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

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  • 1 Department of Clinical Neurosciences, Western General Hospital, Edinburgh;
  • 2 Centre for Clinical Brain Sciences, University of Edinburgh; and
  • 3 Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, United Kingdom
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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.

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.

In Brief

The authors systematically reviewed databases of medical literature to identify studies of cauda equina syndrome and its incidence. This information is important for organizing healthcare services and especially out-of-hours imaging arrangements, as MRI is required for all patients with suspected cauda equina syndrome.

Cauda equina syndrome (CES) is a surgical emergency with potentially significant consequences, including bladder, bowel and sexual dysfunction, numbness, weakness, and pain.18,31 Timely operative intervention can prevent symptom progression and potentially reverse existing symptoms.2,9,46 Due to the high medical, personal, social, and legal costs, prompt investigation with MRI is recommended when CES is suspected.19,49 In the United Kingdom (UK), patients are often transferred for investigation between sites due to a lack of MRI facilities operating outside normal working hours in district general hospitals and the potential need for specialist spinal or neurosurgical intervention.11,29 However, many patients who present with clinical symptoms in keeping with CES will not have cauda equina compression on MRI,26 which complicates planning service design and delivery. Establishing the incidence of CES and the likelihood of a diagnosis of CES in those presenting with symptoms consistent with CES would facilitate planning imaging and operative pathways for patients with suspected CES.

In this systematic review, we aimed to identify studies reporting the incidence of CES and describe the populations in which the incidence of CES has been studied and any differences in incidence between these populations.

Methods

A systematic review was undertaken as described in the study protocol “Incidence of cauda equina syndrome: systematic review protocol” registered with the International Prospective Register of Systematic Reviews (PROSPERO; reference no. CRD42017065865, available at https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=65865).

Studies were included if they reported original data and assessed human subjects with CES. For inclusion, studies had to state the incidence of CES or the proportion of the studied population with CES, or provide sufficient figures for this to be calculated. We defined CES as a clinical diagnosis of CES with radiological cauda equina compression. Studies including only patients with a clinical CES-type syndrome without radiologically confirmed cauda equina compression were excluded. Studies of radiological lesions of the cauda equina or cauda equina compression without clinical features of CES were also excluded. Reference populations could be either asymptomatic or symptomatic populations. Case series or studies without a reference population where the incidence of CES could not be established were excluded. Case series of operated lumbar discs, spinal stenosis, or iatrogenically caused CES were also excluded to ensure that all included studies were applicable to an initial presentation with suspected CES. There were no restrictions on the language or year of publication; type, location, or age of the population studied; or whether the study was published or unpublished.

The final database search was carried out on July 30, 2018, in MEDLINE (Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily 1946 to July 27, 2018, Ovid interface); EMBASE (1980 to week 31 of 2018, Ovid interface); and Scopus. The MEDLINE search strategy was as follows:

  • 1) Polyradiculopathy/
  • 2) cauda equina.ti,ab.
  • 3) Cauda Equina/
  • 4) 1 OR 2 OR 3
  • 5) Incidence/ or Prevalence/
  • 6) Epidemiology/
  • 7) (incidence* or prevalen* or epidemiolog* or frequenc* or rate* or occurrence*).ti,ab
  • 8) 5 OR 6 OR 7
  • 9) 4 AND 8

No limits were applied. EMBASE and Scopus search strategies are given in the Appendix.

Duplicate studies were eliminated, and then all abstracts and titles were screened by 2 reviewers independently (J.W., I.H., P.C.C., or M.W.). When reviewers disagreed, discussion with a third or fourth reviewer was undertaken to provide a consensus. The full text of all included abstracts was retrieved and independently reviewed by 2 reviewers (J.W., I.H., P.C.C., or M.W.). Any disagreements were resolved through discussion with a third or fourth reviewer. The reference lists of all included studies were screened independently by 2 reviewers to identify any additional relevant papers. Studies citing the included studies were identified using Scopus and also screened by 2 reviewers independently. Multiple papers or abstracts reporting the same study were treated as a single study.

Data were extracted from each included paper by 2 reviewers independently, and all instances in which data did not match were checked by a third reviewer (J.W., I.H., P.C.C., or M.W.). The data items extracted were incidence of CES in the population (including confidence intervals and standardized estimates where given); number of cases of CES; size of the reference population; description of the population (location, demographics, time period studied, inclusion criteria); and definition of CES used in the study including any subcategorization.

Study quality and risk of bias were assessed using the following questions adapted from those used in prior systematic reviews of the incidence of neurological conditions16,35 based on published quality assessment guidelines.8,33 As there are no validated diagnostic criteria for CES, studies were assessed on whether they described the definition of CES used.

  • 1) Was the target population clearly described?
  • 2) Were cases ascertained by survey of the entire population or by probability sampling?
  • 3) Was the sample size > 300 subjects?
  • 4) Was the response rate > 70%?
  • 5) Were nonresponders clearly described?
  • 6) Was the sample representative of the population?
  • 7) Were data collection methods standardized?
  • 8) Were the diagnostic criteria used to assess the presence of disease described?
  • 9) Were estimates of incidence given with confidence intervals?
  • 10) Were standardized estimates reported?

