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.

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

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)

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

Male retrograde ejaculation is a well-documented but rare complication of anterior approach lumbar spine surgery. Retraction of the soft tissues which encase the superior hypogastric plexus leads to dysfunction of the sympathetic control of the bladder neck sphincter. We postulated that similar nerve root dysfunction in females may lead to bladder problems and sexual dysfunction. The Female Sexual Function Index Questionnaire was sent to 20 consecutive women who had undergone anterior spinal surgery by the senior author (GM). Questionnaires were returned by 11 of the 20 subjects. 6 had undergone disc replacement surgery and 5 anterior lumbar interbody fusion. All procedures used an anterior retroperitoneal approach. The age range was 20 to 49 years (mean 40.2 years). There were no immediate peri-operative complications. The mean time since surgery was 4.9 years (range 3.1 to 5.8 years). The Female Sexual Function Index is a validated questionnaire used internationally as the gold standard measure of sexual dysfunction in women. Urinary frequency and incontinence were also recorded. 9 women (82%) described a degree of post-operative sexual dysfunction with 7 (64%) recording urinary frequency and urge incontinence. Although some sexual dysfunction may be expected from pre-existing conditions, we highlight this complication following anterior lumbar spine surgery in females. We plan to further investigate its incidence and possible resolution of symptoms after a prolonged period in a larger case series

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

In this study we aim to establish which symptoms and signs are able to reliably predict the presence or absence of cauda equina syndrome. Prospective collection of data was carried out over 10 months on all patients referred with suspected cauda equina syndrome(CES) to a single spinal unit. 28 patients were referred. MRI was normal in 4 (14%) patients. 4 (14%) had disc prolapse causing CES and 3 (11%) had spinal metastatic disease. All patients with CES presented with low back pain, unilateral sciatica, urinary dysfunction (painless retention 2, incontinence 2), altered perianal sensation and abnormal anal tone. 1 described constipation. Of patients without CES or malignancy 21 (100%) complained of low back pain, 19 (90%) sciatica (15 unilateral, 4 bilateral), 12 urinary dysfunction (incontinence 5, reduced sensation 3, painless retention 2, urgency 1, terminal dribbling 1) and 5 described altered bowel habit. 7 (33%) exhibited altered perianal sensation and 1 (5%) abnormal anal tone. The patients with spinal metastases all described back pain but no sciatica. 2 had urinary retention and constipation with 1 having abnormal perianal sensation and anal tone. This study suggests abnormal anal tone (sensitivity 1.0, specificity 0.95) and altered perianal sensation (sensitivity 1.0, specificity 0.67) are the most reliable predictors of CES. Thorough clinical examination is essential. Back pain with bladder and/or bowel dysfunction without sciatica should raise the suspicion of malignancy

The Royal Liverpool and Broadgreen University Hospital, Liverpool, UK. Plasmacytoma is the localised form of multiple myeloma, which can affect any part of the body including the axial skeleton (Kelly et al, 2006; Ampil et al, 1995). These myelomas/plasmacytomas arise from one malignant clone of cells, which secrete the same type of immunoglobulin. Where the clone of cells remains localised, it is known as plasmacytoma, but when there is spread of the malignancy to multiple bones and marrow, it is known as multiple myeloma (Boccadoro and Pileri, 1995). We present a case of solitary sacral bone plasmacytoma (SBP), in a seventy year old man which presented as low back pain, following a fall. He was neurologically intact, and had no sphincteric incontinence, but MRI revealed a large expansile lesion in S1, which caused severe spinal stenosis, involving the left L5 exiting foramen, with an irregular area of low signal posteriorly. Bone scan showed increased tracer uptake in L5 and a mixed hot/photopaenic appearance in the mid-sacral region indicating tumor involvement. Myeloma screen confirmed that the serum IgA was high, with positive kappa monoclonal band, positive Bence Jones Protein (BJP), normal IgM and IgG, and normal calcium profile. CT-guided biopsy revealed sheets of mature plasma cells, consistent with the diagnosis. Fine needle aspiration biopsy of an enlarged groin lymph node revealed neoplastic infiltration, consistent with myeloma. Skeletal survey and CT chest/abdomen/pelvis (CAP) were not contributory. The patient had six courses of radiotherapy and improved remarkably, and is being considered for chemotherapy as well as follow up in the out-patients' department

