The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. Cite this article: Bone Joint J 2024;106-B(3):227–231

Aims. Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research. Methods. A literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had ‘suspected CES’; ‘early CES’; ‘incomplete CES’; or ‘CES with urinary retention’. Inter-rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss’s kappa. Results. Each of the 100 participants were rated by four medical students, five neurosurgical registrars, and four consultant spinal surgeons. No groups achieved reasonable inter-rater agreement for any of the categories. CES with retention versus all other categories had the highest inter-rater agreement (kappa 0.34 (95% confidence interval 0.27 to 0.31); minimal agreement). There was no improvement in inter-rater agreement with clinical experience. Across all categories, registrars agreed with each other most often (kappa 0.41), followed by medical students (kappa 0.39). Consultant spinal surgeons had the lowest inter-rater agreement (kappa 0.17). Conclusion. Inter-rater agreement for categorizing CES is low among clinicians who regularly manage these patients. CES categories should be used with caution in clinical practice and research studies, as groups may be heterogenous and not comparable. Cite this article: Bone Joint J 2023;105-B(9):1007–1012

Aims. Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471

No previous studies have examined the physical characteristics of patients with cauda equina syndrome (CES). We compared the anthropometric features of patients who developed CES after a disc prolapse with those who did not but who had symptoms that required elective surgery. We recorded the age, gender, height, weight and body mass index (BMI) of 92 consecutive patients who underwent elective lumbar discectomy and 40 consecutive patients who underwent discectomy for CES. On univariate analysis, the mean BMI of the elective discectomy cohort (26.5 kg/m. 2. (16.6 to 41.7) was very similar to that of the age-matched national mean (27.6 kg/m. 2. , p = 1.0). However, the mean BMI of the CES cohort (31.1 kg/m. 2. (21.0 to 54.9)) was significantly higher than both that of the elective group (p < 0.001) and the age-matched national mean (p < 0.001). A similar pattern was seen with the weight of the groups. Multivariate logistic regression analysis was performed, adjusted for age, gender, height, weight and BMI. Increasing BMI and weight were strongly associated with an increased risk of CES (odds ratio (OR) 1.17, p < 0.001; and OR 1.06, p <  0.001, respectively). However, increasing height was linked with a reduced risk of CES (OR 0.9, p < 0.01). The odds of developing CES were 3.7 times higher (95% confidence interval (CI) 1.2 to 7.8, p = 0.016) in the overweight and obese (as defined by the World Health Organization: BMI ≥ 25 kg/m. 2. ) than in those of ideal weight. Those with very large discs (obstructing > 75% of the spinal canal) had a larger BMI than those with small discs (obstructing < 25% of the canal; p < 0.01). We therefore conclude that increasing BMI is associated with CES

Aims. The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected. Methods. The search strategy used electronic databases (PubMed, Medline, EMBASE, and AMED) for publications between January 1996 and November 2021. All studies that reported mPVR in patients in whom the diagnosis of CES was suspected, followed by MRI, were included. Results. A total of 2,115 studies were retrieved from the search. Seven fulfilled the inclusion criteria. These included 1,083 patients, with data available from 734 being available for meta-analysis. In 125 patients, CES was confirmed by MRI. The threshold value of mPVR reported in each study varied and could be categorized into 100 ml, 200 ml, 300 ml, and 500 ml. From the meta-analysis, 200 ml had the highest diagnostic accuracy, with 82% sensitivity (95% confidence interval (CI) 0.72 to 0.90) and 65% specificity (95% CI 0.70 to 0.90). When compared using summative receiver operating characteristic curves, mPVR of 200 ml was superior to other values in predicting the radiological confirmation of CES. Conclusion. mPVR is a useful tool when assessing patients in whom the diagnosis of CES is suspected. Compared with other values a mPVR of 200 ml had superior sensitivity, specificity, and positive and negative predictive values. In a patient with a suggestive history and clinical findings, a mPVR of > 200 ml should further raise the suspicion of CES. Caution is recommended when considering the mPVR in isolation and using it as an ‘exclusion tool’, and it should only be used as an adjunct to a full clinical assessment. Cite this article: Bone Joint J 2023;105-B(5):487–495

Aims. 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. Methods. 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. Results. 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. Conclusion. 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

Aims. Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. Methods. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. Results. The study confirms the low predictive value of ‘red flag’ symptoms and signs. Of note ‘bilateral sciatica’ had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed ‘low-risk’ of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. Conclusion. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677–682

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.

