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. 2022;56(6):460-468.
doi: 10.1159/000527727. Epub 2022 Oct 31.

Demographics of Cauda Equina Syndrome: A Population-Based Incidence Study

Julie Woodfield  1   2 , Simon Lammy  3 , Aimun A B Jamjoom  1   2   4 , Mohammed A G Fadelalla  5 , Phillip C Copley  2 , Mohit Arora  4 , Stella A Glasmacher  1   2 , Mohamed Abdelsadg  3   5 , Gabrielle Scicluna  6 , Michael T C Poon  1   2   7 , Savva Pronin  1   2 , Andraay H C Leung  6 , Stacey Darwish  8 , Andreas K Demetriades  2 , Jennifer Brown  3 , Niall Eames  8 , Patrick F X Statham  2 , Ingrid Hoeritzauer  1   2 ; UCES Study Collaborators; British Neurosurgical Trainee Research Collaborative
Affiliations

Demographics of Cauda Equina Syndrome: A Population-Based Incidence Study

Julie Woodfield et al. Neuroepidemiology. 2022.

Abstract

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.

Keywords: Cauda equina syndrome; Demographics; Incidence; Spine.

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Conflict of interest statement

J. Woodfield, S. Lammy, A.A.B. Jamjoom, M.A.G. Fadelalla, P.C. