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Cauda Equina for Orthopaedic Exams
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Cauda Equina for Orthopaedic Exams
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Upload Date:
2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
So welcome, everyone back. Thanks for everyone who come back. Spinel theme again. And we have Ramesh who will talk to us about Kodak winner over to you, Ramesh. Hi, guys.
Right so I'm trying to keep it as brief as I can. So these days, I we have to give them disclosure. That's my disclosure. What's your take on the syndrome? I think this is the key take-home message today. This particular paper, I think, is from the bas status freely available on Google. If you click but you get this document, it's pretty.
This is pretty comprehensive, very self-explanatory. Just make sure you go through this one and there's one by, I think, Jeremy Fairbank about a signal that you need to read before the exam you in the backside. So according to the bus, any patient with acute back pain and/or leg pain, and any suggestion of the blood or bone function disturbance under anesthesia or no sensation since these events should be suspect.
Basically, any referral that you get with prairie waterworks on bowel problems from your GP or from Amy do take it seriously. Like I mentioned, it does cost a lot if you missed one. So this is the more sort of traditional definition by Fraser, which is quite readily accepted. Basically, one or more of the following must be present to qualify as correction syndrome to the bladder and bladder radial sensation in the CR area.
Sexual dysfunction with possible neurologic deficit in the new Allen. I think the last one is more to do with spinal surgeons, but as a newly qualified orthopedic surgeon, you don't need to worry about the sexual dysfunction. But if they complain about it, do take it seriously. So it's a big spectrum. It can be anybody.
And everybody that comes through the doors as. There's a sort of a differentiation in the presentation. Somebody who's very early or suspected is someone who is basically who's had long term unilateral leg pain. They have progressed to bilateral acting. They are. They are the potential people who can develop and incomplete.
CSI is someone who has associated sphincter instruments or bubble or both. Retention is when you have clearly missed the bus retention, and this is usually painless. So there is a progression of 1% in all the deterioration, rather not progression, deterioration in function of bladder and bowel 1% every year. So if you delay your treatment for an established order for a person who has correct or not, we have progressed from CSI to a quarter of the patients will do that.
So this is a good paper if you want to read through. It's quite famous and frequently quoted about someone with bilateral sciatica, bilateral paresthesia, weakness in both legs, perineal pain or paresthesia and altered bowel function. These are the patients who qualify for scan. So we don't keep talking about PR director.
Every time there is a referral, you ask your and equally or your GP. I would not be. There is the rectal examination does not predict or does not tell you whether the patient has got chronic or not. Not, but it is medically really very important. And that's why we do it. So what is more important is the perennial paresthesia, there are enough papers talking about these things perennial paresthesia or sensory loss or disturbances important than the rectal examination.
So if you look at the boss paper, you treat MRI as a triage service, basically, you separate the wheat from the chaff. You do. If you get if you're on a idiot and get a cardiac disease with the scan before you refer the patient across course, that's fine.
So how many positive scans you have? You have a 14% to 15% to 30% of that. And of all the referrals that are only about 7% of patients will end up having a decompression. So it's very low yield. But previous thought process that if you. Don't decompress the connection immediately, but you do it within 48 hours, there is no change in the outcomes.
It's very important that you do it very early. As it progresses, one person per hour, if you do it at 24 hours, they're likely to retain their bowel function and even sexual function. But if you delay it up to 48 hours, we don't recover as much beyond 48 hours. Clearly, there's no recovery. But it's not referring to the spinal surgeon or if not decompressing it.
For whatever reason, we documentation is very important, especially in the spine world. So the things that I did not including so you could have I could have talked about diagrams of a cross section of spinal cord, various incomplete spinal cord syndromes. But I'm sure all these things, that's something you will read about yourself.
And it's all about practice of migrants and moving the various cards and drugs. But I'm sure we will touch upon that in the wire section of this session later on. OK, I'll take my word for it. So she's right. The court syndromes is going to come up on your basic science table very quickly, draw, draw, draw a cross section of the court and then explain why each of these cord injuries have their symptoms.
So we can cover that as a separate topic later on, if need be, if it doesn't come up in hot. Yeah so this could be quite a topic is important. Thanks very much for covering that. It's one of those never to miss, really. If you miss it, I think it would be impossible to come back from it. And as Rami said, the most important thing is to recognize the impending incomplete code, and that's really the stage when you can make a difference to the patient and prevent further progression into complete because once it goes into complete code esquina, first of all, I mean, no one will miss Cole completely esquina.