The incidence of CES was reported per 100,000 population per year in asymptomatic populations. The percentage with CES was reported in symptomatic populations. Statistical heterogeneity was assessed using the Q statistic and the I2 test.24 Proportions were combined using the inverse variance method and a DerSimonian-Laird estimator for τ2.14 Confidence intervals for individual studies were calculated using Clopper-Pearson confidence intervals.10 All statistics were calculated using the meta package in R version 3.4.0.44

Results

The studies identified and excluded at each stage and reasons for exclusion are shown in the PRISMA flow diagram (Fig. 1).36 Of the 1281 studies identified after removal of duplicates, 26 were included, of which 21 were included in the meta-analysis. Four studies reported the incidence of CES occurring in asymptomatic community populations.28,37,40,43 Twenty-three studies investigated the incidence of CES in patients presenting with symptoms.1,3–7,11,13,15,20,22,23,25,27,29,30,32,38,40,41,45,47,48 One study was included in both of these categories.40

FIG. 1.
FIG. 1.

PRISMA flow diagram. Studies identified, included, and excluded.

Population Incidence of CES

Study details and incidence figures for the 4 studies reporting the incidence of CES in community-dwelling asymptomatic populations are shown in Table 1. Hurme et al.28 and Podnar37 investigated European community–dwelling populations and identified similar incidence figures of 0.48 and 0.34 cases per 100,000 population per year, respectively, despite different methods of case ascertainment. Hurme et al.28 identified cases of CES using surgical records, while Podnar37 used a comprehensive clinical and neurophysiological assessment at a rehabilitation center. Reito et al.40 reported the incidence in an adult-only population and found a slightly higher incidence of 0.6 per 100,000 adult population per year. Schoenfeld42 and Schoenfeld and Bader43 studied an American military personnel healthcare database and found a higher incidence of 7 per 100,000 population per year in this working-age population. The study by Reito et al.40 was the only one to divide CES into subcategories. Two patients had CES with retention and 2 patients had incomplete CES, making the incidence of each subtype 0.30 per 100,000 per adult population per year. Both Reito et al. and Schoenfeld and Bader43 used coding to identify cases of CES. Reito et al. also reviewed clinical notes of the identified cases. Meta-analysis of the incidence estimates was not undertaken due to the heterogeneity in the reference populations studied and the methods of CES case ascertainment.

TABLE 1.

Incidence of CES in asymptomatic community populations

Authors & StudyYrs of StudyTime PeriodReference PopulationDefinition of CESTotal PopulationTotal CasesCases/100,000/Yr (95% CI)
Hurme et al., 19831975–19795 yrsHospital catchment population, FinlandUndergoing operation for CES455,000110.48*
Podnar, 20071996–20048 yrsPopulation of SloveniaHistory, examination, neurophysiology & radiology1,989,198670.34
Schoenfeld & Bader, 20122001–20109 yrsAmerican military database, USICD code13,871,384 person-yrs9767
Reito et al., 20182012–20143 yrsHospital catchment population, FinlandICD code; SBNS guideline subcategories based on clinical records661,902 adult person-yrs40.6 (0.16–1.5)

SBNS = Society of British Neurological Surgeons.

Calculated from values given in paper.

Reported as the total number of people in the population in the total number of years during the study time period.

Incidence of CES in Patients With Back Pain

Five studies reported the proportion of patients presenting with nontraumatic low-back pain who were found to have CES.23,30,38,40,48 Study findings are shown in Table 2. Henschke et al.23 found that 0.08% of adults presenting to primary care in Australia with low-back pain were diagnosed with CES by the study rheumatologist using clinical assessment and investigation. The other 4 studies investigated patients presenting to secondary care and reported proportions between 0.15% and 0.54%.30,38,40,48 The diagnosis of CES was determined by ICD code in 2 studies38,40 and by the clinician in 1 study;48 the method was not reported in 1 study.30 Study estimates for the proportion with CES in those presenting to secondary care with nontraumatic low-back pain were combined using a random-effects model to give an estimated proportion of 0.27% (95% CI 0.14%–0.54%). Study estimates and confidence intervals are shown in the forest plot in Fig. 2. There was a high level of statistical heterogeneity, with I2 = 85.2% (95% CI 63.3%–94.0%) and Q = 20.2 (p < 0.001).

TABLE 2.

Incidence of CES in patients presenting with back pain

Authors & StudyYrs of StudyTime PeriodReference PopulationDefinition of CESTotal PopulationTotal CasesProportion w/ CES (95% CI)
Henschke et al., 20092003–200520 mosPrimary care, AustraliaRheumatologist assessment (history, exam, tests)117210.08% (0.0–0.5%)
Thiruganasambandamoorthy et al., 20142009–20103 mosAdults, ED, CanadaClinician determined32910.30%
Kiberd et al., 2018Not stated7 yrsED, CanadaNot stated38,714570.15%
Premkumar et al., 20182005–201611 yrsSpinal surgeon, USICD code9940360.36%
Reito et al., 20182012–20143 yrsAdults, ED, FinlandICD code; SBNS guideline subcategories – based on clinical records900 visits; 737 patients40.44% per visit; 0.54% per patient

ED = emergency department.

FIG. 2.
FIG. 2.

Forest plot. Proportion and number (events) of patients with CES among those presenting with nontraumatic low-back pain to secondary care. Summary proportion calculated using a random effects model.

