis was identified. In a further 22 (37%) cases, disc pathology was identified that was managed conservatively. Thirteen (22%) individuals proceeded to urgent surgical decompression. In 1 (2%) instance, an alternative diagnosis was identified. Compared with MR imaging, the sensitivity, specificity, and positive and negative predictive values for CT in detecting disc pathology in patients presenting with symptoms suggestive of acute neural compression were 97% (95% CI, 82%-99%), 97% (95% CI, 83%-99%), 97% (95% CI, 92%-99%), and 97% (95% CI, 83%-99%), respectively. CT accurately identified all cases requiring urgent decompression. CT accurately predicted MR imaging findings in patients with suspected cauda equina and nerve root compression, demonstrating its utility as an adjunct tool for patient triage in emergency settings with limited MR imaging access. This protocol could enhance the allocation of emergency resources by appropriately selecting patients for emergent MR imaging.

A multi-centre retrospective study of long-term outcomes of spinal re-irradiation with SABR.

Stereotactic ablative body radiotherapy (SABR) is a highly conformal technique utilising a high dose per fraction commonly employed in the re-treatment of spinal metastases. This study sought to determine the safety and efficacy of re-irradiation with SABR to previously treated spinal metastases. This was a retrospective analysis of patients at three Australian centres who have undergone spinal SABR after previous spinal radiotherapy to the same or immediately adjacent vertebral level. Efficacy was determined in terms of rates of local control, while safety was characterised by rates of serious complications. Thirty-three spinal segments were evaluated from 32 patients. Median follow-up for all patients was 2.6 years, and median overall survival was 4.3 years. Eleven of 33 (33.3%) treated spinal segments had local progression, with a local control rate at 12 months of 71.4% (95% C.I. 55.2%-92.4%). Four patients (16.7%) went on to develop cauda equina or spinal cord compression. Thirteen out of 32 patients (40.6%) experienced acute toxicity, of which 12 were grade 2 or less. Five out of 30 spinal (16.7%) segments with follow-up imaging had a radiation-induced vertebral compression fracture. There was one case of radiation myelitis which occurred in a patient who had mediastinal radiotherapy with a treatment field which overlapped their prior spinal radiation. The patients in this study experienced long median survival, durable tumour control and high rates of freedom from long-term sequelae of treatment. These results support the use of SABR in patients who progress in the spine despite previous radiotherapy.

Laminectomy for acute transverse sacral fractures with compression of the cauda equina: A neurosurgical perspective

IntroductionOptimal management of transverse sacral fractures (TSF) remains inconclusive. These injuries may present with neurological deficits including cauda equina syndrome. We present our series of laminectomy for acute TSF with cauda equina compression. MethodsThis was a retrospective chart review of all patients that underwent sacral laminectomy for treatment of cauda equina compression in acute TSF at our institution between 2007 through 2023. ResultsA total of 9 patients (5 male and 4 female) underwent sacral laminectomy to decompress the cauda equina in the setting of acute high impact trauma. Surgeries were done early within a mean time of 5.9 days. All but one patient had symptomatic cauda equina syndrome. In one instance surgery was applied due to significant canal stenosis present on imaging in a patient with diminished mental status not allowing proper neurological examination. Torn sacral nerve roots were repaired directly when possible. All patients regained their neurological function related to the sacral cauda equina on follow up. The rate of surgical site infection (SSI) was 33%. ConclusionAcute early sacral laminectomy and nerve root repair as needed was effective in recovering bowel and bladder function in patients after high impact trauma and TSF with cauda equina compression. A high SSI rate may be reduced by delaying surgery past 1 week from trauma, but little data exists at this time for clear recommendations.

Compensatory upregulation of MT2A alleviates neurogenic intermittent claudication through inhibiting activated p38 MAPK-mediated neuronal apoptosis.

