What is the incidence of cauda equina syndrome? A systematic review

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OBJECTIVE

Cauda equina syndrome (CES) is a surgical emergency requiring timely operative intervention to prevent symptom progression. Accurately establishing the incidence of CES is required to inform healthcare service design and delivery, including out-of-hours imaging arrangements.

METHODS

A systematic literature search of MEDLINE, EMBASE, and Scopus was undertaken to identify original studies stating the incidence of CES, and the estimates were combined in a meta-analysis as described in the protocol registered with PROSPERO (registration no. CRD42017065865) and reported using the PRISMA guidelines.

RESULTS

A total of 1281 studies were identified, and 26 studies were included in the review. Data about CES incidence were available from 3 different populations: asymptomatic community populations, patients with nontraumatic low-back pain, and patients presenting as an emergency with suspected CES. The incidence of CES was 0.3–0.5 per 100,000 per year in 2 asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working-age population. CES occurred in 0.08% of those with low-back pain presenting to primary care in 1 study, and a combined estimate of 0.27% was calculated for 4 studies of those with low-back pain presenting to secondary care. Across 18 studies of adults with suspected CES, 19% had radiological and clinical CES. Difficulties in comparison between studies resulted from the heterogeneous definitions of CES and lack of separation of more advanced CES with retention, which is unlikely to be reversible. In the studies of patients with suspected CES, the small sample size, the high number of single-center studies (18/18), the high number of studies from the United Kingdom (17/18), the retrospective nature of the studies, and the high number of abstracts rather than full texts (9/18) reduced the quality of the data.

CONCLUSIONS

From current studies, it appears that CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Determining accurate incidence figures and designing a bespoke service for investigation of patients with suspected CES would require a consensus clinical and radiological definition of CES and international multisite studies of patient pathways of investigation and management.

ABBREVIATIONS CES = cauda equina syndrome; UK = United Kingdom.
Article Information

Contributor Notes

Correspondence Julie Woodfield: Western General Hospital, Edinburgh, United Kingdom. julie.woodfield@ed.ac.uk.INCLUDE WHEN CITING Published online February 14, 2020; DOI: 10.3171/2019.12.SPINE19839.

A.K.D. and J.W. share senior authorship of this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Ahad AElsayed MTohid H: The accuracy of clinical symptoms in detecting cauda equina syndrome in patients undergoing acute MRI of the spine. Neuroradiol J 28:4384422015

    • Search Google Scholar
    • Export Citation
  • 2

    Ahn UMAhn NUBuchowski JMGarrett ESSieber ANKostuik JP: Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine (Phila Pa 1976) 25:151515222000

    • Search Google Scholar
    • Export Citation
  • 3

    Balasubramanian KKalsi PGreenough CGKuskoor Seetharam MP: Reliability of clinical assessment in diagnosing cauda equina syndrome. Br J Neurosurg 24:3833862010

    • Search Google Scholar
    • Export Citation
  • 4

    Banerjee P: Diagnosis of suspected cauda equina syndrome with urgent MRI. The real life scenario. Global Spine J 8 (1 Suppl 1):277S278S2018 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 5

    Banerjee PJalgaonkar A: Back pain with bladder/bowel dysfunction in a child—is this cauda equina syndrome. Global Spine J 8 (1 Suppl 1):262S2018 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 6

    Bell DACollie DStatham PF: Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 21:2012032007

    • Search Google Scholar
    • Export Citation
  • 7

    Blades DHeyes GRobinson KEames N: Timing of treatment of cauda equina syndrome at a national treatment centre. Eur Spine J 24:S7232015 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 8

    Boyle MH: Guidelines for evaluating prevalence studies. Evid Based Ment Health 1:37391998

  • 9

    Chau AMXu LLPelzer NRGragnaniello C: Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurg 81:6406502014

    • Search Google Scholar
    • Export Citation
  • 10

    Clopper CJPearson ES: The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika 26:4044131934

  • 11

    Crocker MFraser GBoyd EWilson JChitnavis BPThomas NW: The value of interhospital transfer and emergency MRI for suspected cauda equina syndrome: a 2-year retrospective study. Ann R Coll Surg Engl 90:5135162008