Incidence of Confirmed CES in Patients Suspected of Having CES

Eighteen studies reported the proportion of patients presenting with signs and symptoms suspicious for CES who had clinical and radiological confirmation of CES. The study details are shown in Table 3. Ten studies included only patients undergoing MRI for suspected CES.3,6,11,13,15,20,22,25,32,41,47 Two studies included patients undergoing urgent spinal MRI, but did not specify whether this was to investigate CES in every case.1,47 Six studies included all patients referred with suspected CES.4,5,7,27,29,39,45 All studies assessed populations referred to either secondary or tertiary care. Banerjee and Jalgaonkar5 studied only children. All other studies included adult populations but did not state whether they specifically excluded pediatric patients. A diagnosis of CES was established by cauda equina compression on MRI or operative intervention for CES. The imaging type in all studies was MRI. Only 2 studies described findings on MRI defining a diagnosis of CES based on the finding of canal compromise, which was more than 50% in one study29 and more than 75% in the other.26 Three studies stated that cauda equina compression was determined by the reporting radiologist but did not state the criteria used.15,20,32 The cause of cauda equina compression was described in 6 studies. Demetriades et al.13 only included disc prolapses. Five studies included all or some of disc prolapses, tumors, trauma, and hematoma.1,7,11,15,20 One study discussed subtypes of CES (with urinary symptoms or incomplete CES) but did not report the numbers in each group.7 None of the other studies used subcategories or descriptors. Four studies provided information on symptom duration. Urinary symptoms in 2 studies were present for an average of 4 and 5.8 days, and symptoms not further specified were present for between 24 hours and 6 months and a median of 11 days in 2 other papers. Two studies containing small numbers of patients with CES investigated whether any symptoms or signs were predictive of CES. In the 6 patients assessed with bladder scanning, Domen et al. found that urinary retention of > 500 ml plus at least 2 of bilateral sciatica, subjective urinary retention, or rectal incontinence had an odds ratio of 48 for predicting cauda equina compression on MRI.15 In 5 patients with CES, Ahad et al. did not find any predictive symptoms but found that patients with abnormal MRI findings of the spine for back pain prior to CES presentation were significantly more likely to have radiological compression.1 These results are limited in their generalizability by the small numbers of patients involved. The proportion with confirmed CES in those presenting with suspected CES ranged from 0% to 40% in the 18 studies. We excluded the study that included only children5 and combined the other estimates using a random-effects model to give an overall estimate of confirmed CES in 18.9% (95% CI 13.6%–25.6%). The forest plot is shown in Fig. 3. There was a high level of heterogeneity in the study designs and the statistical heterogeneity was high, with I2 = 91.9% (95% CI 88.6%–94.3%) and Q = 197 (p < 0.001).

TABLE 3.

Incidence of CES in patients presenting with suspected CES

Authors & StudyYrs of StudyTime PeriodReference Population: Potential CESDefinition of CESImaging TypeTotal PopulationTotal CasesProportion w/ CES
Bell et al., 2007Not stated4 mosMRI for ?CES, neurosurgery, UKMRI CE compressionMRI23521.7%
Crocker et al., 2008Not stated2 yrsOOH MRI for ?CES, neurosurgery, UKSurgery for CESMRI822732.9%
Demetriades et al., 200920081 yrOOH MRI for ?CES, neurosurgery, UKDisc on MRI & surgery for CESMRI331030.3%
Domen et al., 20092003–20075 yrsUrgent MRI for ?CES neurology/ED, the NetherlandsRadiology report MRI CE compressionMRI58813.8%
Rooney et al., 2009200410 mosMRI for ?CES, neurosurgery, UKSurgery for CESMRI661624.2%
Balasubramanian et al., 201020081 yrMRI for ?CES, spinal surgery, UKRadiology report >75% canal compromiseMRI801518.8%
Thangarajah et al., 20112006–20071 yrUrgent spinal MRI, teaching hospital, UKNot statedMRI8100%
Gooding et al., 201320081 yrMRI for ?CES, hospital w/ spinal unit, UKRadiology report CE compressionMRI571322.8%
Haworth et al., 20132009–20113 yrsOOH MRI for ?CES, neurosurgery, UKMRI CE compressionMRI1623924.1%
Sideris et al., 20142010–20134 yrs?CES, neurosurgery, UKClinical & radiological CESMRI66380*12.0%
Ahad et al., 20152012–20138 mosUrgent spinal MRI, hospital, UKMRI CE compressionMRI7956.3%
Blades et al., 20152008–20147 yrs?CES, spinal unit, UKMRI CE compressionMRI34413740%
Hoeritzauer et al., 20152013–20146 mosUrgent MRI for ?CES spinal unit, UKMRI CE compressionMRI18738.9%
Hoeritzauer et al., 20172013–201416 mos?CES, neurosurgery, UKMRI CE compressionMRI2909131.4%
Kostusiak et al., 20182014–20174 yrsOOH MRI for ?CES, neurosurgery, UKRadiology report CE compressionMRI323154.6%
Hussain et al., 20182013–201414 mos?CES, neurosurgery, UK>50% canal compromise on MRIMRI2503212.8%
Banerjee, 20182014–20163 yrs?CES, district hospital, UKMRI CE compressionMRI43716.3%
Banerjee & Jalgaonkar, 20182012– 20175 yrsChildren (0–15 yrs), ?CES, district hospital, UKMRI CE compressionMRI1500%

?CES = potential CES; CE = cauda equina; OOH = out of hours.

Calculated from paper.

FIG. 3.
FIG. 3.

Forest plot. Proportion and number (events) of patients with confirmed CES among those referred to secondary or tertiary care facilities for assessment for possible CES. Summary proportion calculated using a random effects model.

Study Quality

Study quality assessment is shown in Table 4. All studies described the population being studied and had representative samples. However, definitions of CES and methods used to ascertain the diagnosis of CES varied between studies, and many studies did not adequately describe their methods in a way that could be easily reproduced. Only 2 studies reported excluded patients,40,41 and only 1 study described the excluded patients.40 Only 2 studies calculated confidence intervals for the incidence estimates,23,40 and none reported population-standardized estimates. Of the 26 studies included in this review, 9 were published only in abstract form.4,5,7,13,22,27,30,32,45

TABLE 4.

