More questions than answers to the diagnosis and management of cauda equina syndrome—authors’ reply

Woodfield, Julie; Hoeritzauer, Ingrid; Jamjoom, Aimun A B; Lammy, Simon; Pronin, Savva; Hannan, Cathal John; Watts, Anna; Hughes, Laura; Moon, Richard; Roy, Holly; Poon, Michael T C; Thorpe, Paul; Srikandarajah, Nisaharan; Demetriades, Andreas K.; Eames, Niall; Sell, P; Statham, Patrick

doi:10.1016/j.lanepe.2023.100606

Cited by 3 publications

(3 citation statements)

References 6 publications

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“…The technical aspects of CES surgery, as encountered in this case, involve decompression, the need for stabilization, and the need to address any incidental durotomy. Stabilization using pedicle screws and rods in our patient provided the necessary structural support for the injured vertebrae, while dural sutures mitigated the risks associated with cerebrospinal fluid (CSF) leaks, such as meningitis, pseudomeningocele formation, and wound dehiscence [ 1 ]. Dural repair techniques have evolved over time, with primary sutures favored for their efficacy in preventing CSF-related complications that can otherwise lead to prolonged hospitalization, increased healthcare costs, and additional surgeries.…”

Section: Discussionmentioning

confidence: 99%

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Recovery with posterior decompression and dural suturing in a patient with cauda equina syndrome caused by lamina entrapment in an unstable burst fracture: A case report

Lim

2024

International Journal of Surgery Case Reports

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Section: Discussionmentioning

confidence: 99%

“…The symptoms include lower extremity paralysis, sensory deficits in the “saddle” area, and dysfunction of bladder and bowel control. CES is typically caused by conditions that lead to acute compression of nerve roots, such as herniated discs, tumors, infections, and traumatic spinal injuries [ [1] , [2] , [3] , [4] , [5] ].…”

Section: Introductionmentioning

confidence: 99%

Recovery with posterior decompression and dural suturing in a patient with cauda equina syndrome caused by lamina entrapment in an unstable burst fracture: A case report

Lim

2024

International Journal of Surgery Case Reports

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“…3,13 Poor inter-rater reliability in diagnosing CESR, and lack of clarity surrounding which patients historical studies refer to, may lead to patients being treated less aggressively or having limited rehabilitation due to presumed poor outcome, which could prevent them achieving their full potential recovery. 8,12 Based on the poor agreement within and between all levels of clinicians seeing patients with CES, we would advocate not using CES classifications to decide on whom and when to investigate and operate. Instead, using broad diagnostic criteria to raise the possibility of CES, and prompt individualized investigation and management for all patients with potential CES, seems the safest option to ensure the best possible outcome for each patient.…”

Section: Discussionmentioning

confidence: 99%

Cauda equina syndrome

Hoeritzauer,

Paterson,

Jamjoom

et al. 2023

Bone Joint J

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AimsPatients 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.MethodsA 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.ResultsEach 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).ConclusionInter-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.

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The failure of subcategorization of cauda equina syndrome

Todd,

Casey,

Birch

2024

Bone Joint J

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The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. This paper presents a reassessment of the diagnostic and prognostic subcategories of CES the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.Cite this article: Bone Joint J 2024;106-B(3):227–231.

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More questions than answers to the diagnosis and management of cauda equina syndrome—authors’ reply

Cited by 3 publications

References 6 publications

Recovery with posterior decompression and dural suturing in a patient with cauda equina syndrome caused by lamina entrapment in an unstable burst fracture: A case report

Recovery with posterior decompression and dural suturing in a patient with cauda equina syndrome caused by lamina entrapment in an unstable burst fracture: A case report

Cauda equina syndrome

The failure of subcategorization of cauda equina syndrome

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