    • Search Google Scholar
    • Export Citation
  • 12

    Daniels EWGordon ZFrench KAhn UMAhn NU: Review of medicolegal cases for cauda equina syndrome: what factors lead to an adverse outcome for the provider? Orthopedics 35:e414e4192012

    • Search Google Scholar
    • Export Citation
  • 13

    Demetriades AKBroughton EAkinwunmi JCritchley GGunasekera LNorris JS: Out of hours MRI scanning for cauda equina syndrome (CES): what is the positive pick-up rate and what are the final diagnoses in those with a negative scan? Br J Neurosurg 23:4752009 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 14

    DerSimonian RLaird N: Meta-analysis in clinical trials. Control Clin Trials 7:1771881986

  • 15

    Domen PMHofman PAvan Santbrink HWeber WEJ: Predictive value of clinical characteristics in patients with suspected cauda equina syndrome. Eur J Neurol 16:4164192009

    • Search Google Scholar
    • Export Citation
  • 16

    Etemadifar MNasr ZKhalili BTaherioun MVosoughi R: Epidemiology of neuromyelitis optica in the world: a systematic review and meta-analysis. Mult Scler Int 2015:1747202015

    • Search Google Scholar
    • Export Citation
  • 17

    Fairbank JHashimoto RDailey APatel AADettori JR: Does patient history and physical examination predict MRI proven cauda equina syndrome? Evid Based Spine Care J 2:27332011

    • Search Google Scholar
    • Export Citation
  • 18

    Fraser SRoberts LMurphy E: Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil 90:196419682009

    • Search Google Scholar
    • Export Citation
  • 19

    Germon TAhuja SCasey ATTodd NVRai A: British Association of Spine Surgeons standards of care for cauda equina syndrome. Spine J 15 (3 Suppl):S2S42015

    • Search Google Scholar
    • Export Citation
  • 20

    Gooding BWTHiggins MACalthorpe DAD: Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome? Br J Neurosurg 27:1561592013

    • Search Google Scholar
    • Export Citation
  • 21

    Hauptfleisch JMeagher TMKing DLópez de Heredia LHughes RJ: Out-of-hours MRI provision in the UK and models of service delivery. Clin Radiol 68:e245e2482013

    • Search Google Scholar
    • Export Citation
  • 22

    Haworth AEBhojak MWilby MDas KClark S: Out of hours imaging for suspected cauda equina syndrome—a 3 year audit into positive pick up rates in a regional neurosurgical referral centre. Br J Neurosurg 27:2812013 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 23

    Henschke NMaher CGRefshauge KMHerbert RDCumming RGBleasel J: Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 60:307230802009

    • Search Google Scholar
    • Export Citation
  • 24

    Higgins JPTThompson SG: Quantifying heterogeneity in a meta-analysis. Stat Med 21:153915582002

  • 25

    Hoeritzauer IDoherty CMThomson SKee RCarson AEames N: ‘Scan-negative’ cauda equina syndrome: evidence of functional disorder from a prospective case series. Br J Neurosurg 29:1781802015

    • Search Google Scholar
    • Export Citation
  • 26

    Hoeritzauer IPronin SCarson AStatham PDemetriades AKStone J: The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients. J Neurol 265:291629262018

    • Search Google Scholar
    • Export Citation
  • 27

    Hoeritzauer IPronin SCarson AStatham PStone JDemetriades AK: Investigating the patients who present more than once with cauda equina syndrome symptoms. Spine J 17:S272017

    • Search Google Scholar
    • Export Citation
  • 28

    Hurme MAlaranta HTörmä TEinola S: Operated lumbar disc herniation: epidemiological aspects. Ann Chir Gynaecol 72:33361983

  • 29

    Hussain MMRazak AAHassan SSChoudhari KASpink GM: Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals. Br J Neurosurg 32:2642682018

    • Search Google Scholar
    • Export Citation
  • 30

    Kiberd JHayden JMagee KCampbell S: Utility of red flags to identify serious spinal pathology in patients with low back pain: a retrospective analysis. CJEM 20 (Suppl 1):S33–S342018