Study quality and risk of bias in included studies

Authors & StudyTarget Population Clearly DescribedCases From Entire Population Probability SamplingSample Size >300Response Rate >70%Nonresponders Clearly DescribedSample RepresentativeStandardized Data CollectionDiagnostic Criteria DescribedEstimates Given w/ Confidence IntervalsStandardized Estimates Reported
Hurme et al., 1983YesYesYes?NoYesYesNoNoNo
Podnar, 2007YesNoYes?NoYesYesYesNoNo
Schoenfeld & Bader, 2012YesYesYes?NoYesYesYesNoNo
Reito et al., 2018YesYesYesYesYesYesYesYesYesNo
Henschke et al., 2009YesNoYes?NoYesYesYesYesNo
Thiruganasambandamoorthy et al., 2014YesYesYes?NoYesYesNoNoNo
Kiberd et al., 2018YesYesYes?NoYes?NoNoNo
Premkumar et al., 2018YesNoYes?NoYesYesYesNoNo
Bell et al., 2007YesYesNo?NoYesYesYesNoNo
Crocker et al., 2008YesYesNo?NoYesYesNoNoNo
Demetriades et al., 2009YesYesNo?NoYes?YesNoNo
Domen et al., 2009YesYesNo?NoYesYesYesNoNo
Rooney et al., 2009YesYesNoNoNoYesYesYesNoNo
Balasubramanian et al., 2010YesYesNo?NoYesYesYesNoNo
Thangarajah et al., 2011YesYesNo?NoYesNoNoNoNo
Gooding et al., 2013YesYesNo?NoYes?YesNoNo
Haworth et al., 2013YesYesNo?NoYes?NoNoNo
Sideris et al., 2014YesYesYes?NoYesYesNoNoNo
Ahad et al., 2015YesYesNo?NoYesYesNoNoNo
Blades et al., 2015YesYesYes?NoYesYesNoNoNo
Hoeritzauer et al., 2015YesYesNo?NoYesYesYesNoNo
Hoeritzauer et al., 2017YesYesNo?NoYesYesNoNoNo
Banerjee, 2018YesYesNo?NoYes?NoNoNo

? = no information given.

Studies were assessed against the 11 prespecified criteria.

Studies of patients with suspected CES were of particularly poor quality. They were limited by small sample sizes; only 3 (17%) studies included more than 300 participants,7,32,45 by their retrospective (100%) and single-center design (100%), and by the limited information available, as so many (50%) were published only as an abstract. Of the 18 studies of patients with suspected CES, all but one were from the UK.

Discussion

This is the first systematic review of studies estimating the incidence of CES; 26 studies were included. The incidence of CES is low, at fewer than 1 per 100,000 people in asymptomatic populations per year. Only 0.27% of those with low-back pain and only 18.9% of those with signs and symptoms consistent with CES will have a final diagnosis of radiological and clinical CES.

This review identified a paucity of literature on the incidence of CES. We included all studies from which incidence of CES could be calculated, but few of the studies had a primary aim to calculate incidence. Many did not meet expected epidemiological standards, as can be seen from Table 4. Sample sizes were small in symptomatic populations and estimates did not have confidence intervals and were not standardized for the populations. Few studies described exclusions or missing data. Nine studies were only published in abstract form and provided fewer methodological details and had not been through the peer-review process. All abstracts and full-text articles were screened by at least 2 reviewers, and we only identified 7 additional studies1,11,15,20,25,47,48 through searching reference lists and citations. We are confident that these methods should not have missed any further important studies on this topic.

The criteria used to establish a diagnosis of CES were described in only 13 of the 26 studies, and only 2 studies subdivided CES into clinical categories.40 Diagnosis was determined through clinical coding, record review, urgent operative intervention, radiology reports, clinical assessment, or any combination of these. The variation in definitions and reporting of diagnostic criteria likely reflects the lack of agreed definitions and multiple classifications of CES in use clinically and in the literature.18 The lack of specific clinical phenotyping covered by a broad CES definition hampers accurate assessment of incidence and contributes to the statistical heterogeneity as the incidence will likely differ depending on the definition and case ascertainment methods used. Adopting agreed-on definitions or defining subtypes such as those listed by Todd and Dickson50 might enable more consistent reporting in future studies and allow more accurate incidence figures to be established.

One study was carried out in Australia,23 4 studies were carried out in North America,30,38,43,48 and the remaining studies were in European populations. It is not known whether these estimates are relevant outside the populations and healthcare settings studied. Location may determine the availability of imaging and clinical threshold for investigation. All but one15 study reporting the proportion of patients with CES from those with suspected CES were carried out in the UK. This may reflect the interest in determining the yield of MRI scanning for suspected CES in a healthcare setting where access to out-of-hours MRI is not always readily available. Guidance from the British Association of Spine Surgeons recommends an emergency MRI for suspected CES, and yet only 14% of hospitals in England and Wales surveyed in 2012 reported 24-hour access to MRI.21 As clinical symptoms and signs in those with radiological cauda equina compression are very difficult to distinguish from those without cauda equina compression,17 this leads to a situation in which many patients are transferred to specialist centers for MRI outside office hours and then either transferred back or discharged from locations that can be far from home. In healthcare settings with pressure on MRI services, such as the UK, the threshold for investigating patients with MRI for suspected CES may be higher than in a situation in which MRI is quickly and readily available 24 hours a day. It is not known whether easy access to MRI correlates with a lower diagnostic yield of positive scans for cauda equina compression on MRI due to an increased overall number of patients undergoing MRI.