Cite this article: Bone Joint J 2015;97-B:1390–4

Purpose: Cauda Equina Syndrome (CES) is a frequently cited red flag in patients presenting with back pain and is considered a surgical emergency. The purpose of this paper is to review the current literature on CES, to establish consensus on its definition, clinical presentation and possible aetiology. Methods: The databases (Medline 1951 →, Embase 1974 →, Cinhal 1982 →) were searched using the key words Cauda Equina Syndrome and:. Definition,. Clinical presentation. Signs and Symptoms. Pathology. Aetiology. The findings from these searches were coded to identify individual aspects of CES. The consistency of each aspect was then classified using The Guidelines Development Groups format (where 100% coverage = ‘unanimity’; 75–99% = ‘consensus’; 51–74% = ‘majority view’; and 0– 50% = ‘no consensus’), and the findings summarized. Results: The electronic searches revealed 104 papers comprising case reports, case studies, literature reviews, expert opinion and papers based on clinical experience. From these, there were widely varying descriptions of the definition, clinical presentation and aetiology of CES, and no individual aspects reached 100% agreement. The individual aspect with greatest agreement was found to be bladder dysfunction. Conclusion: Cauda Equina Syndrome is considered a discrete clinical entity; however there is inconsistency within the literature as to its definition, clinical presentation and aetiology. To document its prevalence, clarity in definition is needed. Identifying this surgical emergency is paramount for all those who undertake spinal assessments

To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation. Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008). Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group. Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms. NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows. Orthopaedic. 60. Accident and Emergency. 32. Other. 25. The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel. MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder. Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory

Background. The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined. Aim. Purpose of this study was to examine the presentation, timing of surgery, peri-operative complications and outcome of Cauda Equina Syndrome in relation to Body Mass Index. Methods. A single centre retrospective analysis was performed on 40 patients admitted with cauda equina syndrome. Data was collected regarding patient demographics, body mass index (BMI), co-morbidities, onset & mode of presentation and speed of functional recovery following surgery. Results. There were 18 males and 22 females with an overall average age of 38.9 years. The average height was 168.7 cm, and the average weight was 89.3 kg, giving an average BMI of 30.6 Kg/m2. 80% of patients were considered overweight (BMI 25–29.5) or obese (BMI >30). The average duration of back or leg pain prior to presentation was 4.2 years for the obese group and 1.3 years for the non-obese group. Bilateral sciatica, urinary incontinence and dense peri-anal numbness were the predominant presenting features in the obese group. Onset of symptoms was slow and gradually evolving in the obese group compared to the fast onset in the obese group. In the non-obese group, 71% underwent surgery within 24 hrs as opposed to 31% in the obese group. Average follow-up was 6months (6 weeks to 14 months). We observed that higher the BMI more slower the recovery with residual neurology and sphincter dysfunction. Patients in ideal group had prompt early symptomatic recovery with no residual neurology and full bladder recovery. There was correlation between increasing BMI and increased rate of surgical complications. Conclusion. This is the first study exploring the impact of body mass index on CES presentation and outcome. Specific care in establishing an early diagnosis in obese individuals is imperative for timely intervention