Neurogenic intermittent claudication (NIC), a classic symptom of lumbar spinal stenosis (LSS), is associated with neuronal apoptosis. To explore the novel therapeutic target of NIC treatment, we constructed the rat model of NIC by cauda equina compression (CEC) method and collected dorsal root ganglion (DRG) tissues, a region responsible for sensory and motor function, for mRNA sequencing. Bioinformatic analysis of mRNA sequencing indicated that upregulated metallothionein 2A (MT2A), an apoptosis-regulating gene belonging to the metallothionein family, might participate in NIC progression. Activated p38 MAPK mediated motor dysfunction following LSS and it was also found in DRG tissues of rats with NIC. Therefore, we supposed that MT2A might affect NIC progression by regulating p38 MAPK pathway. Then the rat model of NIC was used to explore the exact role of MT2A. Rats at day 7 post-CEC exhibited poorer motor function and had two-fold MT2A expression in DRG tissues compared with rats with sham operation. Co-localization analysis showed that MT2A was highly expressed in neurons, but not in microglia or astrocytes. Subsequently, neurons isolated from DRG tissues of rats were exposed to hypoxia condition (3% O2, 92% N2, 5% CO2) to induce cell damage. Gain of MT2A function in neurons was performed by lentivirus-mediated overexpression. MT2A overexpression inhibited apoptosis by inactivating p38 MAPK in hypoxia-exposed neurons. Our findings indicated that high MT2A expression was related to NIC progression, and MT2A overexpression protected against NIC through inhibiting activated p38 MAPK-mediated neuronal apoptosis in DRG tissues.

Aneurysmal subarachnoid hemorrhage complicating spinal subarachnoid hematoma causing acute cauda equina syndrome: a case report

BackgroundSpinal subarachnoid hematoma (SSH) is a known but rare entity that can cause cauda equina compression. The occurrence of SSH associated with aneurysmal subarachnoid hemorrhage has rarely been described in the literature.Case presentationA 56-year-old woman presented with subarachnoid hemorrhage secondary to a ruptured middle cerebral artery aneurysm and was managed with coiling embolization without stent assistance. There was no history of either lumbar puncture or the use of anticoagulants. The patient developed severe lumbago radiating to bilateral legs nine days after the procedure. Subsequent magnetic resonance imaging demonstrated a SSH extending from L5 to S2 and wrapping around the cauda equina. The patient was treated with intravenous methylprednisolone (250 mg/day) for four consecutive days, followed by a taper of oral prednisolone (20 mg/day) until complete recovery. Magnetic resonance imaging at one month follow-up revealed complete resolution of the SSH.ConclusionsHere, we report a case of acute cauda equina syndrome caused by a SSH after aneurysmal subarachnoid hemorrhage, which will facilitate timely intervention of patients with this disorder.

Incidence and radiotherapy treatment patterns of complicated bone metastases

BackgroundDespite the encouraging results of the SCORAD trial, single fraction radiotherapy (SFRT) remains underused for patients with complicated bone metastases with rates as low as 18–39%. We aimed to evaluate the incidence and treatment patterns of these metastases in patients being referred to a tertiary centre for palliative radiotherapy. Materials and methodsWe performed a retrospective review of all bone metastases treated at our centre from January 2013 until December 2017. Lesions were classified as uncomplicated or complicated. Complicated was defined as associated with (impending) fracture, existing spinal cord or cauda equina compression. Our protocol suggests using SFRT for all patients with complicated bone metastases, except for those with symptomatic neuraxial compression and a life expectancy of ≥28 weeks. ResultsOverall, 37 % of all bone metastases were classified as complicated. Most often as a result of an (impending) fracture (56 %) or spinal cord compression (44 %). In 93 % of cases, complicated lesions were located in the spine, most commonly originating from prostate, breast and lung cancer (60 %). Median survival of patients with complicated bone metastases was 4 months. The use of SFRT for complicated bone metastases increased from 51 % to 85 % over the study period, reaching 100 % for patients with the poorest prognosis. ConclusionsApproximately 37 % of bone metastases are classified as complicated with the majority related to (impending) fracture. Patients with complicated bone metastases have a median survival of 4 months and were mostly treated with SFRT.

Valproic acid ameliorates cauda equina injury by suppressing HDAC2-mediated ferroptosis.