Healthcare service planning for the investigation and management of CES needs to balance the needs of the majority population with the few CES cases in whom a missed diagnosis or delayed treatment could have significant health and social care consequences for the patient plus medicolegal consequences for the surgeon and healthcare service. Different medicolegal implications in different countries may affect the threshold for investigating and diagnosing CES, which will ultimately affect estimates of incidence. Between 2013 and 2016, there were 131 claims relating to CES in the UK, with a projected value of 68 million.34 These were most commonly due to delay in diagnosis or treatment.34 In the US, the average payout of 15 lawsuits related to CES between 1983 and 2010 was $1.57 million.12 It is unknown whether the frequency of legal action for CES in a country is associated with the clinical threshold for investigation of symptoms with an MRI study, as all but one study of patients with suspected CES were carried out in the UK. The high legal costs to the health service of a missed case must be weighed against the costs involved in implementing systems to ensure timely MRI in patients with suspected CES.

Most patients investigated for suspected CES do not have radiological compression on MRI. Although final diagnoses in patients without cauda equina compression include demyelination, myelitis, and infection, a structural cause is not found in the majority of patients.26 Further characterization of these patients to identify potentially distinguishing features such as Hoover’s sign of functional weakness26 could increase the yield of MRI for suspected CES. However, due to the significance of a missed diagnosis, expansion of local out-of-hours MRI provision is more likely to improve care for those investigated for CES with and without structural radiological cauda equina compression. Local MRI services would avoid unnecessary transfer of patients to tertiary services that they do not require.

Conclusions

CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Major limitations in the published literature make it difficult to provide evidence-based services for patients with CES. Multicenter and international studies are required. However, before these can occur, a consensus definition of CES, including clinical and radiological criteria, is needed to allow comparison across centers and throughout the literature.

Acknowledgments

We thank Sheila Fisken, University of Edinburgh librarian, for her support in designing and developing the search strategy.

Appendix

Search Strategies

Ovid EMBASE: 1980 to 2018 week 31

  • 1) Cauda equina syndrome/
  • 2) cauda equina.ti,ab.
  • 3) Cauda Equina/
  • 4) 1 OR 2 OR 3
  • 5) Incidence/ OR Prevalence/
  • 6) Epidemiology/
  • 7) incidence* OR prevalen* OR epidemiolog* OR frequenc* OR rate* OR occurrence*).ti,ab
  • 8) 5 OR 6 OR 7
  • 9) 4 And 8

Scopus: July 30, 2018

  • 1) “cauda equina”
  • 2) (incidence* OR prevalen* OR epidemiolog* OR frequenc* OR rate* OR occurrence*)
  • 3) 1 AND 2

Disclosures

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

Author Contributions

Conception and design: Woodfield, Hoeritzauer, Demetriades. Acquisition of data: Woodfield, Hoeritzauer, Wood, Copley. Analysis and interpretation of data: Woodfield, Hoeritzauer, Wood, Copley. Drafting the article: Woodfield, Hoeritzauer, Wood, Copley. Critically revising the article: Woodfield, Hoeritzauer, Demetriades. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Woodfield. Statistical analysis: Woodfield, Wood. Administrative/technical/material support: Hoeritzauer, Wood. Study supervision: Woodfield, Hoeritzauer, Demetriades.

Supplemental Information

Previous Presentations

Portions of this paper were presented in poster form at the Society of British Neurological Surgeons, April 11, 2018, Plymouth, United Kingdom.

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    • Export Citation
  • 6

    Bell DA, Collie D, Statham PF: Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 21:201203, 2007

    • Search Google Scholar
    • Export Citation
  • 7

    Blades D, Heyes G, Robinson K, Eames N: Timing of treatment of cauda equina syndrome at a national treatment centre. Eur Spine J 24:S723, 2015 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 8

    Boyle MH: Guidelines for evaluating prevalence studies. Evid Based Ment Health 1:3739, 1998

  • 9

    Chau AM, Xu LL, Pelzer NR, Gragnaniello C: Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurg 81:640650, 2014

    • Search Google Scholar
    • Export Citation
  • 10

    Clopper CJ, Pearson ES: The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika 26:404413, 1934

  • 11

    Crocker M, Fraser G, Boyd E, Wilson J, Chitnavis BP, Thomas NW: The value of interhospital transfer and emergency MRI for suspected cauda equina syndrome: a 2-year retrospective study. Ann R Coll Surg Engl 90:513516, 2008

    • Search Google Scholar
    • Export Citation
  • 12

    Daniels EW, Gordon Z, French K, Ahn UM, Ahn NU: Review of medicolegal cases for cauda equina syndrome: what factors lead to an adverse outcome for the provider? Orthopedics 35:e414e419, 2012

    • Search Google Scholar
    • Export Citation
  • 13

    Demetriades AK, Broughton E, Akinwunmi J, Critchley G, Gunasekera L, Norris 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 23:475, 2009 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 14

    DerSimonian R, Laird N: Meta-analysis in clinical trials. Control Clin Trials 7:177188, 1986

  • 15

    Domen PM, Hofman PA, van Santbrink H, Weber WEJ: Predictive value of clinical characteristics in patients with suspected cauda equina syndrome. Eur J Neurol 16:416419, 2009

    • Search Google Scholar
    • Export Citation
  • 16

    Etemadifar M, Nasr Z, Khalili B, Taherioun M, Vosoughi R: Epidemiology of neuromyelitis optica in the world: a systematic review and meta-analysis. Mult Scler Int 2015:174720, 2015