It's difficult. One to diagnose is the incomplete one. Secondly, obviously the prognosis is quite poor with the complete. So if the examiner says anything about any patient has any symptoms of irritable bladder, poor stream, any diminished abnormal sensation straightaway raise the alarm of Kodak wine and scan the patient immediately if they tell you when to scan with the next morning.
I think I got this that you want to do the scan as soon as possible. You will not go wrong with that. Any comment from assad? No, I think. I think as is, everyone has to have a definition. So so my two points for everything in the exam is need to know the controversy.
Need to know the passwords. So the controversy here is when to operate. The password is the definition and the need for MRI scan. So any as this paper suggests and Ramesh, tell us this any suspicion? Keep high index of suspicion that the scan, even if you don't think it is and then deal with it, respond to check with the neurosurgical unit over here.
Do remember referring patients to neurosurgical unit because you are an idiot? I think we have this guideline as will be a guideline. Yeah, there are big. There is a British Association of spine surgeon guidelines about standards of care for established and suspected called equine syndrome. And if you start cutting this in the exam, that will be to give you extra marks.
There are other papers also published. There is a cohort study published from Leicester in the European spine journal that talks about the duration of symptoms prior to surgery. And how it influences the outcome. I can also share that paper with the group later on, like Sian did earlier, if I just add one thing about the influence. Now that's a new thinking.
There may not be papers to coat it, but people are going away from the timing now. The timing, they are saying, is not as important as the insult to the cordite mania initially. So the degree of contact when I say so very, very bad, the outcome is bad irrespective of. Yeah, I think I would. I would advise that. Don't talk about timing at all.
Yes, if the examiner ask about timings as far as you're concerned, patient needs immediate emergent MRI scan and an immediate discussion with the spinal unit. And don't say anything much more than that, if the Senate starts talking about timing. You say you want things to be done immediately, but it could always, if any evidence, there is evidence, as Arthur says about.
Issues with timing and 12, 24, 48 hours, and so. So there's a couple of things to say about timing, as I said, if you're going to be asked in the exam table, remember you're being judged according to a standard gauge consultant who recognizes you do not take the decision yourself about timing. You must say, I will talk to this fine people. But more importantly, when they got me to talk about timing, they said, what would you like to do for yourself?
My response was, if it was me, I'd want surgery straightaway, and that's what I would want for my patient. So that's the attitude you should take with your patients. Always advocate for them. OK, especially in the exam, but in real life, of course, the second thing to say. There is also some evidence that a residual cost avoidance is one of the most sensitive in terms of picking of the patients that need mandatory scanning.
So my attitude to this is my personal attitude to this. And what I would have said in the exam if I was brought up. This topic. If they asked me about how, what sensitive or not, I find PR to be very insensitive. It's a variation between patients. I use angel wings as a good sign. I catalyzed the patient after the patient avoided and after I've got my ultrasound scan, so first ask the patient to void, then do a residual volume bladder scan the residual blood if it's greater than 200 to 250.
This patient needs an MRI scan, and you can then confirm that the patient might be called acquired by categorizing the patient after that and talk on the catheter. If they feel it. It might not be called acquired, but if they don't feel it, that just confirms what you're going to. You need your MRI scan urgently. So someone is asking the question about what is the degree of compression?
I have a picture for it as well. I'll show it to you. But by degree means is like displacement of distal radius fracture. So the outcome is the degree of displacement. No so it's the same sort of thing that how much of the contact when is compressed because then subsequent compress the blood flow within the Kodak Weiner and then give irreversible damage to the nerves respective to the timing.
Because once the blood flow is completely occluded, then we are looking at a for neural tissue, whatever. It's 30 minutes, I guess. For a brain tissue before the irreversible damage happens at 30 minutes, I think. I don't know why. I have no idea, but if, if, if blood compromise, if a vessel is compromised, I have a picture in mind when I can share it, that picture.
If the vessel compromised, then the dura dies. Yeah, there was a question from about one of the participants about the importance of the catheter tug, which is the technique we use to help us in the diagnosis. And I feel there is no one single test that would confirm or exclude. It's a syndrome and there will be a wide range of symptoms and signs to pick up.
So I would not definitely rely on one side. I don't know what other mentors think. I think it's a perfectly right answer. My our clinical lead, which is, again, a big spine unit. He always talks about five things. So he's a period of sensation in tone and contraction and a wink and bilateral symptoms. So four things on the pr, including the annual event with the pinprick, which is more important.