Background. The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined. Aim. The purpose of this study was to determine the effect of body habitus on the presentation and outcome of cauda equina syndrome. Study Design. Single-centre case series. Methods. A retrospective analysis was performed on 40 patients admitted with cauda equina syndrome. Data was collected regarding patient demographics, body mass index (BMI), co-morbidities, onset & mode of presentation and speed of functional recovery following surgery. Results. There were 18 males and 22 females with an overall average age of 38.9 years. The average height was 167 cm, and the average weight was 95.3 kg, giving an average BMI of 30.3 Kg/m2. 80% of patients were considered overweight (BMI 25-29.5) or obese (BMI >30). The average duration of back or leg pain prior to presentation was 4.2 years for the obese group and 1.3 years for the non-obese group. Bilateral sciatica, urinary incontinence and dense peri-anal numbness were the predominant presenting features in the obese group. Onset of symptoms was fast and rapidly evolving in the non-obese group compared to the obese group. In the non-obese group, 71% underwent surgery within 24 hrs as opposed to 31% in the obese group. There was correlation between increasing BMI and increased rate of surgical complications. Recovery of motor and sensory function appeared to occur more quickly in the non-obese compared to the obese group. Recovery of bladder continence was 83% in non-obese patients and 69% in the obese group at 6 months. Conclusion. This is the first study exploring the impact of body mass index on CES presentation and outcome. Specific care in establishing an early diagnosis in obese individuals is imperative for timely intervention

Objective: A clear definition of cauda equina syndrome (CES) following herniated discs was not available from the literature. Some define CES as a total paralysis of the pelvic viscera. 1. while others consider any dysfunction as sufficient evidence of CES. 2. An extensive search of the literature also demonstrated a lack of a disease specific outcome measure for CES. We aimed to classify CES in the above spectrum and validate a new outcome score for CES. Design and subjects: We present a retrospective study of 38 patients with a minimum of one-year follow up who presented with an acute cauda equina syndrome. We categorized the patients as complete or incomplete and further sub-classified them as acute or chronic. A total paralysis of the pelvic viscera was considered as complete. Presence of only dysfunction of the pelvic viscera was considered as incomplete. If the presenting episode plateaued within 24 hours or less of onset it was classified as acute and if it plateaued later than 24 hours it was considered as chronic. Outcome measures: The new 17-item disease specific questionnaire was compared with the Oswestry Disability Index, SF36 and Urodynamic studies. Results and conclusion: Of the patients studied, 44.7% were complete with acute onset, 21.1% were complete with chronic onset, 10.5% were incomplete with acute onset and 23.7% were incomplete with chronic onset. Outcome score matched the spectrum of our suggested classification

Introduction. The authors recognised that patients presenting to the Orthopaedic Spinal Rapid Access Service with symptoms and or signs of cauda equina syndrome may not have the diagnosis confirmed radiologically. Altered sensation in the ‘saddle area’, bilateral sciatica, urinary incontinence or retention, altered bowel habit, and sexual dysfunction are well recognised symptoms of cauda equina syndrome. Recognised side-effects of neuropathic medications commonly prescribed for radicular pain include: altered sensation, urinary incontinence or retention, and sexual dysfunction. We have undertaken a retrospective cohort analysis in order to identify the relationship between prescribed medications and presenting symptoms and signs. Method. 151 patients were referred to the service within a 6 month period. Case notes of 34 patients presenting with symptoms and or objective signs of CES in absence of positive radiological findings were reviewed. Data collected included the patient's age, sex, prescribed medications and presenting symptoms. Results. Of these 34, 9(26%) presented with altered bladder function and ‘saddle area’ sensation and 25(74%) with isolated bladder symptoms. Mean age was 47 in both female and males, 26 females and 8 males. 16(47%) were taking neuropathic medications, 7(22%) anti-depressants and 9(28%) anti-convulsant medications. Conclusion. 16(47%) of patients presenting with CES in the absence of radiological evidence were prescribed neuropathic medications with known side effects that may contribute to their symptoms. Therefore clinicians should take due consideration of prescribed medications as a possible cause of CES signs and symptoms. Further work is required to analyse data from a larger patient population in order to identify if particular medications carry a higher risk. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose. To establish if the subjective features of both bilateral leg pain and sexual dysfunction are presenting features in cauda equina syndrome (CES). Background. There appears to be conflicting expert opinion ‘red flag’ symptoms in the context of CES with many experts basing clinical decisions on the objective clinical findings only. Bilateral radiculopathy has been suggested as a possible sign of suspected CES, although a consensus statement by BASS and SBNS makes no reference to either this or sexual dysfunction. However, bilateral leg pain is included in the NICE clinical knowledge summary and sexual dysfunction is highlighted within CES guidance by the American Association of Neurological Surgeons. Methods. The clinical documentation of patients undergoing urgent magnetic resonance imaging (MR) due to clinical suspicion of cauda equina syndrome (CES) was reviewed over 12 months. Patients questioned regarding sexual function were included in this retrospective analysis (n=179), along with those with bilateral leg pain (n=294). Patients with confirmed cauda equina compression (CES +ve) were compared to those without (CES -ve). A logistic regression was applied to find the odds ratio. Results. In CES +ve 37.5% had sexual dysfunction, 48% had bilateral leg pain. CES –ve 14% had sexual dysfunction, 27% bilateral leg pain. Both significant to p=0.015 with an odds ratio of 3.6 and 2.5 respectively. Conclusions. Both sexual dysfunction and bilateral leg pain do appear to be ‘red flags’ for CES and should therefore be asked in the ED to aid clinical reasoning when suspecting this diagnosis. No conflicts of interest. No funding obtained