    • Search Google Scholar
    • Export Citation
  • 17

    Fairbank J, Hashimoto R, Dailey A, Patel AA, Dettori JR: Does patient history and physical examination predict MRI proven cauda equina syndrome? Evid Based Spine Care J 2:2733, 2011

    • Search Google Scholar
    • Export Citation
  • 18

    Fraser S, Roberts L, Murphy E: Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil 90:19641968, 2009

    • Search Google Scholar
    • Export Citation
  • 19

    Germon T, Ahuja S, Casey AT, Todd NV, Rai A: British Association of Spine Surgeons standards of care for cauda equina syndrome. Spine J 15 (3 Suppl):S2S4, 2015

    • Search Google Scholar
    • Export Citation
  • 20

    Gooding BWT, Higgins MA, Calthorpe DAD: Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome? Br J Neurosurg 27:156159, 2013

    • Search Google Scholar
    • Export Citation
  • 21

    Hauptfleisch J, Meagher TM, King D, López de Heredia L, Hughes RJ: Out-of-hours MRI provision in the UK and models of service delivery. Clin Radiol 68:e245e248, 2013

    • Search Google Scholar
    • Export Citation
  • 22

    Haworth AE, Bhojak M, Wilby M, Das K, Clark 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 27:281, 2013 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 23

    Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, : Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 60:30723080, 2009

    • Search Google Scholar
    • Export Citation
  • 24

    Higgins JPT, Thompson SG: Quantifying heterogeneity in a meta-analysis. Stat Med 21:15391558, 2002

  • 25

    Hoeritzauer I, Doherty CM, Thomson S, Kee R, Carson A, Eames N, : ‘Scan-negative’ cauda equina syndrome: evidence of functional disorder from a prospective case series. Br J Neurosurg 29:178180, 2015

    • Search Google Scholar
    • Export Citation
  • 26

    Hoeritzauer I, Pronin S, Carson A, Statham P, Demetriades AK, Stone 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 265:29162926, 2018

    • Search Google Scholar
    • Export Citation
  • 27

    Hoeritzauer I, Pronin S, Carson A, Statham P, Stone J, Demetriades AK: Investigating the patients who present more than once with cauda equina syndrome symptoms. Spine J 17:S27, 2017

    • Search Google Scholar
    • Export Citation
  • 28

    Hurme M, Alaranta H, Törmä T, Einola S: Operated lumbar disc herniation: epidemiological aspects. Ann Chir Gynaecol 72:3336, 1983

  • 29

    Hussain MM, Razak AA, Hassan SS, Choudhari KA, Spink GM: Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals. Br J Neurosurg 32:264268, 2018

    • Search Google Scholar
    • Export Citation
  • 30

    Kiberd J, Hayden J, Magee K, Campbell S: Utility of red flags to identify serious spinal pathology in patients with low back pain: a retrospective analysis. CJEM 20 (Suppl 1):S33–S34, 2018

    • Search Google Scholar
    • Export Citation
  • 31

    Korse NS, Veldman AB, Peul WC, Vleggeert-Lankamp CLA: The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome. PLoS One 12:e0175987, 2017

    • Search Google Scholar
    • Export Citation
  • 32

    Kostusiak M, Gnanakumar S, Laing R: Incidence of cauda equina syndrome in patients transferred from district general hospitals to tertiary centre for out of hours MRI. Br J Neurosurg 32:81, 2018 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 33

    Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW: Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can 19:170176, 1998

    • Search Google Scholar
    • Export Citation
  • 34

    Machin JT, Hardman J, Harrison W, Briggs TWR, Hutton M: Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS. Eur Spine J 27:26932699, 2018

    • Search Google Scholar
    • Export Citation
  • 35

    Marrie RA, Cohen J, Stuve O, Trojano M, Sørensen PS, Reingold S, : A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview. Mult Scler 21:263281, 2015

    • Search Google Scholar
    • Export Citation
  • 36

    Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097, 2009

    • Search Google Scholar
    • Export Citation
  • 37

    Podnar S: Epidemiology of cauda equina and conus medullaris lesions. Muscle Nerve 35:529531, 2007

  • 38

    Premkumar A, Godfrey W, Gottschalk MB, Boden 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 100:368374, 2018

    • Search Google Scholar
    • Export Citation
  • 39

    Razak A, Hassan S, Brown D, Hussain M: Who ‘owns’ suspected cauda equina patients? Br J Neurosurg 31:136, 2017 (Abstract)

  • 40

    Reito A, Kyrölä K, Pekkanen L, Paloneva J: Specific spinal pathologies in adult patients with an acute or subacute atraumatic low back pain in the emergency department. Int Orthop 42:28432849, 2018

    • Search Google Scholar
    • Export Citation
  • 41

    Rooney A, Statham PF, Stone J: Cauda equina syndrome with normal MR imaging. J Neurol 256:721725, 2009

  • 42

    Schoenfeld AJ: Incidence and epidemiology of cauda equina syndrome: a review of 976 patients from a complete American population. Spine J 12:100S101S, 2012

    • Search Google Scholar
    • Export Citation
  • 43

    Schoenfeld AJ, Bader JO: Cauda equina syndrome: an analysis of incidence rates and risk factors among a closed North American military population. Clin Neurol Neurosurg 114:947950, 2012

    • Search Google Scholar
    • Export Citation
  • 44

    Schwarzer G, Carpenter JR, Rucker G: Meta-Analysis With R, ed 1. Berlin: Springer International Publishing, 2015

