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January 19, 2021; 96 (3) Article

Scan-Negative Cauda Equina Syndrome

A Prospective Cohort Study

View ORCID ProfileIngrid Hoeritzauer, View ORCID ProfileAlan Carson, View ORCID ProfilePatrick Statham, View ORCID ProfileJalesh N. Panicker, Voula Granitsiotis, Maria Eugenicos, View ORCID ProfileDavid Summers, View ORCID ProfileAndreas K. Demetriades, View ORCID ProfileJon Stone
First published November 11, 2020, DOI: https://doi.org/10.1212/WNL.0000000000011154
Ingrid Hoeritzauer
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Alan Carson
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Patrick Statham
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Jalesh N. Panicker
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Voula Granitsiotis
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Maria Eugenicos
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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David Summers
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Andreas K. Demetriades
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Jon Stone
From the Centre for Clinical Brain Sciences (I.H., A.C., A.K.D., J.S.), University of Edinburgh;Departments of Clinical Neurosciences (I.H., A.C., P.S., A.K.D., J.S.), Neurosurgery (P.S., A.K.D.), Urology (V.G.), Gastroenterology (M.E.), and Neuroradiology (D.S.), Western General Hospital;Department of Rehabilitation Medicine (A.C.), NHS Lothian, Edinburgh;Department of Uro-Neurology (J.N.P.), The National Hospital of Neurology and Neurosurgery and UCL Queen Square Institute of Neurology, London; andEdinburgh Spinal Surgery Outcomes Study Group (I.H., P.S., A.K.D.), UK.
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Citation
Scan-Negative Cauda Equina Syndrome
A Prospective Cohort Study
Ingrid Hoeritzauer, Alan Carson, Patrick Statham, Jalesh N. Panicker, Voula Granitsiotis, Maria Eugenicos, David Summers, Andreas K. Demetriades, Jon Stone
Neurology Jan 2021, 96 (3) e433-e447; DOI: 10.1212/WNL.0000000000011154

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Abstract

Objective To describe clinical features relevant to diagnosis, mechanism, and etiology in patients with “scan-negative” cauda equina syndrome (CES).

Methods We carried out a prospective study of consecutive patients presenting with the clinical features of CES to a regional neurosurgery center comprising semi-structured interview and questionnaires investigating presenting symptoms, neurologic examination, psychiatric and functional disorder comorbidity, bladder/bowel/sexual function, distress, and disability.

Results A total of 198 patients presented consecutively over 28 months. A total of 47 were diagnosed with scan-positive CES (mean age 48 years, 43% female). A total of 76 mixed category patients had nerve root compression/displacement without CES compression (mean age 46 years, 71% female) and 61 patients had scan-negative CES (mean age 40 years, 77% female). An alternative neurologic cause of CES emerged in 14/198 patients during admission and 4/151 patients with mean duration 25 months follow-up. Patients with scan-negative CES had more positive clinical signs of a functional neurologic disorder (11% scan-positive CES vs 34% mixed and 68% scan-negative, p < 0.0001), were more likely to describe their current back pain as worst ever (41% vs 46% and 70%, p = 0.005), and were more likely to have symptoms of a panic attack at onset (37% vs 57% and 70%, p = 0.001). Patients with scan-positive CES were more likely to have reduced/absent bilateral ankle jerks (78% vs 30% and 12%, p < 0.0001). There was no significant difference between groups in the frequency of reduced anal tone and urinary retention.

Conclusion The first well-phenotyped, prospective study of scan-negative CES supports a model in which acute pain, medication, and mechanisms overlapping with functional neurologic disorders may be relevant.

Glossary

ACE=
Adverse Childhood Experiences;
ASEX=
Arizona Sexual Experiences Questionnaire;
AVM=
arteriovenous malformation;
CES=
cauda equina syndrome;
CI=
confidence interval;
DSM-IV=
Diagnostic and Statistical Manual of Mental Disorders, 4th edition;
DSM-5=
Diagnostic and Statistical Manual of Mental Disorders, 5th edition;
FND=
functional neurologic disorder;
HADS=
Hospital Anxiety and Depression Scale;
NBDS=
Neurogenic Bowel Dysfunction Score;
OR=
odds ratio;
PHQ-15=
Patient Health Questionnaire Somatic Symptom Severity Score;
PTSD=
posttraumatic stress disorder;
RR=
relative risk;
SF-12=
Short Form–12;
USP=
Urinary Symptom Profile;
WSAS=
Work and Social Adjustment Scale

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • CME Course: NPub.org/cmelist

  • Received January 29, 2020.
  • Accepted in final form September 4, 2020.
  • © 2020 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Reader Response: Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study
    • Nathan Beucler, Neurosurgery resident, Sainte-Anne Military Teaching Hospital, Toulon, France
    Submitted February 28, 2021
  • Author Response: “Scan-negative” cauda equina syndrome: A prospective cohort study
    • Ingrid Hoeritzauer, Neurologist, 1. Centre for Clinical Brain Sciences, University of Edinburg, UK 2. Department of Clinical Neurosciences, Royal Infirmary
    • Alan Carson, Professor of Neuropsychiatry, 1. Centre for Clinical Brain Sciences, University of Edinburgh 2. Department of Clinical Neurosciences, Royal Infirmary Hospital
    • Patrick Statham, Consultant Neurosurgeon, 1. Department of Neurosurgery, Royal Infirmary Hospital Edinburgh, UK 2. Department of Clinical Neurosciences, Royal Infirmary
    • Andreas Demetriades, Consultant Neurosurgeon, 1. Department of Neurosurgery, Royal Infirmary Edinburgh, UK
    • Jon Stone, Professor of Neurology, 1. Centre for Clinical Brain Sciences, University of Edinburg, UK 2. Department of Clinical Neurosciences, Royal Infirmary
    Submitted January 04, 2021
  • Reader response: “Scan-negative” cauda equina syndrome: A prospective cohort study
    • Aymeric Amelot, neurosurgeon and specialist of medullar cord lesion, Département de Neurochirurgie, Hôpital de Bretonneau, Tours, France and INSERM U1253, faculté de Tours, France, Tours
    • Alexia Planty-Bonjour, Neurosurgeon, Département de Neurochirurgie, Hôpital de Bretonneau, Tours, France and INSERM U1253, faculté de Tours, France, Tours
    • Louis-Marie Terrier, Neurosurgeon and neurophysiologist, Département de Neurochirurgie, Hôpital de Bretonneau, Tours, France and INSERM U1253, faculté de Tours, France, Tours
    Submitted December 17, 2020
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