Background Cauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures. Methods This is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated. Findings In 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1-8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95% CI:1.5-3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8-20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2-0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up. Interpretation Post-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively. Copyright (c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Aims Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient's prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter -rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research. Methods A literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had 'suspected CES'; 'early CES'; 'incomplete CES'; or 'CES with urinary retention'. Inter -rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss's kappa. Results Each of the 100 participants were rated by four medical students, five neurosurgical registrars, and four consultant spinal surgeons. No groups achieved reasonable inter -rater agreement for any of the categories. CES with retention versus all other categories had the highest inter -rater agreement (kappa 0.34 (95% confidence interval 0.27 to 0.31); minimal agreement). There was no improvement in inter -rater agreement with clinical experience. Across all categories, registrars agreed with each other most often (kappa 0.41), followed by medical students (kappa 0.39). Consultant spinal surgeons had the lowest inter -rater agreement (kappa 0.17). Conclusion Inter -rater agreement for categorizing CES is low among clinicians who regularly manage these patients. CES categories should be used with caution in clinical practice and research studies, as groups may be heterogenous and not comparable.

AimsPatients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.MethodsA literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had ‘suspected CES’; ‘early CES’; ‘incomplete CES’; or ‘CES with urinary retention’. Inter-rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss’s kappa.ResultsEach of the 100 participants were rated by four medical students, five neurosurgical registrars, and four consultant spinal surgeons. No groups achieved reasonable inter-rater agreement for any of the categories. CES with retention versus all other categories had the highest inter-rater agreement (kappa 0.34 (95% confidence interval 0.27 to 0.31); minimal agreement). There was no improvement in inter-rater agreement with clinical experience. Across all categories, registrars agreed with each other most often (kappa 0.41), followed by medical students (kappa 0.39). Consultant spinal surgeons had the lowest inter-rater agreement (kappa 0.17).ConclusionInter-rater agreement for categorizing CES is low among clinicians who regularly manage these patients. CES categories should be used with caution in clinical practice and research studies, as groups may be heterogenous and not comparable.Cite this article: Bone Joint J 2023;105-B(9):1007–1012.

Introduction: Cauda equina syndrome (CES) has significant medical, social, and legal consequences. Understanding the number of people presenting with CES and their demographic features is essential for planning healthcare services to ensure timely and appropriate management. We aimed to establish the incidence of CES in a single country and stratify incidence by age, gender, and socioeconomic status. As no consensus clinical definition of CES exists, we compared incidence using different diagnostic criteria. Methods: All patients presenting with radiological compression of the cauda equina due to degenerative disc disease and clinical CES requiring emergency surgical decompression during a 1-year period were identified at all centres performing emergency spinal surgery across Scotland. Initial patient identification occurred during the emergency hospital admission, and case ascertainment was checked using ICD-10 diagnostic coding. Clinical information was reviewed, and incidence rates for all demographic and clinical groups were calculated. Results: We identified 149 patients with CES in 1 year from a total population of 5.4 million, giving a crude incidence of 2.7 (95% CI: 2.3–3.2) per 100,000 per year. CES occurred more commonly in females and in the 30–49 years age range, with an incidence per year of 7.2 (95% CI: 4.7–10.6) per 100,000 females age 30–39. There was no association between CES and socioeconomic status. CES requiring catheterization had an incidence of 1.1 (95% CI: 0.8–1.5) per 100,000 adults per year. The use of ICD-10 codes alone to identify cases gave much higher incidence rates, but was inaccurate, with 55% (117/211) of patients with a new ICD-10 code for CES found not to have CES on clinical notes review. Conclusion: CES occurred more commonly in females and in those between 30 and 49 years and had no association with socioeconomic status. The incidence of CES in Scotland is at least four times higher than previous European estimates of 0.3–0.6 per 100,000 population per year. Incidence varies with clinical diagnostic criteria. To enable comparison of rates of CES across populations, we recommend using standardized clinical and radiological criteria and standardization for population structure.

Cauda equina syndrome (CES) is a devastating condition for quality of life which may lead to permanent loss of bladder, bowel and sexual function with associated neurological pain affecting the patient, their family and relationships. It is a time-sensitive syndrome, requiring rapid and effective assessment, diagnosis and treatment if the best possible outcome for the patient is to be achieved. Assessment and diagnosis should be undertaken as an emergency. Surgery when it is required must be performed at the earliest opportunity. Nevertheless, despite optimal medical care, many patients with CES will suffer long-term symptoms with significant disability, which is often hidden for the rest of their lives.