  • 45

    Sideris M, Moore E, Sakthithasan M, Williams AP, Whitfield 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:S54, 2014

    • Search Google Scholar
    • Export Citation
  • 46

    Srikandarajah N, Boissaud-Cooke MA, Clark S, Wilby MJ: Does early surgical decompression in cauda equina syndrome improve bladder outcome? Spine (Phila Pa 1976) 40:580583, 2015

    • Search Google Scholar
    • Export Citation
  • 47

    Thangarajah T, O’Donoghue D, Pillay 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 93:7680, 2011

    • Search Google Scholar
    • Export Citation
  • 48

    Thiruganasambandamoorthy V, Turko E, Ansell D, Vaidyanathan A, Wells GA, Stiell IG: Risk factors for serious underlying pathology in adult emergency department nontraumatic low back pain patients. J Emerg Med 47:111, 2014

    • 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 25:503508, 2011

    • Search Google Scholar
    • Export Citation
  • 50

    Todd NV, Dickson RA: Standards of care in cauda equina syndrome. Br J Neurosurg 30:518522, 2016

If the inline PDF is not rendering correctly, you can download the PDF file here.

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.

  • View in gallery

    PRISMA flow diagram. Studies identified, included, and excluded.

  • View in gallery

    Forest plot. Proportion and number (events) of patients with CES among those presenting with nontraumatic low-back pain to secondary care. Summary proportion calculated using a random effects model.

  • View in gallery

    Forest plot. Proportion and number (events) of patients with confirmed CES among those referred to secondary or tertiary care facilities for assessment for possible CES. Summary proportion calculated using a random effects model.

  • 1

    Ahad A, Elsayed M, Tohid H: The accuracy of clinical symptoms in detecting cauda equina syndrome in patients undergoing acute MRI of the spine. Neuroradiol J 28:438442, 2015

    • Search Google Scholar
    • Export Citation
  • 2

    Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP: Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine (Phila Pa 1976) 25:15151522, 2000

    • Search Google Scholar
    • Export Citation
  • 3

    Balasubramanian K, Kalsi P, Greenough CG, Kuskoor Seetharam MP: Reliability of clinical assessment in diagnosing cauda equina syndrome. Br J Neurosurg 24:383386, 2010

    • 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):277S278S, 2018 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 5

    Banerjee P, Jalgaonkar A: Back pain with bladder/bowel dysfunction in a child—is this cauda equina syndrome. Global Spine J 8 (1 Suppl 1):262S, 2018 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 6

    Bell DA, Collie D, Statham PF: Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 21:201203, 2007

    • Search Google Scholar
    • Export Citation
  • 7

    Blades D, Heyes G, Robinson K, Eames N: Timing of treatment of cauda equina syndrome at a national treatment centre. Eur Spine J 24:S723, 2015 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 8

    Boyle MH: Guidelines for evaluating prevalence studies. Evid Based Ment Health 1:3739, 1998

  • 9

    Chau AM, Xu LL, Pelzer NR, Gragnaniello C: Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurg 81:640650, 2014

    • Search Google Scholar
    • Export Citation
  • 10

    Clopper CJ, Pearson ES: The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika 26:404413, 1934

  • 11

    Crocker M, Fraser G, Boyd E, Wilson J, Chitnavis BP, Thomas NW: The value of interhospital transfer and emergency MRI for suspected cauda equina syndrome: a 2-year retrospective study. Ann R Coll Surg Engl 90:513516, 2008

    • Search Google Scholar
    • Export Citation
  • 12

    Daniels EW, Gordon Z, French K, Ahn UM, Ahn NU: Review of medicolegal cases for cauda equina syndrome: what factors lead to an adverse outcome for the provider? Orthopedics 35:e414e419, 2012

    • Search Google Scholar
    • Export Citation
  • 13

    Demetriades AK, Broughton E, Akinwunmi J, Critchley G, Gunasekera L, Norris 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 23:475, 2009 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 14

    DerSimonian R, Laird N: Meta-analysis in clinical trials. Control Clin Trials 7:177188, 1986

  • 15

    Domen PM, Hofman PA, van Santbrink H, Weber WEJ: Predictive value of clinical characteristics in patients with suspected cauda equina syndrome. Eur J Neurol 16:416419, 2009

    • Search Google Scholar
    • Export Citation
  • 16

    Etemadifar M, Nasr Z, Khalili B, Taherioun M, Vosoughi R: Epidemiology of neuromyelitis optica in the world: a systematic review and meta-analysis. Mult Scler Int 2015:174720, 2015

    • Search Google Scholar
    • Export Citation
  • 17

    Fairbank J, Hashimoto R, Dailey A, Patel AA, Dettori JR: Does patient history and physical examination predict MRI proven cauda equina syndrome? Evid Based Spine Care J 2:2733, 2011

    • Search Google Scholar
    • Export Citation
  • 18

    Fraser S, Roberts L, Murphy E: Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil 90:19641968, 2009

    • Search Google Scholar
    • Export Citation
  • 19

    Germon T, Ahuja S, Casey AT, Todd NV, Rai A: British Association of Spine Surgeons standards of care for cauda equina syndrome. Spine J 15 (3 Suppl):S2S4, 2015

    • Search Google Scholar
    • Export Citation
  • 20

    Gooding BWT, Higgins MA, Calthorpe DAD: Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome? Br J Neurosurg 27:156159, 2013

    • Search Google Scholar
    • Export Citation
  • 21

    Hauptfleisch J, Meagher TM, King D, López de Heredia L, Hughes RJ: Out-of-hours MRI provision in the UK and models of service delivery. Clin Radiol 68:e245e248, 2013