Aims. Cauda equina syndrome (CES) is a rare condition which requires urgent treatment to reduce the risk of long term neurological morbidity. Most authors recommend surgical decompression within 24–48 hours of the onset of symptoms, which may not be possible if there are delays in referral to hospital, performance of diagnostic imaging or poor access to a spine surgeon. We present a snap shot of referrals of patients with suspected cauda equina syndrome to the Orthopaedic department in a district general hospital including the diagnoses, management and outcome. Methods. A retrospective review of 20 consecutive patients (mean age 49, 11 males, 9 females) referred via Primary Care to the orthopaedic on call team between April and December 2010 was carried out. Data were recorded including the clinical symptoms and signs on admission, time taken to undergo MRI, diagnosis and treatment. Results. 18/20 patients had red flag symptoms. Two patients with convincing neurological evidence of CES were transferred to the local neurosurgical unit for urgent assessment and surgical intervention. 12 patients required urgent inpatient MRI scans; mean time to MRI for these patients was 22 hours from the initial Orthopaedic assessment. Of these, none showed cauda equina and 3 were offered elective surgery for spinal nerve root compression. 14 out of 20 patients presented outside normal working hours when immediate access to MRI was unavailable. Conclusions. The majority of patients in this study had red flag symptoms, although few actually had CES. Usually patients present in the evening when access to MRI is unavailable, potentially delaying the diagnosis. Such information may be useful to radiology departments to help plan out of hours services or help district hospital Orthopaedic departments develop protocols with nearby neurosurgical units for rapid patient transfer when CES is suspected

Introduction: Recent articles in the MPS Casebook (Cauda equina syndrome, Gardner and Morley) and BMJ (Cauda Equina Syndrome, Lavy) highlighted the potential dangers of Cauda equina syndrome (CES). CES has the highest rates of litigation due to the risk of symptoms not resolving and having a devastating impact on patients. This study aimed to assess clinician knowledge of the urinary symptoms of CES and the timeframe in which treatment should be offered. Method: A 4 part questionnaire was constructed. The first part established the status and type of health care professional. The second part assesses how many musculoskel-etal patients are seen in an average week. In the third part the participant is asked to rank 15 urinary symptoms; with 1 being the least alarming and 15 being the most alarming. 7 of the symptoms were not related to CES and so should have been ranked in the bottom seven. Lastly, to highlight an issue raise in the BMJ article; the participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES, with the options being within 24 hours; 24–48 hours; and 48 hours to 2 weeks. The questionnaire was distributed to Health Care Professionals in Southport and Ormskirk Hospital. Results: The questionnaire was completed by 23 participants (12 Doctors and 11 Physiotherapists). 90.91% of Physiotherapists and 10 Doctors (83.3%) managed to complete the questionnaire as specified. An average of 24 patients was seen by each professional (25 patients doctors; 31 patients Physiotherapist). The 7 false CES urinary symptoms were ranked in the bottom 7 in 76.40% of questionnaires (77.92% in Doctors; 81.82% in Physiotherapists). True CES urinary symptoms were ranked in the bottom 7 in 59.63% of cases (66.23% Doctors; 58.44% Physiotherapists). Finally 91.30% of those asked thought Complete CES should be treated within 24 hours (83.33% Doctors; 100% Physiotherapist); 56.52% thought Incomplete CES should be treated within 24 hours (66.67% Doctors; 45.45% Physiotherapists); 30.43% within 24 to 48 hours (8.33% Doctors; 54.55% Physiotherapists) and lastly 13.04% thought Incomplete CES should be treated within 2 weeks (25% Doctors and 0% of Physiotherapists). Conclusion: The results show that there is a gap in knowledge of all professional with regards to CES urinary symptoms and the optimal timing of treatment. The results showed that Physiotherapists are more likely to recognise True CES than doctors. False symptoms were ranked lower by Physiotherapists than Medical Professionals. These results demonstrate that physiotherapists are better than Doctors at identifying urinary symptoms in CES. Finally the majority of those asked would treat Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical personnel in the symptoms of Cauda Equina Syndrome and also the timing of treatment