Introduction: Lumbar disc herniation causing radiculopathy is a common reason for referral to spinal out-patient clinics. At our centre following routine referral, patients wait a mean of 109 weeks for a consultation with a spinal surgeon. A pathway in keeping with the National Health Service England Low Back and Radicular Pain Pathway was introduced with two objectives. Patients would be seen sooner by suitably trained health care professionals to avoid long waiting times for assessment with a spinal surgeon, and if a set of criteria were met, they would receive a selective nerve root injection to manage their pain. Methods: Patients were seen by specially trained orthopaedic physiotherapists following routine general practitioner (GP) referral. A radiologically guided nerve root injection was carried out if patients had radicular pain between 6 and 52 weeks duration and a magnetic resonance imaging (MRI) scan demonstrating an intervertebral disc prolapse correlating with their radicular symptoms. Patient-recorded outcome measures were taken before and after nerve root injection. Results: Seventy five patients entered the pathway. Mean patient age was 49.9 years and 27 patients (36.0%) were male. Mean time from referral to assessment was 15.5 weeks. Mean visual analogue score (VAS) for leg pain was 7.4 out of 10 before nerve root injection and 4.8 out of 10 following nerve root injection (p < 0.001). Mean Oswestry Low Back Pain Disability Questionnaire score before nerve root injection was 58.4% and 49.7% following nerve root injection (p = 0.024). Mean Euroqol EQ-5D-5L Health Index was 0.2 before nerve root injection and 0.4 afterwards (p < 0.001). Conclusion: This study suggests that this pathway may help to reduce waiting times for patients with lumbar radiculopathy secondary to intervertebral disc prolapse. The resulting enhanced care may be associated with a reduction in leg and back pain and an improvement in quality of life.

PURPOSE:There is no doubt that the best outcome achieved in Cauda equina syndrome (CES) involves surgical decompression. The controversy regarding outcome lies with timing of surgery. This study reports outcomes on a large population based series. Timing of surgery, Cauda Equina syndrome classification based on British Association of Spine Surgeons (BASS) guidelines and co-morbid illness will be assessed to evaluate influence on outcome. MATERIALS AND METHODS:A retrospective review of all patients surgically decompressed for CES between 01/01/2008 to 01/08/2014 was conducted. Patients with ongoing symptoms were followed up for a minimum of 2 years. Cauda Equina Syndrome (CES) was classified according to the BASS criteria: CES suspicious (CESS), incomplete (CESI) and painless urinary retention (CESR). Time and symptom resolution were assessed. RESULTS:A total of 136 patients were treated for CES; 69 CESR, 22 CESI and 45 CESS. There was no statistical difference in age, sex, smoking status and alcohol status with regards to timing of surgery. No correlation between increasing co-morbidity score and poor outcome was demonstrated in any subgroupAll CESR/I patients demonstrated some improvement in bowel and bladder dysfunction post-operatively. No significant difference in improved autonomic dysfunction was demonstrated in relation to timing of surgery. CES subclassification may predict outcome of non-autonomic symptoms. Statistically better outcomes were found in CESS groups with regards to post-operative lower back pain (P 0.049) and saddle paraesthesia (P 0.02). CONCLUSION:Surgical Decompression for CES is an effective treatment that significantly improves patient symptoms including bowel and bladder dysfunction Early surgical decompression <24 h from symptom onset does not appear to significantly improve resolution of bowel or bladder dysfunction.