Persistent neuroinflammatory response after cauda equina injury (CEI) lowers nociceptor firing thresholds, accompanied by pathological pain and decreasing extremity dysfunction. Histone deacetylation has been considered a key regulator of immunity, inflammation, and neurological dysfunction. Our previous study suggested that valproic acid (VPA), a histone deacetylase inhibitor, exhibited neuroprotective effects in rat models of CEI, although the underlying mechanism remains elusive. The cauda equina compression surgery was performed to establish the CEI model. The Basso, Beattie, Bresnahan score, and the von Frey filament test were carried out to measure the animal behavior. Immunofluorescence staining of myelin basic protein and GPX4 was carried out. In addition, transmission electron microscope analysis was used to assess the effect of VPA on the morphological changes of mitochondria. RNA-sequencing was conducted to clarify the underlying mechanism of VPA on CEI protection. In this current study, we revealed that the expression level of HDAC1 and HDAC2 was elevated after cauda equina compression model but was reversed by VPA treatment. Meanwhile, HDAC2 knockdown resulted in the improvement of motor functions and pathologic pain, similar to treatment with VPA. Histology analysis also showed that knockdown of histone deacetylase (HDAC)-2, but not HDAC1, remarkably alleviated cauda equina injury and demyelinating lesions. The potential mechanism may be related to lowering oxidative stress and inflammatory response in the injured region. Notably, the transcriptome sequencing indicated that the therapeutic effect of VPA may depend on HDAC2-mediated ferroptosis. Ferroptosis-related genes were analyzed invivo and DRG cells further validated the reliability of RNA-sequencing results, suggesting HDAC2-H4K12ac axis participated in epigenetic modulation of ferroptosis-related genes. HDAC2 is critically involved in the ferroptosis and neuroinflammation in cauda equina injury, and VPA ameliorated cauda equina injury by suppressing HDAC2-mediated ferroptosis.

Rates of Radiosurgical Decompression for High Grade Epidural Spinal Disease Due to Solid Tumor Metastases

A recent phase 2 study reported a significant difference in Bilsky grading of treated lesions before and after SBRT. This study reports rates of epidural downgrading following spine SBRT in a larger cohort of patients with high grade epidural disease. Patients with high grade epidural disease from solid spinal metastases treated with SBRT from 2009-2021 were retrospectively reviewed. High grade epidural disease was defined as Bilsky grade 1c-3 for lesions above the conus. A modified Bilsky grading was developed and used for lesions below the conus; grade 0 is spinal bone involvement only; grade 1 is epidural involvement without contact of cauda equina; grade 2 is contact of cauda equina with visible cerebrospinal fluid (CSF); grade 3 is compression of cauda equina with no visible CSF. High grade epidural disease below the conus was defined as a modified Bilsky grade 1-3. Patients who received upfront surgery were included in the current study if post-surgical grading met inclusion criteria. The first post-SBRT MRI was compared to the SBRT simulation imaging to evaluate the extent of epidural downgrading. Epidural disease grading pre- and post-SBRT were compared using the Wilcoxon signed-rank test. A total of 460 vertebral segments from 201 patients were included. The most common histologies were GI (19.3%), breast (16.0%), renal cell carcinoma (13.9%), and prostate (12.6%). Metastases were most often in the T-spine (45.8%), L-spine (34.8%), C-spine (11.8%), and Sacrum (7.6%). Most cases were treated with 3 (37.4%) or 5 (44.5%) fractions with a median prescription dose of 27 Gy or 30 Gy, respectively. 43.3% of cases were treated in the postoperative setting, while 18.5% of cases had prior radiation therapy at the same vertebral level. Median time to first post-SBRT MRI was 3.0 months (IQR 1.8-3.6). Among those with disease above the conus, 98 of the 139 cases (70.5%) had a pre-SBRT Bilsky grade of 2. For those with disease below the conus, 70 of the 99 cases (70.7%) had a pre-SBRT modified Bilsky grade of 1. Epidural downgrading was seen in 32.3% of all cases, 24.3% of postoperative cases, and 25.0% of reirradiation cases. The change in epidural grading was statistically different between pre- and post-SBRT evaluation for all cases (p<0.001), postoperative cases (p<0.001), and reirradiation cases (p = 0.01). We report the largest study to date exploring epidural downgrading following spine SBRT. Although surgery is typically deemed essential for decompression of neural elements, this study suggests that SBRT results in epidural downgrading in as many as one quarter to one third of patients, depending on the clinical scenario.

Evaluating the impact of the metastatic spinal cord compression coordinator in a regional cancer network: a prospective, non- randomized pilot study.

