Cauda equina syndrome.

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.

Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: A multi-centre prospective cohort study.

Background: Cauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures. Methods: This is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated. Findings: In 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1-8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5-3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8-20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2-0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up. Interpretation: Post-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively. Funding: DCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.

Demographics of Cauda Equina Syndrome: A Population-Based Incidence Study.

INTRODUCTION: Cauda equina syndrome (CES) has significant medical, social, and legal consequences. Understanding the number of people presenting with CES and their demographic features is essential for planning healthcare services to ensure timely and appropriate management. We aimed to establish the incidence of CES in a single country and stratify incidence by age, gender, and socioeconomic status. As no consensus clinical definition of CES exists, we compared incidence using different diagnostic criteria. METHODS: All patients presenting with radiological compression of the cauda equina due to degenerative disc disease and clinical CES requiring emergency surgical decompression during a 1-year period were identified at all centres performing emergency spinal surgery across Scotland. Initial patient identification occurred during the emergency hospital admission, and case ascertainment was checked using ICD-10 diagnostic coding. Clinical information was reviewed, and incidence rates for all demographic and clinical groups were calculated. RESULTS: We identified 149 patients with CES in 1 year from a total population of 5.4 million, giving a crude incidence of 2.7 (95% CI: 2.3-3.2) per 100,000 per year. CES occurred more commonly in females and in the 30-49 years age range, with an incidence per year of 7.2 (95% CI: 4.7-10.6) per 100,000 females age 30-39. There was no association between CES and socioeconomic status. CES requiring catheterization had an incidence of 1.1 (95% CI: 0.8-1.5) per 100,000 adults per year. The use of ICD-10 codes alone to identify cases gave much higher incidence rates, but was inaccurate, with 55% (117/211) of patients with a new ICD-10 code for CES found not to have CES on clinical notes review. CONCLUSION: CES occurred more commonly in females and in those between 30 and 49 years and had no association with socioeconomic status. The incidence of CES in Scotland is at least four times higher than previous European estimates of 0.3-0.6 per 100,000 population per year. Incidence varies with clinical diagnostic criteria. To enable comparison of rates of CES across populations, we recommend using standardized clinical and radiological criteria and standardization for population structure.

Assessment of the utility of the National Health Service England Low Back and Radicular Pain Pathway: analysis of patient reported outcomes.

INTRODUCTION: Lumbar disc herniation causing radiculopathy is a common reason for referral to spinal out-patient clinics. At our centre following routine referral, patients wait a mean of 109 weeks for a consultation with a spinal surgeon. A pathway in keeping with the National Health Service England Low Back and Radicular Pain Pathway was introduced with two objectives. Patients would be seen sooner by suitably trained health care professionals to avoid long waiting times for assessment with a spinal surgeon, and if a set of criteria were met, they would receive a selective nerve root injection to manage their pain. METHODS: Patients were seen by specially trained orthopaedic physiotherapists following routine general practitioner (GP) referral. A radiologically guided nerve root injection was carried out if patients had radicular pain between 6 and 52 weeks duration and a magnetic resonance imaging (MRI) scan demonstrating an intervertebral disc prolapse correlating with their radicular symptoms. Patient-recorded outcome measures were taken before and after nerve root injection. RESULTS: Seventy five patients entered the pathway. Mean patient age was 49.9 years and 27 patients (36.0%) were male. Mean time from referral to assessment was 15.5 weeks. Mean visual analogue score (VAS) for leg pain was 7.4 out of 10 before nerve root injection and 4.8 out of 10 following nerve root injection (p < 0.001). Mean Oswestry Low Back Pain Disability Questionnaire score before nerve root injection was 58.4% and 49.7% following nerve root injection (p = 0.024). Mean Euroqol EQ-5D-5L Health Index was 0.2 before nerve root injection and 0.4 afterwards (p < 0.001). CONCLUSION: This study suggests that this pathway may help to reduce waiting times for patients with lumbar radiculopathy secondary to intervertebral disc prolapse. The resulting enhanced care may be associated with a reduction in leg and back pain and an improvement in quality of life.

Advancing spinal fellowship training: an international multi-centre educational perspective.

PURPOSE: The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery. METHODS: Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training. RESULTS: Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training. CONCLUSIONS: Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.

Understanding cauda equina syndrome: protocol for a UK multicentre prospective observational cohort study.

INTRODUCTION: Cauda equina syndrome (CES) is a potentially devastating condition caused by compression of the cauda equina nerve roots. This can result in bowel, bladder and sexual dysfunction plus lower limb weakness, numbness and pain. CES occurs infrequently, but has serious potential morbidity and medicolegal consequences. This study aims to identify and describe the presentation and management of patients with CES in the UK. METHODS AND ANALYSIS: Understanding Cauda Equina Syndrome (UCES) is a prospective and collaborative multicentre cohort study of adult patients with confirmed CES managed at specialist spinal centres in the UK. Participants will be identified using neurosurgical and orthopaedic trainee networks to screen referrals to spinal centres. Details of presentation, investigations, management and service usage will be recorded. Both patient-reported and clinician-reported outcome measures will be assessed for 1 year after surgery. This will establish the incidence of CES, current investigation and management practices, and adherence to national standards of care. Outcomes will be stratified by clinical presentation and patient management. Accurate and up to date information about the presentation, management and outcome of patients with CES will inform standards of service design and delivery for this important but infrequent condition. ETHICS AND DISSEMINATION: UCES received a favourable ethical opinion from the South East Scotland Research Ethics Committee 02 (Reference: 18/SS/0047; IRAS ID: 233515). All spinal centres managing patients with CES in the UK will be encouraged to participate in UCES. Study results will be published in medical journals and shared with local participating sites. TRIAL REGISTRATION NUMBER: ISRCTN16828522; Pre-results.