Introduction There has been an increase in popularity in cycling over the past 16 years in the UK. Whilst the number of killed or seriously injured (KSI) road users in Northern Ireland (NI) has decreased over this period, the proportion of KSI cyclists has increased steadily. We performed an epidemiological study of serious cycling-related injuries admitted to a UK Regional Trauma Centre and look at associated sporting, cultural, economic and infrastructural changes over this period. Method Retrospective Analysis of the NI Fractures Outcomes Research Database (FORD) of all significant cycling-related injuries presenting in NI requiring hospital admission and operative intervention between 2000 and 2016. Results Over 16 years we captured 734 patients with serious cycling injuries requiring hospital admission and operative intervention with a mean age of 38.73±16.3 (13-87), 85.6% (n=628) of which were male. Males were significantly younger: ANOVA (F2:732=15.363; pu003c0.001); Male mean age 37.77±15.93 (13-87), Female mean age 44.42±17.54 (14-84).  Upper limb injuries predominate (47%), followed by lower limb (21%), spinal trauma (17%), hip fractures (10%), and pelvic trauma (5%). 10% were multiply-injured patients with operative fixation required for ³ 2 of these body regions. Males in general had higher energy injuries, with more pelvic and spinal injuries noted. 29/735 fractures were open (25 of which were in males 86.2%). 50/72 (69.4%) of femoral injuries were femoral neck fractures (Mean age 56.15±13.57, range 36-84) with 2x native hip dislocations. We had 18 patients admitted to our Intensive Care Unit (ICU), with total ICU bed days = 259.75 in 16years; mean 18.55±20.50days (Min 0.02 days, Max 68.54). Length of in-patient hospital stay was mean 8.66±15.85 days (Range 0-142 days). Emergency surgery was carried out in 554/735 (75.37%) of our patients. Over our study period the incidence of lower limb injuries (R 2 =0.037 over time) and pelvic injuries (R 2 =0.049 over time) remained static, whilst upper limb injuries (R 2 =0.690 over time) and spinal injuries (R 2 =0.603 over time) have increased. We show sporadic spikes in injury during seasons and following key sporting events and local infrastructural changes, however any causal link is difficult to demonstrate Conclusion Over the study period cycling has gained popularity as a mode of transport in NI and the UK. The percentage of KSI cyclists has dramatically increased. We demonstrate the preponderance for male patients with higher energy injuries and note an increase in incidence of upper limb and spinal injuries. Whilst the popularity of cycling, both for recreation and as a means of commuter transport have undoubtedly increased over our study period, unfortunately this has a direct correlation with the incidence of associated serious cycle-related injuries generated. This may have implications on healthcare provision, as well as regional government strategies for cycling infrastructure in NI.

IntroductionCauda equina syndrome (CES) is a potentially devastating condition caused by compression of the cauda equina nerve roots. This can result in bowel, bladder and sexual dysfunction plus lower limb weakness, numbness and pain. CES occurs infrequently, but has serious potential morbidity and medicolegal consequences. This study aims to identify and describe the presentation and management of patients with CES in the UK.Methods and analysisUnderstanding Cauda Equina Syndrome (UCES) is a prospective and collaborative multicentre cohort study of adult patients with confirmed CES managed at specialist spinal centres in the UK. Participants will be identified using neurosurgical and orthopaedic trainee networks to screen referrals to spinal centres. Details of presentation, investigations, management and service usage will be recorded. Both patient-reported and clinician-reported outcome measures will be assessed for 1 year after surgery. This will establish the incidence of CES, current investigation and management practices, and adherence to national standards of care. Outcomes will be stratified by clinical presentation and patient management. Accurate and up to date information about the presentation, management and outcome of patients with CES will inform standards of service design and delivery for this important but infrequent condition.Ethics and disseminationUCES received a favourable ethical opinion from the South East Scotland Research Ethics Committee 02 (Reference: 18/SS/0047; IRAS ID: 233515). All spinal centres managing patients with CES in the UK will be encouraged to participate in UCES. Study results will be published in medical journals and shared with local participating sites.Trial registration numberISRCTN16828522; Pre-results.

In March 2017, waiting times for an outpatient appointment at a consultant-led spinal clinic in Northern Ireland had reached 152 weeks. This falls significantly outside national targets and has resulted in a backlog of 6000 patients. A specialist, multi-clinician, co-located, consultant-led NHS clinic that would enable us to evaluate these patients was designed. Six megaclinics have been held and in total 909 patients were reviewed. Patient numbers ranged from 88 – 185, with an average did not attend rate of 3.3%. Only 9.1% of patients were boarded for surgery, while discharge rates ranged between 78–91%. Patient satisfaction has been maintained at over 90% for each clinic. A significant increase in clinician confidence in the management of orthopaedic spinal conditions was demonstrated. Cost analysis has demonstrated a saving of £39 087, in comparison to previous waiting list initiative costs for patients reviewed in the private sector.

BACKGROUND CONTEXT: The spinal service was unable to meet demand with 800 referrals received monthly to the central spinal orthopaedic hub from the region's five Health and Social Care Trusts. There was no agreed pathway for the management of patients with spinal pain in Northern Ireland. Audit data showed documented conservative management was insufficient and orthopaedic outcomes varied widely by referral source with a low conversion rate to surgery.

BACKGROUND CONTEXT: Concerns have been expressed regarding the safety of rugby. It remains a popular sport. Cycling continues to increase in popularity and is expounded as a good form of exercise.