Extradural metastatic spinal cord compression (MSCC) is a debilitating and potentially irreversible complication of cancer. Delay in treatment could lead to irreversible neurological damage, adverse quality of life and a burden on health care resources. Lack of effective communication between teams has been identified as one of the reasons for delay in treatment. The MSCC coordinator (often a nurse, radiotherapy radiographer or a doctor) is responsible for coordinating the diagnosis and management of patients with MSCC. The role has been shown to streamline service, ensure timely decision-making and improved survival outcomes. However, available data are anecdotal or from limited series presented as abstracts in conferences. In this study, we assessed the impact (time to treatment) of the newly introduced role on the treatment pathway compared to similar period in the preceding year. This was a multi-centre, prospective, pilot study carried out in Kent, UK between 1st April to 30th June 2021. Patients were considered eligible if they had MRI-confirmed cauda equina or cord compression. The data prospectively collected include: (I) time from diagnostic imaging to radiotherapy treatment; (II) number of referrals to hospital palliative care (HPC), occupational/physiotherapy (OPH) and community hospice referrals (CHP). A comparative retrospective data for (I) was collected for the same time period in the preceding year. The study outcome assessed was reduction in time from radiological diagnosis of MSCC to receiving radiotherapy. Fifty-eight patients in 2020 and 24 patients in 2021 were included in the dataset. The MSCC coordinator role (introduced in 2021) led to reduction in the time from imaging to treatment (P=0.045). Compared to 2020, there was a shorter mean/median time to treatment, seeing more patients being treated within 24 hours. All hospitals except East Kent Hospitals saw more patients being treated within 24 hours. 7 referrals each made to HPC, OPH and CHP respectively. Introduction of MSCC coordinator role led to improved time from imaging to radiotherapy treatment. The new service led to engagement with rehabilitative and palliative services. Future work should be done to assess the long-term impact of this role on utilization of support services and patient recovery.

Lumbosacral endplate contour defect is frequently observed concurrent with other lumbosacral abnormalities on spinal CT of French Bulldogs.

Lumbosacral osteochondrosis has been previously described in large breed dogs with variable clinical signs. Its CT features are a contour defect at the dorsal aspect of either vertebral endplate, commonly with an adjacent fragment. Descriptions of this condition have not been previously published in an increasingly popular breed, French Bulldogs. Aims of this retrospective, descriptive, single center study were to evaluate CT lumbosacral abnormalities and the frequency of lumbosacral endplate contour defect in a large sample of French Bulldogs. The presence and location of lumbosacral endplate contour defect and the presence of a concurrent osseous fragment were recorded. Other abnormal CT findings such as L7-S1 disc herniation, cauda equina nerve roots compression or thickening, disc mineralization, endplate sclerosis, spondylosis deformans, S1 articular processes hypertrophy, transitional vertebrae, hemivertebrae, spina bifida, and block vertebrae were recorded. Lumbosacral CT abnormalities were present in 91.8% of dogs (168/183). The most common abnormality was an L7-S1 dorsal disc herniation (77.4%, 130/168). Among dogs with lumbosacral abnormalities, the frequency of a lumbosacral endplate contour defect was 47% (79/168). It mostly involved L7 (78.5%, 62/79) at its dorsolateral aspect (61.3%, 38/62). A mineralized fragment was identified in 62% of the defects (49/79). Endplate contour defects were most frequently seen with a concurrent disc herniation (93.7%, 74/79) causing nerve root compression in 63.3% (50/79) and with sclerosis (65.8%, 52/79). There was no definitive evidence of a relationship with clinical presentation in this sample of French Bulldogs; therefore, this finding should be interpreted with caution. The etiology remains unclear.

Imaging study to establish the classification criteria of brucellar spondylitis based on MRI findings

