Hussain Muhammad Masood, Razak Adam Alexander, Hassan Syed Sibet, Choudhari Kishor A, Spink George Michael
a Department of Neurosurgery , Hull Royal Infirmary , Hull , UK.
Br J Neurosurg. 2018 Jun;32(3):264-268. doi: 10.1080/02688697.2018.1457771. Epub 2018 Apr 2.
Cauda equina syndrome (CES) is a condition with significant implications and medico-legal profile. The literature still lacks large primary studies to provide strong evidence for a robust management pathway. Statements from Neurosurgical and Spinal societies support early diagnosis and imaging but this has not resulted in any noticeable shift in referral pattern. We strongly feel the need for a nationally agreed, evidence-based referral pathway in practice. We present our large series and in-depth analysis of the referral pathway to provide strong evidence for more robust referrals and management.
We reviewed 250 referrals of suspected CES (sCES) to the regional neurosurgical unit, evaluating the importance of clinical findings and the imaging pathway.
After clinico-radiological evaluation only 32 (13%) had confirmed CES requiring urgent surgery. There was no significant difference in terms of clinical presentation between these true cases of CES (tCES) and false cases (fCES). Imaging was therefore the key rate-limiting step. MRI was the most common investigation used. 73 patients presented without imaging out of hours (OOH). In this group, investigation was delayed to the next day in 60/73 (82%) patients while only 13 (18%) patients underwent OOH MRI. Only 2 (3%) were able to have this at their local hospital.
As with previous studies we conclude that signs/symptoms are insufficient to identify tCES. Taking into consideration the improved outcome with early diagnosis, the importance of early scanning in diagnosing tCES, and the poor availability of OOH MRI scanning outside of neurosurgical units, we recommend a national policy of 24/7 MRI availability for cases of sCES at all hospitals with MRI scanners. This would remove the 87% of patients not requiring urgent surgery from an unnecessary and distracting referral process.
马尾综合征（CES）是一种具有重大影响和法医学意义的病症。目前的文献中仍缺乏大型的原发性研究，无法为完善的管理路径提供有力证据。神经外科和脊柱学会的声明支持早期诊断和影像学检查，但这并未导致转诊模式发生任何明显转变。我们强烈认为在实际操作中需要一个全国统一的、基于证据的转诊路径。我们展示了我们关于转诊路径的大型系列研究和深入分析，为更完善的转诊和管理提供有力证据。
我们回顾了250例疑似马尾综合征（sCES）转诊至区域神经外科单元的病例，评估临床发现和影像学检查路径的重要性。
经过临床放射学评估，只有32例（13%）确诊为CES需要紧急手术。这些真正的CES病例（tCES）和假病例（fCES）在临床表现方面没有显著差异。因此，影像学检查是关键的限速步骤。MRI是最常用的检查方法。73例患者在非工作时间（OOH）就诊时未进行影像学检查。在这组患者中，60/73（82%）的患者检查被推迟到第二天，而只有13例（18%）患者在OOH时进行了MRI检查。只有2例（3%）能够在当地医院进行该项检查。
与之前的研究一样，我们得出结论，体征/症状不足以识别tCES。考虑到早期诊断能改善预后、早期扫描在诊断tCES中的重要性，以及神经外科单元以外OOH MRI扫描的可及性较差，我们建议制定一项全国性政策，即所有配备MRI扫描仪的医院，对于sCES病例应提供全天候MRI检查。这将使87%不需要紧急手术的患者免受不必要且分散注意力的转诊过程。