BACKGROUND CONTEXT: Waiting times for patients undergoing elective spinal surgery at Royal Victoria Hospital (RVH) are increasing due to increasing trauma commitments in the unit. Prior to surgery, consultants require ‘up to date’ magnetic resonance imaging (MRI) scans performed within 12 months from date of surgery.

Introduction The objective of this study was to determine whether posterior only stabilization of metastatic spinal lesions provides adequate stability over the life span of the recipient patient. There are no gold standards for surgical stabilization of metastatic spinal lesions however National Institute of Clinical Excellence guidelines (UK) state that anterior reconstruction should be considered in patients with metastatic spinal cord compression who are likely to survive a year. Standard practice in our regional unit has been to stabilize metastatic spinal lesions through a posterior only approach. Our rationale is that posterior stabilization provides sufficient stability while avoiding the additional risks, time, and cost of anterior stabilization. Materials and Method Retrospective review of all cases of posterior only spinal stabilization performed for metastatic disease over a 5 year period. Patient demographics, pathology and metal work construct including number of levels stabilized was recorded. All post-operative imaging was reviewed. Failures and revisions were recorded. Clinical notes were reviewed for surviving patients. Results Of the 94 cases 49 were male, average age at time of surgery was 62. 77 (81.9%). Of the patients who were deceased by the study end date mean time from surgery to death was 504 (15 to 1865) days. 72 (93.5%) of constructs remained stable until death. 5 patients required further surgery. 3 had broken rods requiring revision and 2 required anterior decompression and stabilization for disease progression. None of the 17 alive patients required further surgery and all remained neurologically intact. Conclusion This case series revealed very low rates of posterior construct failure or need for further surgery for disease progression. This indicates that posterior only stabilization is a safe and effective surgical management option for metastatic spinal lesions.

INTRODUCTION:Spinal metastases secondary to renal cell carcinoma are associated with significant intra-operative blood loss. Our aim was to assess if embolisation reduced the intra-operative blood loss and transfusion requirement. METHODS:We performed a retrospective cohort study of 25 patients undergoing surgery between 2003 and 2011. RESULTS:14 underwent pre-operative embolisation; 11 did not. There was no significant difference in intra-operative blood loss, 1336 ml vs 1492 ml in the non-embolised (p value = 0.116). 43% of embolised patients required an intra operative blood transfusion vs 27% in the non-embolised. CONCLUSION:Our results suggest that not all patients with spinal metastatic renal carcinoma require pre-operative embolisation.

In the first prospective comparison of 'scan-negative' (n = 11) and 'scan-positive' (n = 7) patients with cauda equina syndrome (CES) we found that Hoover's sign of functional leg weakness but not routine clinical features differentiated the two groups (p < 0.02). This offers a new direction of study in this area, although magnetic resonance imaging is still required for all patients with possible CES.

We read Carter’s editorial with much interest.1 In the past year, few subjects in sport have generated as much interest as injuries and concussions in school rugby. This is particularly true for Northern Ireland, where two catastrophic injuries recently occurred. The current lack of comprehensive, clear, and coherent data from a surveillance study is striking and makes its development …

Background: Fractures of the distal radius are one of the most common extremity fractures, and operation rates are increasing. Staff within our unit felt that formal teaching, particularly of new medical staff, with regards to fracture reduction and appropriate cast application could result in a reduction in operation rates.Methods: Retrospective data was extracted from FORD (Fracture Outcome and Research Database), including: number of fractures, number of fractures undergoing ORIF, fracture configuration, patient demographics, and mechanism of injury. All patients undergoing ORIF had their radiographs assessed by two separate reviewers. Information regarding adequate fracture reduction, adequate cast application (using Gap Index), and appropriate plaster cast moulding was recorded. Formal teaching was then given to the next group of medical staff rotating through the unit, and the same data was collected prospectively for that six-month period. Exclusion criteria included bilateral injuries, and polytrauma patients.Results: A total of 1623 distal radial fractures were treated in our unit over the 12-month period, with 71 undergoing ORIF in the first 6 months and 39 in the second 6 months, this was statistically significant (p = 0.0009). Our study found that formal teaching and education significantly reduced the operation rate for distal radial fractures. This effect was most significant for extra-articular, dorsally angulated fractures of the distal radius.Conclusion: Our study proves that just 1 h of basic training at the beginning of an attachment can have significant benefits to both the unit and, more importantly, the patients. (C) 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.