Objective: Establishment of brucellosis spondylitis of imaging classification; provision reference for clinical treatment methods. Methods: Form January 2008 to July 2012, 89 cases imaging data confirmed by clinical examination and laboratory of brucellosis spondylitis patients were analyzed retrospectively, based on X-ray, CT and MRI imaging of their clinical manifestations- Vertebral inflammatory infiltration and extent of the damage, the extent of damage to the intervertebral space, periostitis inflammatory changes, paraspinal abscess, spinal cord, cauda equina and nerve root compression. All this imaging indicators above were the evaluation criteria. Acquisition and analysis of the imaging data was implemented by the blinded reading group which was composed of Imaging Center physicians and orthopedic surgeons. According to these imaging performances, develop the imaging classification. Results: Brucellosis spondylitis image was made up of I-VI type: type I: vertebral inflammation; type II: Discitis; type III: periostitis; type IV: abscess; type V: spinal nerve and type VI: compound. The group of 54 cases accounted for 60.67% of the compound, in which the incidence of type I Image companied by type II was maximum: 22 cases accounted for 40.74% (22/54) and second type II Image and companied by V type was 20 cases: accounted for 37.03% (20/54). In the group, 35 cases of simple type accounted for 39.33%: type I: 4 cases; type II: 12 cases; type III: 3 cases; type IV: 2 cases; type: 4 cases. Simple and complex type of type II imaging accounted for 59.55% (53/89) the highest occurrence rate, in which the type I was 47 cases: accounted for 52.81% (47/89). Based on imaging classification, 67 cases was treated by surgery, in which 59 cases was treated by debridement and 8 cases was treated by percutaneous minimally invasive surgery, 22 cases was not treated by surgery. The group of 89 cases had been followed for 1 year: 83 cases had been cured without prognosis, and 6 cases had been improved. Conclusion: Brucellosis spondylitis images classification has a reference value and guiding significance for the strategies of clinical treatment. According to this classification, simply type I, type II, type III, and IV type can be used in clinical conservative treatment, and when the evolution of the disease has surgical indications, or type V and VI type the patients should be treated actively by surgery

Spinal Epidural Abscess: Early Suspicion in Emergency Department Using C-Reactive Protein and Erythrocyte Sedimentation Rate Tests.

Spinal epidural abscess (SEA) is an uncommon but serious differential diagnosis of acute spinal pain with high paralysis and mortality rate. This study aims to provide local data on its bioclinical characteristics and evaluate potential strategies to enhance its diagnostic rate in accident and emergency department (AED). A retrospective case study from 2013 to 2019 was conducted in United Christian Hospital. SEA cases were classified as study group, spinal pain due to non-SEA cases were classified as control group. Data collected from study group included symptoms, radiological diagnosis, microbiological culture, treatment, and outcome. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) of both groups were compared to analyze their diagnostic power. In the study group (n = 42), 93% of patients had spinal pain, 55% had fever, 60% had neurological deficits, and only 26% had the classic triad on presentation. Seventy-four percent of patients presented with spinal cord or cauda equina compression in their first magnetic resonance imaging. Mortality rate was 23.8%, and paralysis rate was 7.1%. Diagnostic accuracy in AED was 12%. Admission to orthopedic ward (n = 23) resulted in a significantly lower mean time-to-imaging (4.39 days vs. 14.58 days) and mean time-to-treatment (6.56 days vs. 16.9 days) as compared to other specialties. The area under curves of CRP and ESR were 0.893 and 0.874 respectively, the optimal threshold levels were 45.9 mg/L (sensitivity 82.9%, specificity 79%) and 59.5 mm/hr (sensitivity 87.2%, specificity 80.4%), respectively. Diagnosis of SEA in emergency department based on clinical symptomatology is not reliable due to low incidence of the classic triad, despite a more advanced disease on presentation. We proposed incorporating CRP and ESR tests into evaluation of patients with spinal pain since both tests demonstrated excellent discriminative power in diagnosing SEA.

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

BackgroundThe 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. AimTo evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome. DesignService evaluation with an embedded case series of patients with radiological CES. MethodThe 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. ResultsIn 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. ConclusionsFindings 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 canal invasion as a predictor of neurological deficit in traumatic vertebral burst fractures

This study correlated the extent of spinal canal compression from retropulsed traumatic burst cervical, thoracic, and lumbar spine fractures with the severity of neurological dysfunction. One hundred and sixty-nine patients with cervical, thoracic, or lumbar sub-axial traumatic burst fractures were seen in an emergency department from 2019 to 2021; 79.3% were men, averaging 37 years of age. The lumbar spine was most frequently involved (42%), followed by the thoracic (36.1%) and cervical (21.9%) levels. The extent of spinal canal compression was quantitated utilizing Hashimoto's method, and correlated with patients' extent of neurological injury based on their American Spinal Injury Association scores. There was a positive correlation between the extent of cervical and thoracic spinal cord compression due to retro pulsed burst fragments and the severity of the patients' neurological deficits, but this was not true for the lumbar spine. The extent of spinal cord compression from retropulsed cervical and thoracic traumatic burst fractures was readily correlated with the severity of patients' neurological dysfunction. However, there was no such correlation between the extent of cauda equina compression from retropulsed lumbar burst fractures and the severity of their cauda equina syndromes.