And it can not be subjective because if you use all the rest, you can have lose and adorned by various other reasons.
Segment:0 .
So welcome, everyone back. Thanks for everyone who come back. Spinel theme again. And we have Ramesh who will talk to us about Kodak winner over to you, Ramesh. Hi, guys.
Right so I'm trying to keep it as brief as I can. So these days, I we have to give them disclosure. That's my disclosure. What's your take on the syndrome? I think this is the key take-home message today. This particular paper, I think, is from the bas status freely available on Google. If you click but you get this document, it's pretty.
This is pretty comprehensive, very self-explanatory. Just make sure you go through this one and there's one by, I think, Jeremy Fairbank about a signal that you need to read before the exam you in the backside. So according to the bus, any patient with acute back pain and/or leg pain, and any suggestion of the blood or bone function disturbance under anesthesia or no sensation since these events should be suspect.
Basically, any referral that you get with prairie waterworks on bowel problems from your GP or from Amy do take it seriously. Like I mentioned, it does cost a lot if you missed one. So this is the more sort of traditional definition by Fraser, which is quite readily accepted. Basically, one or more of the following must be present to qualify as correction syndrome to the bladder and bladder radial sensation in the CR area.
Sexual dysfunction with possible neurologic deficit in the new Allen. I think the last one is more to do with spinal surgeons, but as a newly qualified orthopedic surgeon, you don't need to worry about the sexual dysfunction. But if they complain about it, do take it seriously. So it's a big spectrum. It can be anybody.
And everybody that comes through the doors as. There's a sort of a differentiation in the presentation. Somebody who's very early or suspected is someone who is basically who's had long term unilateral leg pain. They have progressed to bilateral acting. They are. They are the potential people who can develop and incomplete.
CSI is someone who has associated sphincter instruments or bubble or both. Retention is when you have clearly missed the bus retention, and this is usually painless. So there is a progression of 1% in all the deterioration, rather not progression, deterioration in function of bladder and bowel 1% every year. So if you delay your treatment for an established order for a person who has correct or not, we have progressed from CSI to a quarter of the patients will do that.
So this is a good paper if you want to read through. It's quite famous and frequently quoted about someone with bilateral sciatica, bilateral paresthesia, weakness in both legs, perineal pain or paresthesia and altered bowel function. These are the patients who qualify for scan. So we don't keep talking about PR director.
Every time there is a referral, you ask your and equally or your GP. I would not be. There is the rectal examination does not predict or does not tell you whether the patient has got chronic or not. Not, but it is medically really very important. And that's why we do it. So what is more important is the perennial paresthesia, there are enough papers talking about these things perennial paresthesia or sensory loss or disturbances important than the rectal examination.
So if you look at the boss paper, you treat MRI as a triage service, basically, you separate the wheat from the chaff. You do. If you get if you're on a idiot and get a cardiac disease with the scan before you refer the patient across course, that's fine.
So how many positive scans you have? You have a 14% to 15% to 30% of that. And of all the referrals that are only about 7% of patients will end up having a decompression. So it's very low yield. But previous thought process that if you. Don't decompress the connection immediately, but you do it within 48 hours, there is no change in the outcomes.
It's very important that you do it very early. As it progresses, one person per hour, if you do it at 24 hours, they're likely to retain their bowel function and even sexual function. But if you delay it up to 48 hours, we don't recover as much beyond 48 hours. Clearly, there's no recovery. But it's not referring to the spinal surgeon or if not decompressing it.
For whatever reason, we documentation is very important, especially in the spine world. So the things that I did not including so you could have I could have talked about diagrams of a cross section of spinal cord, various incomplete spinal cord syndromes. But I'm sure all these things, that's something you will read about yourself.
And it's all about practice of migrants and moving the various cards and drugs. But I'm sure we will touch upon that in the wire section of this session later on. OK, I'll take my word for it. So she's right. The court syndromes is going to come up on your basic science table very quickly, draw, draw, draw a cross section of the court and then explain why each of these cord injuries have their symptoms.
So we can cover that as a separate topic later on, if need be, if it doesn't come up in hot. Yeah so this could be quite a topic is important. Thanks very much for covering that. It's one of those never to miss, really. If you miss it, I think it would be impossible to come back from it. And as Rami said, the most important thing is to recognize the impending incomplete code, and that's really the stage when you can make a difference to the patient and prevent further progression into complete because once it goes into complete code esquina, first of all, I mean, no one will miss Cole completely esquina.
