Management Of Cauda Equina Syndrome Research Articles

More questions than answers to the diagnosis and management of cauda equina syndrome.

More questions than answers to the diagnosis and management of cauda equina syndrome.

96. Health care disparities in complication and mortality rates following surgical management of cauda equina syndrome

96. Health care disparities in complication and mortality rates following surgical management of cauda equina syndrome

Cauda equina syndrome\u2014a practical guide to definition and classification

PurposeInternational uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians when discussing CES with patients and relatives, and for medicolegal purposes.MethodsWe reviewed published literature using PubMed on definition and classification of cauda equina syndrome since 2000 (21 years). Using the search terms ‘cauda equina’ and ‘definition’ or ‘classification’, we found and reviewed 212 papers.ResultsThere were 17 different definitions of CES used in the literature. There were three well-defined methods of classification of CES. The two-stage system of incomplete CES (CESI) versus CES with retention (CESR) is the most commonly used classification, and has prognostic value although the details of this continue to be debated.ConclusionWe used the existing literature to propose a clear definition of CES. We also drew on peer-reviewed published literature that has helped to amplify and expand the CESI/CESR dichotomy, adding categories that are both less severe than CESI, and more severe than CESR, and we propose clear definitions in a table form to assist current and future discussion and management of CES.

A service evaluation of patients suspected of Cauda Equina Syndrome referred to accident and emergency departments from a national telephone triage service

BackgroundThe presentation and management of Cauda Equina Syndrome (CES) remains contentious in medical literature, however it is widely agreed that CES requires emergency medical attention. Physiotherapists will often refer suspected cases to A&E departments for emergency medical review in order to safeguard patient safety. ObjectivesTo evaluate the management of patients triaged by a national telephone service referred to A&E for suspected CES. MethodKnown escalations (17 cases) from January 2017 to June 2017 from a national telephone triage service referred to A&E with suspected CES were included. Results53% of cases with CES symptoms that conformed to the BASS definition of having a requirement for diagnostic imaging were not investigated by MRI scan. The MRI and non-MRI groups had similar group sizes (8 : 9) and mean ages (42.4 years ± 8SD and 45.7 years ± 12SD). Overall, there were more females (11) compared to males (6) referred to A&E. ConclusionThere appears to be significant variability in the management of this cohort of patients once referred to emergency departments. Further guidance is needed as to when watchful waiting is clinically appropriate, and what best practice should be to facilitate safe patient management.

Management of Cauda Equina Syndrome: NHS Staff Perceptions in a DGH

Objective: Cauda Equina Syndrome (CES) is a challenging condition to diagnose due to such variability in clinical features and poor correlation with MRI findings. It requires surgery within hours to avoid damage to the bowel, bladder, sexual organs and lower limbs. There are empirical studies exploring patients’ perspectives of having CES, however, there is no literature to review NHS staff perceptions of managing this neurosurgical emergency. The aim is to explore perceptions of senior clinical staff who commonly manage patients with suspected CES in secondary care within the Emergency Department (ED) and Trauma and Orthopaedics (T&O) to improve the management of CES. The main objective is to identify barriers to successful management and possible solutions to improve care. Methods: A self-administered non-validated questionnaire was designed to identify barriers experienced and potential solutions. In addition, a Nominal Group Technique (NGT) was used to gain a greater insight. The qualitative data obtained was analysed by thematic analysis. Results: The questionnaire generated a 73% response rate. Six senior clinicians attended the NGT with representation from the three clinical specialities; ED, T&O and Advanced Physiotherapy Practitioner (APP). The challenges and potential solutions were categorised into themes and subthemes. The barriers highlighted included; staff confidence in clinical diagnosis; fear of litigation and inter-professional relations; patient psychosocial factors, expectations and comorbidities; lack of agreed local pathway. The solutions raised include; staff training; standardising local/national pathway; access to daily Magnetic Resonance Imaging (MRI) slots. Conclusion: Patient safety and accurate diagnosis of CES is at the forefront of decision-making despite organisation barriers and limitations of existing pathways. A shift away from admission to expedite an urgent MRI requires a change to traditional clinical practice and expectations. In times of rising pressures and financial constraints, collaborative working is essential to implement and sustain the required changes highlighted in this study.

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.

Expediting the management of cauda equina syndrome in the emergency department through clinical pathway design

IntroductionCauda equina syndrome (CES) is a neurosurgical emergency. Early diagnosis with MRI and subsequent surgical decompression surgery can prevent permanent neurological dysfunction. Charing Cross Hospital (CXH) is a tertiary neurosurgical...

