Objectives. To assess health care professional's knowledge with regards to the urinary symptoms of CES and when treatment should be offered. Background. Recent articles in the medical press highlight the potential dangers of Cauda Equina Syndrome (CES). CES has the highest rates of litigation due to its long-term neurological impairment. Method. A 4-part questionnaire was given to 60 professionals. The participant was asked to rank 15 urinary symptoms, 7 of these symptoms were not related to CES, also the ideal time to surgical intervention for Complete CES and Incomplete CES. Results. A total of 44 questionnaires were analysed. CES symptoms were ranked significantly higher than then non-CES symptoms. The physiotherapists rated the CES symptoms significantly higher than the doctors (P = 0.05) and on average rated the non-CES symptoms significantly lower than doctors (P < 0.05). 87.8% thought that complete CES should be treated < 24 hours and 9.76% thought that complete CES should be treated from 24-48 hours. 46.34% thought that CESI should be treated < 24 hours and 43.9% thought that CESI should be treated from 24-48 hours. Conclusion. These results demonstrate that physiotherapists are better than Doctors at identifying the urinary symptoms in CES. The majority of health care professional who took part in this study stated that they would offer surgical intervention for both Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical professionals in the symptoms of CES and also the timing of treatment

Recent articles in the medical press highlight the potential dangers of Cauda Equina Syndrome (CES). CES has the highest rates of litigation due to its long-term neurological impairment, which can lead to devastating outcome on patients. The aim of this study was to assess health care professionals knowledge with regards to the urinary symptoms of CES and the timeframe in which treatment should be offered. To assess health care professionals knowledge with regards to urinary symptoms of CES and when treatment should be offered. A 4-part questionnaire established profession and number of cases seen per week. The participant was asked to rank 15 urinary symptoms, 7 of these symptoms were not related to CES. The participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES. Primary and Secondary Care. 60 questionnaires were complete. Participants had to successfully complete the first three parts of the questionnaire (n = 44). Any who failed to complete section four were excluded from analysis from that part only (n = 41). A total of 44 questionnaires were analysed. Both doctors and physiotherapists ranked the CES symptoms on average significantly higher than then the non-CES symptoms. The physiotherapists rated the CES symptoms significantly higher than the doctors (P = 0.05) and on average rated the non-CES symptoms significantly lower than doctors (P < 0.05). 87.8% thought that complete CES should be treated < 24 hours and 9.76% thought that complete CES should be treated from 24-48 hours. 46.34% thought that CESI should be treated < 24 hours and 43.9% thought that CESI should be treated from 24-48 hours. These results demonstrate that physiotherapists are better than Doctors at identifying the urinary symptoms in CES. The majority of health care professional who took part in this study stated that they would offer surgical intervention for both Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical professionals in the symptoms of CES and also the timing of treatment

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

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. 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

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. 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 aim of the study was to determine if there was a direct correlation between the pain and disability experienced by patients and size of their disc prolapse, measured by the disc’s cross-sectional area on T2 axial MRI scans.