    • Search Google Scholar
    • Export Citation
  • 22

    Haworth AE, Bhojak M, Wilby M, Das K, Clark 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 27:281, 2013 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 23

    Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, : Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 60:30723080, 2009

    • Search Google Scholar
    • Export Citation
  • 24

    Higgins JPT, Thompson SG: Quantifying heterogeneity in a meta-analysis. Stat Med 21:15391558, 2002

  • 25

    Hoeritzauer I, Doherty CM, Thomson S, Kee R, Carson A, Eames N, : ‘Scan-negative’ cauda equina syndrome: evidence of functional disorder from a prospective case series. Br J Neurosurg 29:178180, 2015

    • Search Google Scholar
    • Export Citation
  • 26

    Hoeritzauer I, Pronin S, Carson A, Statham P, Demetriades AK, Stone 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 265:29162926, 2018

    • Search Google Scholar
    • Export Citation
  • 27

    Hoeritzauer I, Pronin S, Carson A, Statham P, Stone J, Demetriades AK: Investigating the patients who present more than once with cauda equina syndrome symptoms. Spine J 17:S27, 2017

    • Search Google Scholar
    • Export Citation
  • 28

    Hurme M, Alaranta H, Törmä T, Einola S: Operated lumbar disc herniation: epidemiological aspects. Ann Chir Gynaecol 72:3336, 1983

  • 29

    Hussain MM, Razak AA, Hassan SS, Choudhari KA, Spink GM: Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals. Br J Neurosurg 32:264268, 2018

    • Search Google Scholar
    • Export Citation
  • 30

    Kiberd J, Hayden J, Magee K, Campbell S: Utility of red flags to identify serious spinal pathology in patients with low back pain: a retrospective analysis. CJEM 20 (Suppl 1):S33–S34, 2018

    • Search Google Scholar
    • Export Citation
  • 31

    Korse NS, Veldman AB, Peul WC, Vleggeert-Lankamp CLA: The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome. PLoS One 12:e0175987, 2017

    • Search Google Scholar
    • Export Citation
  • 32

    Kostusiak M, Gnanakumar S, Laing R: Incidence of cauda equina syndrome in patients transferred from district general hospitals to tertiary centre for out of hours MRI. Br J Neurosurg 32:81, 2018 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 33

    Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW: Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can 19:170176, 1998

    • Search Google Scholar
    • Export Citation
  • 34

    Machin JT, Hardman J, Harrison W, Briggs TWR, Hutton M: Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS. Eur Spine J 27:26932699, 2018

    • Search Google Scholar
    • Export Citation
  • 35

    Marrie RA, Cohen J, Stuve O, Trojano M, Sørensen PS, Reingold S, : A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview. Mult Scler 21:263281, 2015

    • Search Google Scholar
    • Export Citation
  • 36

    Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097, 2009

    • Search Google Scholar
    • Export Citation
  • 37

    Podnar S: Epidemiology of cauda equina and conus medullaris lesions. Muscle Nerve 35:529531, 2007

  • 38

    Premkumar A, Godfrey W, Gottschalk MB, Boden 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 100:368374, 2018

    • Search Google Scholar
    • Export Citation
  • 39

    Razak A, Hassan S, Brown D, Hussain M: Who ‘owns’ suspected cauda equina patients? Br J Neurosurg 31:136, 2017 (Abstract)

  • 40

    Reito A, Kyrölä K, Pekkanen L, Paloneva J: Specific spinal pathologies in adult patients with an acute or subacute atraumatic low back pain in the emergency department. Int Orthop 42:28432849, 2018

    • Search Google Scholar
    • Export Citation
  • 41

    Rooney A, Statham PF, Stone J: Cauda equina syndrome with normal MR imaging. J Neurol 256:721725, 2009

  • 42

    Schoenfeld AJ: Incidence and epidemiology of cauda equina syndrome: a review of 976 patients from a complete American population. Spine J 12:100S101S, 2012

    • Search Google Scholar
    • Export Citation
  • 43

    Schoenfeld AJ, Bader JO: Cauda equina syndrome: an analysis of incidence rates and risk factors among a closed North American military population. Clin Neurol Neurosurg 114:947950, 2012

    • Search Google Scholar
    • Export Citation
  • 44

    Schwarzer G, Carpenter JR, Rucker G: Meta-Analysis With R, ed 1. Berlin: Springer International Publishing, 2015

  • 45

    Sideris M, Moore E, Sakthithasan M, Williams AP, Whitfield 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:S54, 2014

    • Search Google Scholar
    • Export Citation
  • 46

    Srikandarajah N, Boissaud-Cooke MA, Clark S, Wilby MJ: Does early surgical decompression in cauda equina syndrome improve bladder outcome? Spine (Phila Pa 1976) 40:580583, 2015

    • Search Google Scholar
    • Export Citation
  • 47

    Thangarajah T, O’Donoghue D, Pillay 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 93:7680, 2011

    • Search Google Scholar
    • Export Citation
  • 48

    Thiruganasambandamoorthy V, Turko E, Ansell D, Vaidyanathan A, Wells GA, Stiell IG: Risk factors for serious underlying pathology in adult emergency department nontraumatic low back pain patients. J Emerg Med 47:111, 2014

    • 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 25:503508, 2011

    • Search Google Scholar
    • Export Citation
  • 50

    Todd NV, Dickson RA: Standards of care in cauda equina syndrome. Br J Neurosurg 30:518522, 2016

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