Influence of timing of surgery on Cauda equina syndrome: Outcomes at a national spinal centre.

PURPOSE: There is no doubt that the best outcome achieved in Cauda equina syndrome (CES) involves surgical decompression. The controversy regarding outcome lies with timing of surgery. This study reports outcomes on a large population based series. Timing of surgery, Cauda Equina syndrome classification based on British Association of Spine Surgeons (BASS) guidelines and co-morbid illness will be assessed to evaluate influence on outcome. MATERIALS AND METHODS: A retrospective review of all patients surgically decompressed for CES between 01/01/2008 to 01/08/2014 was conducted. Patients with ongoing symptoms were followed up for a minimum of 2 years. Cauda Equina Syndrome (CES) was classified according to the BASS criteria: CES suspicious (CESS), incomplete (CESI) and painless urinary retention (CESR). Time and symptom resolution were assessed. RESULTS: A total of 136 patients were treated for CES; 69 CESR, 22 CESI and 45 CESS. There was no statistical difference in age, sex, smoking status and alcohol status with regards to timing of surgery. No correlation between increasing co-morbidity score and poor outcome was demonstrated in any subgroupAll CESR/I patients demonstrated some improvement in bowel and bladder dysfunction post-operatively. No significant difference in improved autonomic dysfunction was demonstrated in relation to timing of surgery. CES subclassification may predict outcome of non-autonomic symptoms. Statistically better outcomes were found in CESS groups with regards to post-operative lower back pain (P 0.049) and saddle paraesthesia (P 0.02). CONCLUSION: Surgical Decompression for CES is an effective treatment that significantly improves patient symptoms including bowel and bladder dysfunction Early surgical decompression <24 h from symptom onset does not appear to significantly improve resolution of bowel or bladder dysfunction.

Is it necessary to embolise all spinal metastases from primary renal tumours?

INTRODUCTION: Spinal metastases secondary to renal cell carcinoma are associated with significant intra-operative blood loss. Our aim was to assess if embolisation reduced the intra-operative blood loss and transfusion requirement. METHODS: We performed a retrospective cohort study of 25 patients undergoing surgery between 2003 and 2011. RESULTS: 14 underwent pre-operative embolisation; 11 did not. There was no significant difference in intra-operative blood loss, 1336 ml vs 1492 ml in the non-embolised (p value = 0.116). 43% of embolised patients required an intra operative blood transfusion vs 27% in the non-embolised. CONCLUSION: Our results suggest that not all patients with spinal metastatic renal carcinoma require pre-operative embolisation.

'Scan-negative' cauda equina syndrome: Evidence of functional disorder from a prospective case series.

In the first prospective comparison of 'scan-negative' (n=11) and 'scan-positive' (n=7) patients with cauda equina syndrome (CES) we found that Hoover's sign of functional leg weakness but not routine clinical features differentiated the two groups (p<0.02). This offers a new direction of study in this area, although magnetic resonance imaging is still required for all patients with possible CES.

Does formal education and training of staff reduce the operation rate for fractures of the distal radius?

BACKGROUND: Fractures of the distal radius are one of the most common extremity fractures, and operation rates are increasing. Staff within our unit felt that formal teaching, particularly of new medical staff, with regards to fracture reduction and appropriate cast application could result in a reduction in operation rates. METHODS: Retrospective data was extracted from FORD (Fracture Outcome and Research Database), including: number of fractures, number of fractures undergoing ORIF, fracture configuration, patient demographics, and mechanism of injury. All patients undergoing ORIF had their radiographs assessed by two separate reviewers. Information regarding adequate fracture reduction, adequate cast application (using Gap Index), and appropriate plaster cast moulding was recorded. Formal teaching was then given to the next group of medical staff rotating through the unit, and the same data was collected prospectively for that six-month period. Exclusion criteria included bilateral injuries, and polytrauma patients. RESULTS: A total of 1623 distal radial fractures were treated in our unit over the 12-month period, with 71 undergoing ORIF in the first 6 months and 39 in the second 6 months, this was statistically significant (p = 0.0009). Our study found that formal teaching and education significantly reduced the operation rate for distal radial fractures. This effect was most significant for extra-articular, dorsally angulated fractures of the distal radius. CONCLUSION: Our study proves that just 1 h of basic training at the beginning of an attachment can have significant benefits to both the unit and, more importantly, the patients.

Magnetic resonance imaging in a patient with a dual chamber pacemaker.

Having a pacemaker has been seen an absolute contraindication to having an MRI scan. This has become increasingly difficult in clinical practice as insertion of pacemakers and implantable cardiac defibrillators is at an all time high. Here we outline a case where a 71-year-old male patient with a permanent pacemaker needed to have an MRI scan to ascertain the aetiology of his condition and help guide further management. Given this clinical dilemma, an emergency clinical ethics consultation was arranged. As a result the patient underwent an MRI scan safely under controlled conditions with a consultant cardiologist and radiologist present. The results of the MRI scan were then able to tailor further treatment. This case highlights that in certain conditions an MRI can be performed in patients with permanent pacemakers and outlines the role of clinical ethics committees in complex medical decision making.