    • Search Google Scholar
    • Export Citation
  • 31

    Korse NSVeldman ABPeul WCVleggeert-Lankamp CLA: The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome. PLoS One 12:e01759872017

    • Search Google Scholar
    • Export Citation
  • 32

    Kostusiak MGnanakumar SLaing R: Incidence of cauda equina syndrome in patients transferred from district general hospitals to tertiary centre for out of hours MRI. Br J Neurosurg 32:812018 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 33

    Loney PLChambers LWBennett KJRoberts JGStratford PW: Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can 19:1701761998

    • Search Google Scholar
    • Export Citation
  • 34

    Machin JTHardman JHarrison WBriggs TWRHutton M: Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS. Eur Spine J 27:269326992018

    • Search Google Scholar
    • Export Citation
  • 35

    Marrie RACohen JStuve OTrojano MSørensen PSReingold S: A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview. Mult Scler 21:2632812015

    • Search Google Scholar
    • Export Citation
  • 36

    Moher DLiberati ATetzlaff JAltman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e10000972009

    • Search Google Scholar
    • Export Citation
  • 37

    Podnar S: Epidemiology of cauda equina and conus medullaris lesions. Muscle Nerve 35:5295312007

  • 38

    Premkumar AGodfrey WGottschalk MBBoden SD: Red flags for low back pain are not always really red: a prospective evaluation of the clinical utility of commonly used screening questions for low back pain. J Bone Joint Surg Am 100:3683742018

    • Search Google Scholar
    • Export Citation
  • 39

    Razak AHassan SBrown DHussain M: Who ‘owns’ suspected cauda equina patients? Br J Neurosurg 31:1362017 (Abstract)

  • 40

    Reito AKyrölä KPekkanen LPaloneva J: Specific spinal pathologies in adult patients with an acute or subacute atraumatic low back pain in the emergency department. Int Orthop 42:284328492018

    • Search Google Scholar
    • Export Citation
  • 41

    Rooney AStatham PFStone J: Cauda equina syndrome with normal MR imaging. J Neurol 256:7217252009

  • 42

    Schoenfeld AJ: Incidence and epidemiology of cauda equina syndrome: a review of 976 patients from a complete American population. Spine J 12:100S101S2012

    • Search Google Scholar
    • Export Citation
  • 43

    Schoenfeld AJBader JO: Cauda equina syndrome: an analysis of incidence rates and risk factors among a closed North American military population. Clin Neurol Neurosurg 114:9479502012

    • Search Google Scholar
    • Export Citation
  • 44

    Schwarzer GCarpenter JRRucker G: Meta-Analysis With R ed 1. Berlin: Springer International Publishing2015

  • 45

    Sideris MMoore ESakthithasan MWilliams APWhitfield PC: The evaluation of the clinical presentation, MRI findings and immediate management of potential cauda equina syndrome referrals in a tertiary neurosurgical centre. Int J Surg 12:S542014

    • Search Google Scholar
    • Export Citation
  • 46

    Srikandarajah NBoissaud-Cooke MAClark SWilby MJ: Does early surgical decompression in cauda equina syndrome improve bladder outcome? Spine (Phila Pa 1976) 40:5805832015

    • Search Google Scholar
    • Export Citation
  • 47

    Thangarajah TO’Donoghue DPillay R: Today or tomorrow? A retrospective analysis of the clinical indications used to request urgent magnetic resonance imaging of the spine. Ann R Coll Surg Engl 93:76802011

    • Search Google Scholar
    • Export Citation
  • 48

    Thiruganasambandamoorthy VTurko EAnsell DVaidyanathan AWells GAStiell IG: Risk factors for serious underlying pathology in adult emergency department nontraumatic low back pain patients. J Emerg Med 47:1112014

    • Search Google Scholar
    • Export Citation
  • 49

    Todd NV: Causes and outcomes of cauda equina syndrome in medico-legal practice: a single neurosurgical experience of 40 consecutive cases. Br J Neurosurg 25:5035082011

    • Search Google Scholar
    • Export Citation
  • 50

    Todd NVDickson RA: Standards of care in cauda equina syndrome. Br J Neurosurg 30:5185222016

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