Cauda Equina Syndrome

We prospectively evaluated the association between the diagnosis of LSS and clinical information, including the history and physical examination of patients with leg symptoms. This study was performed in six university hospitals, ten medical centers, and sixty eight hospitals and clinics affiliated with university hospitals or medical centers during July and September in 2004. We enrolled consecutive patients older than 20 years of age with primary symptoms of pain or numbness in the legs. We excluded patients who have been treated by some medical practices within one year before examination. Patients with cervical myelopathy, previous surgery, degenerative scoliosis (defined as lateral tilting of more than 10 degrees) and inflammatory disorders were also excluded. This study included 250 patients who complained of leg symptoms, including cases of LSS (n = 165), lumbar disc herniation (n = 61), diabetic neuropathy (n = 13), and peripheral vascular disease (n = 11) (Table 3). The study was approved by the institutional review board of each study institution as necessary. Written informed consent was obtained from the all patients. The patients gave informed consent and then answered the SSHQ. The following steps were taken to reach a final diagnosis for each of the enrolled patients (Figure 1). In the first step, at each institution the orthopedic physician who saw a patient made the clinical diagnosis based on the history, physical examination, and radiographic findings. In addition, to verify the diagnosis made by each physician, six board-certified spine surgeons approved by the Japanese Board of Spine Surgery also made a diagnosis for each patient based on the clinical information and findings of the MRI. The opinions of six board-certified spine surgeons approved by the Japanese Board of Spine Surgery were used as the gold standard for diagnosis of LSS. The radicular type was characterized by symptoms of pain, burning, numbness, and paresthesias following a specific dermatome with radiological evidence of the responsible nerve root compression, which was confirmed if intermittent claudication was abolished following single nerve root infiltration. Patients of the cauda equina type presented some bilateral symptoms related to cauda equina compression syndrome with less dermatomal-specific neurogenic claudication and radiological evidence of cauda equina compression.
The sensitivity, specificity, likelihood ratio, and area under the receiver operating characteristic (ROC) curve were estimated. 217 patients classified by investigators as suffering from lower back pain without a significant change in symptoms were given the SSHQ two weeks later during an outpatient visit, and the test-retest reliability over two weeks was investigated in these patients.

The eligibility criteria for study selection used in this review are summarised in Table 1. Titles were initially screened by one reviewer (SS). When eligibility could not be determined on the basis of the title, abstracts were reviewed. To select full text papers, two reviewers (SS, KK) independently screened titles and abstracts of the remaining citations. Any disagreements were resolved through discussion and consensus. Selected full text papers and additional papers identified in reference lists of the included full text papers were screened by the same two reviewers and final agreement was reached on which papers to be included in the review.Table 1

Study eligibility criteria

Published studies were included if they fulfilled any of the following criteria:

• Developed and described an original classification system for back pain that included adult patients with low back related leg pain (LBLP). Leg pain was defined as pain below the gluteal fold. • Adapted an existing classification system that was designed for or included LBLP patients. • Provided approaches to appraising or validating an existing classification system for LBLP.

Exclusion criteria:

• Studies looking at specific spinal “red flag” conditions such as cauda equina syndrome, tumours or spinal fractures or a specific disease cohort such as diabetes. • Studies that only used expensive or advanced investigations or technology more likely to be feasible for secondary care settings (e.g. electromyography, surgical findings, imaging or expensive kinematic equipment) for classification of patients. • Case studies and case series design studies.

After approval by the ethics committee in our hospital, a retrospective review of 247 consecutive patients who were diagnosed with DLS between January 2019 and December 2021 was performed. All patients were recruited from outpatient spinal surgery clinics and scheduled to undergo spine surgery. 3D printing molds are used for preoperative planning and surgical simulation.
The inclusion requirements included: (1) L4 DLS; (2) Meyerding grade I or II; and (3) complete radiographic data, including whole-spine anteroposterior and lateral radiographs and lateral flexion and extension X-ray of the lumbar spine.
The exclusion criteria were as follows: (1) multilevel DLS; (2) isthmic spondylolisthesis; (3) history of prior lumbar trauma, tumor, infection, cauda equina syndrome, or revision surgery; and (4) surgery requiring more than two-level instrumentation and fusion.
Demographic data were collected using electronic medical record reviews, including age, gender, height, weight, and body mass index. Overall, 101 patients were ultimately enrolled in the present study.

Multiple village-wide announcements facilitated by village/ward heads (traditional rulers) and adverts via local posters pasted at the research centre and different locations in the community were used to recruit participants until the target sample size was achieved. Potential participants were invited to the primary health care centre and upon their arrival, eligibility was ensured using the stipulated study inclusion and exclusion criteria. The eligibility assessments were carried out by physiotherapists with the use of body charts to identify pain in the lower back, history taking, and screening to rule out ‘red flags’ for low back pain [56 (link)]. All participants provided written informed consent. Inclusion criteria were as follows: (1) male or female between the age of 18 and 70 years, (2) nonspecific low back pain with or without leg pain experienced for 12 weeks or more, and (3) ability to read and understand Hausa or English language or both. Exclusion criteria were: (1) history of spine surgery, (2) obvious spine or limb deformities, (3) serious spinal pathology (e.g. infection, metastases, cauda equina syndrome, and fracture) (4) unstable or severe disabling chronic cardiovascular and pulmonary diseases, (5) inadequate visual and hearing ability, (6) previous physiotherapy treatment in the form of exercise and/or education in the last 3 months, (7) body mass index (BMI) ≥ 35 kg/cm², and (8) pregnancy. Verbal information about the study purpose and potential benefits using an information sheet was read to the eligible participants. Those willing to participate were then given a written informed consent form to sign or make a thumbprint.

After approval by the ethics committee at our hospital, a retrospective review was performed of 279 consecutive patients diagnosed with DLSS between January 2018 and August 2020. The inclusion requirements necessitated that patients were [7 (link), 12 (link)] 1) aged 40–80 years and 2) underwent ICS and transforaminal lumbar interbody fusion (TLIF), 3) with a minimum follow-up of 12 months. The exclusion criteria included 1) previous spinal surgery, 2) osteopenia or osteoporosis, 3) degenerative lumbar scoliosis (Cobb angle > 25°), 4) cauda equina syndrome, 5) spinal infection, and 6) radiographically confirmed damage of the vertebrae caused by trauma or tumors. A total of 89 patients were included in the final analysis after selection.
Demographic data, such as age, sex, height, weight, and body mass index (BMI), were collected via electronic medical record reviews. The bone mineral density (BMD) at the lumbar spine was assessed via dual-energy X-ray absorptiometry.
The patients were classified into three groups based on the fusion levels. Patients with L5-S1 TLIF and ICS at L4-L5 were assigned to Group A, patients with L4-S1 TLIF and ICS at L3-L4 were assigned to Group B, and those with L3-S1 TLIF and ICS at L2-L3 were assigned to Group C.