It's difficult. One to diagnose is the incomplete one. Secondly, obviously the prognosis is quite poor with the complete. So if the examiner says anything about any patient has any symptoms of irritable bladder, poor stream, any diminished abnormal sensation straightaway raise the alarm of Kodak wine and scan the patient immediately if they tell you when to scan with the next morning.
I think I got this that you want to do the scan as soon as possible. You will not go wrong with that. Any comment from assad? No, I think. I think as is, everyone has to have a definition. So so my two points for everything in the exam is need to know the controversy.
Need to know the passwords. So the controversy here is when to operate. The password is the definition and the need for MRI scan. So any as this paper suggests and Ramesh, tell us this any suspicion? Keep high index of suspicion that the scan, even if you don't think it is and then deal with it, respond to check with the neurosurgical unit over here.
Do remember referring patients to neurosurgical unit because you are an idiot? I think we have this guideline as will be a guideline. Yeah, there are big. There is a British Association of spine surgeon guidelines about standards of care for established and suspected called equine syndrome. And if you start cutting this in the exam, that will be to give you extra marks.
There are other papers also published. There is a cohort study published from Leicester in the European spine journal that talks about the duration of symptoms prior to surgery. And how it influences the outcome. I can also share that paper with the group later on, like Sian did earlier, if I just add one thing about the influence. Now that's a new thinking.
There may not be papers to coat it, but people are going away from the timing now. The timing, they are saying, is not as important as the insult to the cordite mania initially. So the degree of contact when I say so very, very bad, the outcome is bad irrespective of. Yeah, I think I would. I would advise that. Don't talk about timing at all.
Yes, if the examiner ask about timings as far as you're concerned, patient needs immediate emergent MRI scan and an immediate discussion with the spinal unit. And don't say anything much more than that, if the Senate starts talking about timing. You say you want things to be done immediately, but it could always, if any evidence, there is evidence, as Arthur says about.
Issues with timing and 12, 24, 48 hours, and so. So there's a couple of things to say about timing, as I said, if you're going to be asked in the exam table, remember you're being judged according to a standard gauge consultant who recognizes you do not take the decision yourself about timing. You must say, I will talk to this fine people. But more importantly, when they got me to talk about timing, they said, what would you like to do for yourself?
My response was, if it was me, I'd want surgery straightaway, and that's what I would want for my patient. So that's the attitude you should take with your patients. Always advocate for them. OK, especially in the exam, but in real life, of course, the second thing to say. There is also some evidence that a residual cost avoidance is one of the most sensitive in terms of picking of the patients that need mandatory scanning.
So my attitude to this is my personal attitude to this. And what I would have said in the exam if I was brought up. This topic. If they asked me about how, what sensitive or not, I find PR to be very insensitive. It's a variation between patients. I use angel wings as a good sign. I catalyzed the patient after the patient avoided and after I've got my ultrasound scan, so first ask the patient to void, then do a residual volume bladder scan the residual blood if it's greater than 200 to 250.
This patient needs an MRI scan, and you can then confirm that the patient might be called acquired by categorizing the patient after that and talk on the catheter. If they feel it. It might not be called acquired, but if they don't feel it, that just confirms what you're going to. You need your MRI scan urgently. So someone is asking the question about what is the degree of compression?
I have a picture for it as well. I'll show it to you. But by degree means is like displacement of distal radius fracture. So the outcome is the degree of displacement. No so it's the same sort of thing that how much of the contact when is compressed because then subsequent compress the blood flow within the Kodak Weiner and then give irreversible damage to the nerves respective to the timing.
Because once the blood flow is completely occluded, then we are looking at a for neural tissue, whatever. It's 30 minutes, I guess. For a brain tissue before the irreversible damage happens at 30 minutes, I think. I don't know why. I have no idea, but if, if, if blood compromise, if a vessel is compromised, I have a picture in mind when I can share it, that picture.
If the vessel compromised, then the dura dies. Yeah, there was a question from about one of the participants about the importance of the catheter tug, which is the technique we use to help us in the diagnosis. And I feel there is no one single test that would confirm or exclude. It's a syndrome and there will be a wide range of symptoms and signs to pick up.
So I would not definitely rely on one side. I don't know what other mentors think. I think it's a perfectly right answer. My our clinical lead, which is, again, a big spine unit. He always talks about five things. So he's a period of sensation in tone and contraction and a wink and bilateral symptoms. So four things on the pr, including the annual event with the pinprick, which is more important.
And it can not be subjective because if you use all the rest, you can have lose and adorned by various other reasons.
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