Chronic back pain in axial spondylarthritis : Current diagnostic challenges and treatment possibilities

Among chronic back diseases, axial spondylarthritis (axSpA) is the entity with the largest spectrum of specific anti-inflammatory treatment modalities; however, from ageneral medical perspective axSpA is only ranked as another etiology of back pain to be considered after spinal cord or cauda equina compression, bone metastases, epidural abscess or osteomyelitis of the vertebrae, radiculopathy or spinal stenosis. Due to its relatively low prevalence and mostly later occurring sequelae, there is a danger that axSpA will be arelatively neglected entity for specialists. This article recapitulates the recommendations of the Assessment of Ankylosing Spondyloarthritis International Society (ASAS). This review addresses the practical aspects of the detailed evaluation of treatment attempts carried out so far with nonsteroidal anti-inflammatory drugs (NSAID) for back pain. Undesired effects on the symptoms of the lower intestinal tract could be of particular interest here. The sex-specific differences in the response to treatment with tumor necrosis factor (TNF) inhibitors in axSpA are mentioned. Further aspects of treatment options with biologics in axSpA are discussed based on a case of maintained remission after acourse of interleukin (IL) 17 inhibitors in undifferentiated, HLA-B27 and magnetic resonance imaging (MRI) positive axSpA and long-standing good treatment response to IL-12/23 inhibitor treatment in axial psoriatic arthritis. Furthermore, the literature is discussed with respect to uveitis, carditis and amyloidosis in the context of axSpA. The early diagnosis in the general medical context and the specific consideration of numerous predictive factors play an increasingly more important role in the personalized treatment of axSpA.

Cauda Equina Compression an Ayurvedic management w.r.s to Gridrasi and Pakwasaya Gata Vata

Cauda equina compression at the level of L4/L5 or L5/S1 level is a surgical emergency with potentially significant consequences, including motor and sensory dysfunction. The causes include disc herniation, spinal stenosis, cancer, trauma, epidural abscess. The common cause is usually a disc herniation which is most commonly due to trauma, age, connective tissue disorders and congenital disorders. Cauda equina syndrome a disorder caused by compression of the nerve roots in the cauda equina region. This can cause permanent loss of bladder and bowel control if not treated within time. The incidence of a herniated disc is about 5 to 20 cases per 1000 adults annually and is most common in people in their third to the fifth decade of life with a male to female ratio 2:1. If decompressive surgery is delayed, there can be catastrophic consequences for the patient in terms of bladder, bowel and sexual function. In the present case study, a 36 year old female patient who was diagnosed as a case of Cauda Equina compression due to an extruded L4-L5 disc refused to undergo surgery and opted for Ayurvedic treatment. She was admitted in the Kayachikitsa IPD for 45 days. She was treated with the principle of Gridrasi along with Pakwasayagata vata. Deepana pachana and Vasti or Sodhana is the main treatment choice. Rooksha and Snigdha swedas were done which also help to reduce the stiffness and pain. After the management her physical condition and quality of life improved.

Identification and Triage of Emergent Spinal Pathology via Telemedicine: A Case Report

Background There is little published literature concerning assessment of low-back pain (LBP) and emergent spinal pathologies via remote platforms. Case Presentation The patient was a 64-year-old female with complex medical history, referred to physical therapy for iliotibial band syndrome, reporting new onset severe LBP, bilateral leg pain/paresthesia, and urinary retention. Per the telemedicine examination, the American College of Radiology imaging guidelines for LBP, and the Guidance Document on Elective, Emergent, and Urgent Procedures for COVID-19 by the North American Spine Society (NASS), the patient was referred for magnetic resonance imaging and surgical consultation for suspected cauda equina syndrome. Outcome and Follow-Up Magnetic resonance imaging demonstrated multilevel lumbar spondylosis, facet hypertrophy, right lateral stenosis at L3–4, and a disc herniation resulting in severe central canal stenosis and cauda equina compression at L4–5. The patient subsequently underwent surgery to L4–L5 laminotomy and microdiscectomy and reported complete resolution of symptoms. Discussion Telemedicine may be effective for triaging patients with serious spinal pathology, as evidenced by the successful examination and identification of red flag symptoms, identification for advanced imaging, and referral for surgical consultation on an individual case basis. JOSPT Cases 2022;2(3):168–172. Epub: 21 June 2022. doi:10.2519/josptcases.2022.10820