Clinical Presentation as a Predictor of Radiologically Confirmed Cauda Equina Syndrome

Cauda Equina Syndrome (CES) is something clinicians should always be on the look out for, especially in patients with lumbosacral radiculopathy. This week, an update from the literature on how clinical signs relate to eventual imaging fundings. For us as chiropractors, this paper is a great reminder about relevant symptoms to watch for, as clinical suspicion should warrant referral for emergent assessment (which would then likely involve imaging).…

Patients with CES typically present with back and/or leg pain plus disturbance of one or more of the following: bladder, bowel or sexual function/sensation, and/or perineal/perianal sensation. When one or more of these symp­toms is present and a large intervertebral disc or other type of cauda equina compression (CEC) is found on MRI, emergency surgery is required.

CES is only present in about 19% of patients presenting with CES symptoms and its incidence is very small, approximately 1 in 100,000 in primary care. Nonetheless, if a patient with CES is not managed correctly and urgently, permanent impairments are likely. Unfortunately, there are many different descriptions of CES in the literature, making differential diagno­sis challenging. There is also a lack of standardization of how to define CEC radiologically.

Previous studies on the predictive value of clinical findings leading to a confirmed CEC diagnosis have produced mixed results. For instance, incomplete voidance of the bladder and the presence of bilateral leg pain, dermatomal sensory loss and loss of lower limb reflexes were highly predictive, whereas a systematic review reported poor predictive value associated with any objective findings.
 
The authors of this paper have developed a clinical pathway for managing CES based on existing evidence, input from a consultant surgeon team, and being informed by their own data they have collected. Based on their previous work, the purpose of this project was to identify clinical predictors of subjective and objec­tive features in patients with suspected CES that might help predict MRI findings of an acute large canal occupying disc extrusion.

This paper is full of useful reminders for practicing chiropractors!

From Dr. Thistle:

CES is a condition you don’t want to miss, and your threshold for referral should be clear in your mind and actionable in your clinic. Make sure you have a plan and become comfortable with having these discussions with patients, before the emergency arises. This includes telling disc/radiculopathy patients concerning signs and symptoms to watch out for, what they may mean, and what action steps to take. As we saw again in this study, the progression to bilateral leg pain/sciatica is always a concerning evolution of symptoms to watch out for!

This paper was published in the European Spine Journal (2024)

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