Purpose and background. Cauda Equina Syndrome (CES), a rare (<1 per 100,000) and potentially devasting condition, involves compression of the lumbosacral nerve roots. If not quickly identified and treated, it can lead to lasting disability, and high medicolegal costs (>£186 million in the decade to 2018). This study identified why people with suspected CES attend the emergency department (ED) and explored any delays in attending. Methods and Results. The design was a secondary analysis of a qualitative dataset comprising patients with back pain who attended the ED, undertaken using an interpretivist approach. Fourteen patients (8M:6F, aged 23–63 years) with suspected CES were purposively sampled from 4 EDs (2 Northern and 2 Southern) in England between August and December 2021. Semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed thematically. Acopia with pain was the biggest factor in a participant's decision to attend the ED, along with the need for a diagnosis. This pain was the worst ever experienced and debilitating, leaving people unable to cope and desperate for relief. 12/14 were advised to attend the ED following identification of red flags by: GPs (n=9); physiotherapists (n=2); surgical colleague (n=1); and 111 (n=1). Factors such as guilt, previous experience of being disregarded, and symptom misattribution were seen to cause delays in seeking care. Conclusion. This paper revealed a disconnect between the priorities of patients and clinicians prior to attending the ED. Clinicians need to validate the pain experience, communicate clearly why signs and symptoms are concerning, and convey the urgency and potential impact of CES. Conflicts of interest. None. Sources of funding. Funding for primary data: Health Education England & National. Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Purpose and background. Cauda equina syndrome (CES) leads to nerve compression in the lumbar spine, and requires immediate treatment to prevent permanent neurological dysfunction, including urinary/anorectal incontinence. The consequences for the patient are significant as, in the decade to 2018, CES has cost the NHS £186,134,049. No study has reported patients’ experiences of being managed with suspected CES in an emergency department (ED), and this study explores patients’ experiences and how the NHS can optimise care for patients experiencing this condition. Methods and Results. In this qualitative secondary analysis, 14 participants (aged 23–63 years) with suspected CES were purposively sampled from 4 EDs in England. Online, semi-structed interviews were undertaken (in 2021, during the pandemic), and were audio-recorded and transcribed verbatim. Data were managed using a Framework approach and analysed thematically. Three themes were identified: quality of care; environmental factors; and expectations. The quality of care included managing uncertainty, the importance of communication, appropriate assessment and follow-up care. Environmental factors, including the chairs, waiting times and the busy nature of the ED, negatively impacted patients’ experiences. Furthermore, an expectation gap was identified, as most individuals came to the ED expecting to receive a scan, an accurate diagnosis and a cure. Despite frustrations, patients expressed gratitude towards the ED staff. Conclusion. This study highlights the importance of empathically acknowledging the patient's pain and providing comprehensive assessments and management plans for people attending ED with suspected CES. Optimising the ED environment to minimise patients’ pain and distress while waiting to access care is paramount and overdue. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Background. Cauda equina syndrome (CES) is a spinal condition requiring emergency spinal surgery once diagnosed. The patient-reported symptoms are often subtle and none have been shown to be sensitive or specific in confirming CES. Magnetic resonance image (MRI) is the diagnostic gold standard, and guidelines recommend MRI access within 24-hours of symptom presentation. Limited sequence MRI scans (sagittal T2 sequences of the whole spine) have been shown to successfully identify patients with scan-positive CES despite reducing the duration of an MRI. The aim of this audit was to examine utilisation of same-day MRI requests by spinal practitioners from a newly operational same-day emergency care spinal unit over the two-year period. Methods and results. Data was routinely collected over the two-year period and retrospectively reviewed. Data extraction occurred for cases of suspected CES with a same-day scan. Data extraction included type of MRI scan (lumbar/ whole spine/ CES protocol); outcome (admission/ discharge); final diagnosis. After clinical examination, only 258 (24% of 1085) suspected CES cases were identified and scanned within 24 hours, 58% (n=149) of which were with CES limited sequence scans. Only 12% (n=30) demonstrated scan- positive CES resulting in surgery within 24-hours. MRI same-day requests increased between 2020 (n=81, 21%) and 2021 (n=177, 26%), although utilisation of limited sequence scans improved (n=39, 48% in 2020; n=109, 62% in 2021). Conclusion. Limited sequence MRI scans are a time- and cost-saving means of providing screening for those with suspected CES. Improved utility was demonstrated over the 2-year period by the spinal practitioners. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

Purpose of study. Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition. Background. Thirty physiotherapists working in a community musculoskeletal service were purposively invited to participate in semi-structured interviews. Data was transcribed and thematically analysed. Methods and Results. All participants routinely asked bladder, bowel function and saddle anaesthesia screening questions although only 9 routinely asked about sexual function. Whether questions are asked in the correct way has never been studied. Sufficient depth of questioning was achieved by 63% of participants, 76% used lay terminology and 73% used explicit language. Only 43% framed the questions before asking them and only 16% combined all four dimensions. Whilst most participants (n = 25) felt comfortable asking general CES questions, 50% reported feeling uncomfortable when asking about sexual function. Issues around; gender, culture and language were also highlighted. Conclusion. Four main themes emerged from this study; i) Physiotherapists ask the right questions but frequently omit sexual function questions, ii) mostly, Physiotherapists ask CES questions in a way that patients understand however, there needs to be improvement in framing the context of the questions, iii) Physiotherapists generally feel comfortable with CES screening but there is some awkwardness surrounding discussion of sexual function and iv) Physiotherapists perceive there to be barriers to effective CES screening caused by culture and language. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained. Previously presented poster at BritSpine 2021 and VPUK 2021