Cauda equina syndrome (CES) due to central disc prolapse produces acute neurological deficit. We investigated long-term urological disability after surgery for CES and the impact of emergency versus next day surgery. 20 CES patients (M=F), were assessed using a validated quality of life questionnaire; comparison was made with a matched group undergoing simple lumbar disc surgery. Median length of history before presentation was seven days. Nine were operated on within 4. 5 hours, the remainder all within 24 hours after neurosurgical admission. While the patients’ perception was of good general health (no different from controls), urological symptoms adversely affected their lives (P=0. 02). Only two patients had no urological symptoms. Emergency surgery (within 4. 5 hours of presentation) was not associated with reduced disability

Background. Cauda equina syndrome (CES) is a physical process. There is compression of the cauda equina resulting in arrest of the electrochemical signal from the central nervous system. Previous studies have demonstrated that anthropomorphic features influence nerve conduction properties. Aim. We therefore sought to if there was an association between biophysical parameters and CES. Setting and design. Single centre retrospective comparative study. Method and materials. We analysed consecutive patients who had elective lumbar discectomy. Demographic data-including age, gender, height, weight and BMI were recorded. Identical information was collected in consecutive patients who underwent emergency lumbar discectomy for MRI-proven CES. Results. There were 40 patients who underwent emergency surgery for CES. There were 22 women and 18 men with a mean age of 38.6 years. 92 patients underwent elective lumbar discectomy. There were 45 men and 47 women with a mean age of 44 years. Patient undergoing emergency discectomy for CES were significantly heavier (p=0.001) and had a significantly higher BMI (p< 0.0005) compared to the elective surgery cohort. The mean difference in weight and BMI were 11.2 kg (95% confidence interval: 3.8–18.7) and 4.6kg/m2 (95% confidence interval: 2.4–6.9) respectively. The CES-group was also slightly younger (mean difference 5.4 years 95% CI: 1.7–9.8 p=0.01). There was no statistically significant difference between the heights of the two groups or the gender ratio. Multivariate binary logistic regression showed increasing weight to be associated with the increasing odds of CES (P< 0.0005). In contrast increasing height was correlated with a reducing likelihood of CES (P< 0.01). Increasing BMI was associated with increased odds of CES (p< 0.0005). Conclusion. This is the first study to relate anthropometric features to CES. Our study observed that increasing BMI is linked with the increased odds of CES syndrome as was increasing weight and decreasing height

Meticulous haemostasis not only improves the operative field facilitating spinal surgery, but also diminishes chances of post-operative neurological complications from a compressive haematoma. Since being introduced in the 1940’s, implantable haemostats have proven a useful adjunct in achieving haemostasis with relatively few complications. However, their use in spaces bounded by bony architecture can lead to compressive effects on neurological structures. We present three cases of post-operative cauda equina syndrome – two cases following surgery for lumbar disc herniation and one case following surgery for lumbar canal stenosis. In each case, implantable haemostats were utilised to control haemorrhage for complications during the surgery. All three patients underwent urgent exploration, which revealed cauda equina compression from clot organised around the haemostat. Neurological recovery was variable. We recommend careful attention to intra-operative haemostasis. Although haemostats can assist in achieving haemostasis, we caution against leaving them in situ