Reliability of clinical assessment in diagnosing cauda equina syndrome

Abstract

Cauda equina syndrome (CES) is a neurological syndrome presenting with non-specific symptoms and signs that often leads to diagnostic confusion and delay. Acute onset CES is a surgical emergency. The common aetiology is a prolapsed lumbar disc. If the diagnosis is missed, it can have devastating consequences for the patient and a high financial cost to healthcare providers. The objective of this study was to evaluate the efficacy of clinical assessment in clinching the diagnosis. Eighty patients who underwent urgent clinical assessment and magnetic resonance imaging (MRI) for suspected CES over a 1-year period (from January 1st 2008 to 31 December 2008) were included in the study. Fifteen of these patients had a CES and underwent urgent lumbar discectomy and decompression. Medical notes and MRI scans of all these patients were reviewed. The presenting symptoms and signs were analysed against a positive MRI scan. Chi-square test with Yates correction was used to test association of each clinical symptom and sign for a positive MRI. In this study, only 18.8% of assessed patients had a CES producing compression seen on the MRI. Presence of saddle sensory deficit was the only clinical feature with a statistically significant association with MRI positive CES (p = 0.03). This series shows that saddle sensory deficit has a higher predictive value than other clinical features in diagnosing a CES. However, as there is no symptom or sign which has an absolute predictive value in establishing the diagnosis of CES, any patient in whom a reasonable suspicion of CES arises must undergo urgent MRI to exclude this diagnosis.

Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction

“…This study displays unique data on the presenting symptoms of a large group of CES patients, proving that, next to the well-acknowledged micturition dysfunction, also defecation and sexual dysfunction are common at presentation. Anal sphincter tension and anal sphincter reflex are often tested in CES patients, even though several studies found no diagnostic value for these tests [18][19][20][21]. In the current study, abnormal anal sphincter reflex was not significantly associated with any of the diagnostic criteria for CES used in this study (closest to an association was defecation dysfunction with p = 0.096).…”

Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature

“…4,9 There are two methods that help to identify the LDH. These methods are the MRI and the CT. 19,24,41 The MRI depicts detailed pictures of spine. The CT is used when there are obstacles to the implementation of MRI, such as claustrophobic patients.…”

“…3,5,8,14,19,28,41 According to the literature, a wide laminectomy and the extensive decompression of the nerves of CES is one of the methods which are the "key role" in the treatment of CES. 1,8,12,25,27,29,45 Several authors report that a removing of the disc space material "takes place" after the decompression.…”

“…Another surgical technique is the discectomy or the combination of laminectomy and discectomy. 1,5,12,25,41 The laminotomy/ hemilaminectomy with micro-discectomy, is a technique which is not recommended because of retraction of the thecal sac, which leads to aggravated damages of nerves during the decompression. In few instances, the clinical doctor uses the transthecal decompression.…”

“…1,7,9,18,25,34 The methods that help to identify the reasons of CES are the MRI and the CT. Generally, the MRI is performed to prove any compression of the thecal sac. 19,24,25,30,41 The MRI is the fi rst clinical examination in the spinal cord for the patients who present the symptoms of CES. 5,15,18,20,42,43 Lumbar disc herniation, tumor, hematoma and infection are illustrated in the MRI.…”