Background. Cauda Equina Syndrome (CES) needs to be diagnosed and managed promptly to ensure the best outcome for patients. Our current spinal service has been centralised, with referrals currently delivered via an online system. This means that patients aren't seen by spinal specialists until confirmed radiological diagnosis. To ensure patient safety, we must make sure that our CES pathway is as robust as possible. Methods & Results. A Google Forms questionnaire was emailed to various health professionals involved in the CES patient journey throughout the Lancashire & South Cumbria region. Participants were asked to identify problems with our current pathway and to provide possible solutions for improvement. 64 responses were received from 5 different departments throughout 6 NHS employers: 21 (33%) consultants, 6 (9%) middle grade doctors, 31 physiotherapists (48%), 3 (5%) GPs and 3 (5%) others. Many common themes were identified: the need to improve CES education to both referrers and patients (22% responses), addressing the issue of scan availability (39% responses), the need for a clearer pathway for GPs (26% responses) among others. Participants were asked to rate their confidence in the management of both suspected (mean=7.6 +/−2.3) and diagnosed CES (mean=8.0 +/− 2.0). Discussion. These results have made it evident that there is a need for improvement to our current CES pathway at all levels. Our current system is overloaded with poor referrals that backlog the MRI scanner, leading to delays. Providing training for referrers in the first instance may improve things, however a more thorough overhaul of the pathway is required. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purposes of the study and background. A Qualitative study exploring patient's experience of Cauda Equina Syndrome (CES) was carried out. The aim of this study was to identify how Cauda Equina Syndrome symptoms may be more effectively identified by patients and their clinician. Patient's symptoms and experiences of their condition were explored, including issues associated with bladder, bowel and sexual function. A summary of the methods used and the results. Via in-depth questions, participants were enabled to share their stories within a confidential setting. Narrative analysis of the patient's story allowed symptom progression and recognition to be explored and language used by participants themselves to describe symptoms identified. Seven themes emerged from the study. The findings were used to develop clinical tools to assist in the consultation process of potential CES patients. Finally the tools were validated by CES patients and clinicians prior to use within a clinical setting. Conclusion. The findings of this research have been utilised, working with patients as partners, to establish clear, sensitive and understandable language to use during clinical questioning of potential CES patients. This patient choice of language for sensitive questions has been replicated on a clinical cue card to use during the consultation and on a credit card sized leaflet to give to patients. Working with patients, clear methods of communication have been developed surrounding potentially embarrassing but critical symptoms in order to assist ‘bringing the individual patient and the surgical team together at the earliest practical opportunity’. No conflicts of interest. Source of funding; Physiotherapy Research Foundation (Part of the CSP Charitable Trust registered charity 279882)

Purpose and background:. Cauda Equina Syndrome (CES) is a rare condition which, even in the presence of prompt surgical decompression, can have devastating consequences for patients in terms of bladder and bowel dysfunction. The aim of this project was to develop a post-operative pathway for the assessment and management of bladder and bowel dysfunction in patients with CES. Method:. Beaumont Hospital performs a high volume of spinal surgeries. A small number are lumbar decompression surgeries due to CES. While sphincter function is routinely screened by a physiotherapist post-operatively, to date there has been no protocol in place for assessment and management of bladder and bowel dysfunction in this population. This project was carried out in collaboration with consultants in urology and colorectal surgery, as well as clinical nurse specialists in both areas. Results:. All patients undergoing lumbar decompression due to CES will be referred to a colorectal surgeon for post-operatively review and out-patient monitoring. A routine bladder ultrasound will be completed post-operatively to assess for urinary retention with a post void residual > 150 mls of urine indicating the need for referral to a urologist for in-patient review and out-patient follow-up. A patient education leaflet has also been developed. Conclusions:. A pathway has been implemented at Beaumont Hospital to ensure timely referral to specialised teams for both assessment and management of bladder and bowel dysfunction in CES. This pathway will ensure prompt access to specialised and supportive multi-disciplinary teams in the days/weeks/months/years post-operatively thereby minimising the emotional distress and health risks associated with secondary complications of CES

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

Back pain affects 70% of the population in developed countries and accounts for 13% of sickness absence in the United Kingdom. 1. The clinical presentation might be taken less seriously and could result in significant morbidity and mortality. We did a retrospective observational study of patients admitted on an “acute” basis in our unit. Our aim was to identify the epidemiological proportion of patients who had significant life changing spinal conditions. 239 patients were admitted between January 2004 to December 2008 who presented with non traumatic back pain and related symptoms. The group of patients who had osteoporotic compression fractures were excluded. The mean age was 53.6 and patients were predominantly females. Disc protrusions and degenerative conditions accounted for majority of the patients. Cauda Equina Syndrome (CES) and Cord compressions together contributed to 7.9% and 8.7% respectively. The mean length of stay was 10.4 days and the average wait for MRI scan was 2.4 days. Among the patients who present with back pain in the primary care setting, 3% have disc protrusions and 1% neoplastic lesions. 1. But the epidemiological distribution among the back pain admissions in the hospital setting is not very clear. Medico legal costs especially with CES are quite substantial. 2. and hence it would be useful to know the volume of patients with potential disabling lesions. Our study reveals that a significant proportion of patients who had to be admitted with back pain and especially those having red flag signs have serious spinal pathologies. Early diagnosis and timely intervention could prevent unwarranted morbidity and mortality

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

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