Thanks for reading the 64th edition of my newsletter. This newsletter tracks my work on lumbar nerve root syndromes aka sciatica.
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Hi everyone,
I was recently asked to compile a reading list on CES for the BritSpine conference. The full reading list is here. I thought it would also be fun to put together a ‘starter for 10’ list - if you’ve not delved into the literature on CES before, which ten papers should you start with?
First you want to get a handle on what CES actually is, beyond that list of red flags we can all repeat in our sleep!
For that, Fraser et al. (2009): Cauda Equina Syndrome: A Literature Review of Its Definition and Clinical Presentation gives some nice background about how this thing we call ‘CES’ has been described and defined over the years. And Lavy et al. (2021): Cauda equina syndrome—a practical guide to definition and classification puts a nice bow around it all, while also describing the all-important ‘stages’ of CES.
Next, you’ll want to know how to look out for CES in your practice. Of all the terrific papers by this research team, Assessment and management of cauda equina syndrome by Sue Greenhalgh and colleagues is probably the most comprehensive. Next, you’d do well to read two sets of guidlines, firstly The British Association of Spine Surgeons standards of care for cauda equina syndrome by Germon and colleagues (2015) and secondly Getting it Right First Time: National Suspected Cauda Equina Syndrome Pathway compiled by Mike Hutton and many others, and released just this year. Full disclosure, I haven’t read the latter myself yet, but it’s clearly going to be the North Star for practice for the next few years, in the UK at least.
Next, here’s a good high-level review: Gardner et al. (2011): Cauda equina syndrome: a review of the current clinical and medico-legal position. It includes a nice history of the debate about the timing of surgery (not many people know there was quite recently an argument that you could delay surgery even for acute CES).
Going back to that list of red flags we could all repeat in our sleep, Rob and I are always banging the drum about how important it is to know that you don’t need a ‘full house’ of red flags, that you just need one card; and that many of the red flags we look out for are in fact end-stage CES, when we should be aquianting ourselves with the earlier, more subtle symptoms. I think two good papers to help work out how CES actually presents are Angus et al. (2021): Determination of potential risk characteristics for cauda equina compression in emergency department patients presenting with atraumatic back pain: a 4-year retrospective cohort analysis and Woodfield et al. (2023): Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: a multi-centre prospective cohort study. They’re similar; I reviewed them here.
What happens to your patient in the emergency room? If they’re lucky, they get an and MRI; they might instead (or also) get a bladder scan and, if they’re unlucky, a digital rectal exam. What’s all that about? A good paper on the digital rectal exam, at least, is Tabrah et al. (2022): Can digital rectal examination be used to detect cauda equina compression in people presenting with acute cauda equina syndrome? A systematic review and meta-analysis.
Most people referred for an emergency assessment for CES don’t actually have it. To understand why someone might really, really seem like they have CES but have a pristine MRI scan, read Hoeritzauer et al. (2021): 'Scan-negative' cauda equina syndrome: what to do when there is no neurosurgical cause.
Finally, I’m a big fan of reading historical papers, which always give the best clinical descriptions and always seem to illuminate something elusive about a topic that modern papers just don’t. There are a few on CES, but a good one to start with is Shephard (1959): Diagnosis and Prognosis of Cauda Equina Syndrome Produced by Protrusion of Lumbar Disk (which I reviewed here).
And that makes 10! Note that you can click on the paper names to open a pdf…
Again, the full reading list is here - I am happy to share any pdfs from that, too. Just reply to this email.
Til next time,
Tom
P.S. All this research and more is synthesised in our book, Cauda Equina Syndrome, The MSK Clinician’s Guide.