BNTRC: British Neurosurgical Trainee Research Collaborative Understanding Cauda Equina Syndrome

Introduction: Cauda equina syndrome (CES) is a rare but potentially devastating condition caused by compression of the cauda equina nerve roots. The clinical syndrome can include bilateral sciatica, saddle anaesthesia, bladder, bowel, and sexual dysfunction. The disabling nature of these symptoms has significant medical, social, and legal implications. Guidelines for the investigation and management of CES are based on evidence from small retrospective case series that include a range of presentations. Outcomes for those presenting with established loss of function may not be comparable to those with incipient symptoms. Arrangements for emergency imaging, patient transfer to specialist spinal units, and techniques for decompression also vary and could lead to differences in outcomes. Aims: This study aims to provide evidence for appropriate investigation and management of CES through: ascertaining the incidence of CES describing the clinical and radiological features of patients who are treated for CES establishing current practice in timing of investigations and choice of management of CES determining patient outcome and service usage following CES diagnosis Patients All patients over 18 years old treated for CES in a UK or Irish neurosurgical or orthopaedic spinal unit will be included. Patients will be identified via emergency admissions, and case ascertainment will be checked using coding records. Comparator: Outcomes and management will be stratified by presenting features and timing and type of surgical intervention. Outcome: Patient outcome will be assessed using validated patient reported outcome measures for back pain, leg pain, bladder, bowel, and sexual function. Health care services used over the following year will be recorded. Study design: This is a prospective cohort study with patients identified on admission to a spinal unit. Patients will be asked to consent for use of their data, contact for follow up assessments, and data linkage with existing NHS and surgical registries.

Assessment and management of cauda equina syndrome

IntroductionCauda 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. PurposeThe 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 practiceCES has significant implications for patients and clinicians alike. Timely, effective diagnosis and management of patients with CES results in a better outcome.

Outcomes Following Surgical Management of Cauda Equina Syndrome: Does Race Matter?

Cauda equina syndrome (CES) is a surgical emergency requiring urgent spinal decompression. Our objective is to analyze the association between race and in-hospital outcomes (complications, mortality, length of stay, and discharge disposition) in patients with CES. This is a retrospective cohort study of CES patients identified via the Nationwide Inpatient Sample (NIS) from 2000 to 2010 in inpatient hospitalizations in the USA. The patient sample includes 46,017 patients ≥18 undergoing spine surgery for CES. Using ICD9-CM codes, patient records with a diagnosis of CES from 2003 to 2010 were selected from the NIS database and sorted by mortality, complications, length of hospital stay, and discharge status. Demographic information (age, gender, race, and insurance status) and hospital characteristics were evaluated. African-American patients were 1.38-fold (p<0.02; 95% odds ratio [OR] 1.05-1.83) more likely than Caucasian patients to develop complications based on a multivariate logistic regression model adjusted for patient age, insurance status, surgical approach, and hospital size. There was no difference in mortality among patients of various races in both univariate and multivariate analysis. A multivariate linear regression model adjusted for insurance status, surgical approach, and hospital size revealed that, compared to Caucasian patients, length of hospitalization in African-American patients was 1.92days longer (p<0.01), 1.34days longer (p<0.01) in Hispanic patients, and 2.24days longer (p<0.01) in Asian-American patients. African-American patients were 0.59-fold (p<0.01; 95% OR 0.494-0.708) less likely than Caucasian patients to have routine discharge to home. African-American patients hospitalized for surgical management of CES experience significantly more complications, longer length of hospitalizations, and higher discharge to non-home locations, compared to Caucasian patients.

Successful non-operative management of cauda equina syndrome in a case of thalassemia major

Thalassemia is associated with several challenging comorbidities. Here we report a 20 year old thalassemic who presented with cauda equina syndrome due to paraspinal extra medullary hematopoiesis (EMH) and was treated with hydroxyurea, repeated blood transfusions, and radiotherapy. Thus compressive myelopathy due to EMH was successfully managed conservatively.

Comparative Analysis of Cauda Equina Syndrome (CES) Patients Treated with Fusion versus Nonfusion

Traditional management of cauda equina syndrome (CES) has been to perform an extensive decompression, including bilateral wide lumbar laminectomies and/or discectomies with removal of any additional structures contributing to compression of the cauda equina. Less accepted in the treatment of CES is the role of spinal arthrodesis.

Medical realities of cauda equina syndrome secondary to lumbar disc herniation.

An analysis of 44 cauda equina syndrome cases. To determine the neurologic outcome of cauda equina syndrome cases, in light of the significant medical implications of this disorder. Cauda equina syndrome from lumbar disc herniation accounts for up to 1% of all disc herniations. Most of the literature supports surgery within 24 hours as a means of improving the outcome. A retrospective chi 2 analysis was performed of 44 patients surgically treated for lumbar disc herniation who initially sought treatment for cauda equina syndrome. In 20 patients, diagnosis was made and surgery performed within 48 hours of the cauda equina syndrome onset, including 18 patients (90%) who underwent surgery within 24 hours. In 24 patients, surgery was performed more than 48 hours after the onset of cauda equina syndrome, with a mean delay of 9 days, including 17 patients (71%) with a mean delay of 3.7 days. Causes for delay were patient-related in 4 cases (17%) and physician-related in 20 cases (83%). According to chi 2 analysis, a greater chance of persistent bladder/sphincter problem (P = 0.008), persistent severe motor deficit (P = 0.006), persistent pain (P = 0.025), and sexual dysfunction (P = 0.006) existed with delayed surgery. The data strongly support the management of cauda equina syndrome from lumbar disc herniation as a diagnostic and surgical emergency.