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

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

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

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.

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People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

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The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

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This study was performed to explore the effect of melatonin on pyroptosis in nucleus pulposus cells (NPCs) and the underlying mechanism of that effect.

Magnetic Resonance Imaging (MRI) is the cornerstone investigation for cervical disc disease (CDD). However, MRI changes suggestive of CDD are found in people above forty, even in asymptomatic healthy individuals [1]. Mere presence of MRI changes of CDD does not exclude the presence of concomitant extra-foraminal pathology. No study design. We present here a series of three cases where use of ‘high resolution ultrasound’ has allowed accurate diagnosis of concomitant extra-foraminal pathology in patients with MRI-proven CDD. The three cases were acute neuropraxia of aberrant C5 nerve root, anterior interossous nerve compression due to pseudo-aneurysm of brachial artery and ‘acute brachial neuritis’ respectively. No outcome measure. Use of diagnostic high resolution ultrasound revealed accurate diagnosis of concomitant extra-foraminal pathology in all three cases. The cases with acute neuropraxia and acute brachial neuritis recovered with conservative treatment. Pseudo-aneurysm was treated successfully with surgery. High resolution ultrasound of the brachial plexus and peripheral nerves may be useful in following scenarios to identify an extra-foraminal pathology: (1) when symptoms and signs are out of proportion to the MRI findings of CDD; (2) when there is obvious discordance between MRI and nerve conduction findings; (3) where an entrapment neuropathy is suspected but the site of nerve lesion cannot be located

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

We investigated the incidence of evidence of irritation of the brachial plexus in 119 patients with whiplash injuries sustained in road-traffic accidents. We compared the symptoms, physical signs, autonomic status, psychological status and findings from radiographs of the cervical spine using examination charts and a modified Cornell Medical Index Health questionnaire, in patients in two distinct groups: those with irritation of the brachial plexus and those without. There were 45 patients (37.8%) in the first group. The ratio of women to men was significantly higher in patients with irritation of the plexus as was the incidence of symptoms other than neck pain. There was no significant difference between the two groups with regard to psychological status or findings in radiographs of the cervical spine. Symptoms and signs attributable to stretching of the brachial plexus do occur in a significant proportion of patients after a whiplash injury. Their presence and persistence are associated with a poor outcome

Aims

The aim of this study was to use diffusion tensor imaging (DTI) to investigate changes in diffusion metrics in patients with cervical spondylotic myelopathy (CSM) up to five years after decompressive surgery. We correlated these changes with clinical outcomes as scored by the Modified Japanese Orthopedic Association (mJOA) method, Neck Disability Index (NDI), and Visual Analogue Scale (VAS).

Non-dysraphic intradural spinal cord lipomas are very rare lesions and the management remains controversial. We present our experience with five cases, review the literature and propose guidelines for their management. The case notes of the patients were retrospectively reviewed. An extensive literature search was done, and the relevant articles were analyzed. Between January 2004 and April 2009, we operated on five cases of non-dysraphic intradural spinal cord lipomas. The age at presentation ranged from 17 years to 52 years (mean 32.2). Minimum follow up was 6 months and maximum follow up 5 years. All patients underwent decompression with a laminectomy/ laminoplasty and debulking. The dura was primarily closed in one patient. All patients had regular clinical and radiological follow-up with serial MRI scans. Neurological improvement was noted in all patients. There was significant residual tumour on the MRI scan in all patients. Guidelines for management were formulated on the basis of our experience and literature review. The aim of surgery should be adequate decompression with preservation of neural structures. Aggressive debulking should be avoided. Onset of any neurological symptoms/signs, bowel or bladder symptoms or intractable local symptoms should be an indication for surgery

Purpose. To question the reliability of Thoracic Spine pain as a red flag and symptoms of a possible cause of Serious Spinal Pathology (SSP). Methods. The clinical notes and Magnetic Resonance Imaging (MRI) results of patients presenting to the Sheffield Spinal Service with Thoracic spine symptoms but no signs were retrospectively reviewed over the period of 2 year (September 2008-August 2010). The clinical reason for request of Thoracic MRIs were noted and the patient notes were reviewed to determine their presentation, length of time of symptoms, age and also it was noted whether any other recognized red flag symptoms were present. Exclusion criteria consisted of patients referred with known SSP or myelopathic symptoms. Results. 57 thoracic spine MRI requests were made in total by the orthopaedic spinal teams for patients presenting with thoracic spine pain in the time period. 8 patients were excluded as per criteria as they were referred with known SSP as were 4 other patients with a history of previous cancer. 45 patients presented with thoracic spine pain but no other red flag signs or symptoms of these none had MRI evidence of serious spinal pathology or indeed anything pathological indicating the cause of their symptoms. Conclusion. The majority of those presenting to orthopaedic spinal clinic with thoracic spine pain alone with no other red flag signs have no pathological cause. Thoracic pain is a widely accepted indicator (red flag) of potential serious spinal pathology. The findings from this review would not support thoracic pain alone as an indicator of SSP

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The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation.

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The surgical treatment of tuberculosis (TB) of the spine consists of debridement and reconstruction of the anterior column. Loss of correction is the most significant challenge. Our aim was to report the outcome of single-stage posterior surgery using bone allografts in the management of this condition.

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Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness.

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’.

We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk.

Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.

The aim of this study was to evaluate the feasibility of using the intact S1 nerve root as a donor nerve to repair an avulsion of the contralateral lumbosacral plexus. Two cohorts of patients were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients with a unilateral fracture of the sacrum and sacral nerve injury were stimulated during surgery to establish the precise functional distribution of the S1 nerve root and its proportional contribution to individual muscles. In cohort 2, the contralateral uninjured S1 nerve root of six patients with a unilateral lumbosacral plexus avulsion was transected extradurally and used with a 25 cm segment of the common peroneal nerve from the injured leg to reconstruct the avulsed plexus.

The results from cohort 1 showed that the innervation of S1 in each muscle can be compensated for by L4, L5, S2 and S3. Numbness in the toes and a reduction in strength were found after surgery in cohort 2, but these symptoms gradually disappeared and strength recovered. The results of electrophysiological studies of the donor limb were generally normal.

Severing the S1 nerve root does not appear to damage the healthy limb as far as clinical assessment and electrophysiological testing can determine. Consequently, the S1 nerve can be considered to be a suitable donor nerve for reconstruction of an avulsed contralateral lumbosacral plexus.

Cite this article: Bone Joint J 2015; 97-B:358–65.