Introduction. Metastatic Spinal Cord Compression (MSCC) is a well recognised complication of cancer and a surgical emergency. We present the results of a prospective audit of process focusing on the timing of intervention for these patients from presentation/diagnosis to surgery. Methods. Prospective audit of all patients referred to a tertiary spine unit over 6 months (April –September 2010). All data captured on an excel database. Results. During the study period, 36 patients were referred to our unit with suspected MSCC. Thirty patients (mean age 64.9 years (46-89)) had confirmed MSCC, and of these 25 underwent decompression/stabilisation surgery (vertebroplasty/kyphoplasty (4), declined operation/unfit (7)). The presenting symptoms in the MSCC group were pain and neurological deterioration (16), pain only (7) and progressive neurology (3). The mean duration of pain was 131 days (3 days-over 2 years), and neurological progression was 14 days (1-120 days; Frankel C (3), D (16), E (7)) Four patients were non-ambulatory and 3 had urinary incontinence. The tumour histologies were Prostate (6), Renal (4), Breast (4), Haematological (4), Lung (3), Unknown (1), Others (3). The time from presentation to surgery was 12.9 hours (160mins- 36 hours) if the MRI was organised in our unit. But, if all patients with MSCC were included, together with those referred from other hospitals, the mean time from radiological diagnosis (MRI) to surgery was 29 hours (range 160 mins- >76 hours). Conclusion. This audit of process over 6 months shows that if MSCC is suspected, then patients should be referred to a specialist centre with out of hours MRI provision and where definitive treatment can take place

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

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.

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

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

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/m² (16.6 to 41.7) was very similar to that of the age-matched national mean (27.6 kg/m², p = 1.0). However, the mean BMI of the CES cohort (31.1 kg/m² (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/m²) 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.

The purpose of this study was to evaluate the long-term outcome of adults with spina bifida cystica (SBC) who had been treated either operatively or non-operatively for scoliosis during childhood.

We reviewed 45 patients with a SBC scoliosis (Cobb angle ≥ 50º) who had been treated at one of two children’s hospitals between 1991 and 2007. Of these, 34 (75.6%) had been treated operatively and 11 (24.4%) non-operatively. After a mean follow-up of 14.1 years (standard deviation (sd) 4.3) clinical, radiological and health-related quality of life (HRQOL) outcomes were evaluated using the Spina Bifida Spine Questionnaire (SBSQ) and the 36-Item Short Form Health Survey (SF-36).

Although patients in the two groups were demographically similar, those who had undergone surgery had a larger mean Cobb angle (88.0º (sd 20.5; 50.0 to 122.0); versus 65.7º (sd 22.0; 51.0 to 115.0); p < 0.01) and a larger mean clavicle–rib intersection difference (12.3 mm; (sd 8.5; 1 to 37); versus 4.1 mm, (sd 5.9; 0 to 16); p = 0.01) than those treated non-operatively. Both groups were statistically similar at follow-up with respect to walking capacity, neurological motor level, sitting balance and health-related quality of life (HRQOL) outcomes.

Spinal fusion in SBC scoliosis corrects coronal deformity and stops progression of the curve but has no clear effect on HRQOL.

Cite this article: Bone Joint J 2014; 96-B:1244–51

We have treated 175 patients with a chordoma over a ten-year period. Only two had a family history of the condition and we describe these in this paper. In one patient the tumour was at the craniocervical junction and in the other the lesion affected the sacrum. We have undertaken a literature review of familial chordoma and have identified chromosomal abnormalities associated with the condition.

Segmental vessel ligation during anterior spinal surgery has been associated with paraplegia. However, the incidence and risk factors for this devastating complication are debated.

We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who underwent surgery for anterior spinal deformity through a thoracic or thoracoabdominal approach, during which 2651 segmental vessels were ligated. There were 173 patients with idiopathic scoliosis, 80 with congenital scoliosis or kyphosis, 43 with neuromuscular and 31 with syndromic scoliosis, 12 with a scoliosis associated with intraspinal abnormalities, and seven with a kyphosis.

There was only one neurological complication, which occurred in a patient with a 127° congenital thoracic scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a thoracic diastematomyelia and tethered cord. This patient was operated upon early in the series, when intra-operative spinal cord monitoring was not available.

Intra-operative spinal cord monitoring with the use of somatosensory evoked potentials alone or with motor evoked potentials was performed in 331 patients. This showed no evidence of signal change after ligation of the segmental vessels.

In our experience, unilateral segmental vessel ligation carries no risk of neurological damage to the spinal cord unless performed in patients with complex congenital spinal deformities occurring primarily in the thoracic spine and associated with intraspinal anomalies at the same level, where the vascular supply to the cord may be abnormal.

We have reviewed 1858 patients who had undergone a cervical laminoplasty and identified 43 (2.3%) who had developed a C5 palsy with a MMT (MRC) grade of 0 to 2 in the deltoid, with or without involvement of the biceps, but with no loss of muscular strength in any other muscles. The clinical features and radiological findings of patients with (group P; 43 patients) and without (group C; 100 patients) C5 palsy were compared. CT scanning of group P revealed a significant narrowing of the intervertebral foramen of C5 (p < 0.005) and a larger superior articular process (p < 0.05). On MRI, the posterior shift of the spinal cord at C4–5 was significantly greater in group P, than in group C (p < 0.01).

This study is the first to correlate impairment of the C5 nerve root with a C5 palsy. It may be that early foraminotomy in susceptible individuals and the avoidance of tethering of the cord by excessive laminoplasty may prevent a post-operative palsy of the C5 nerve root.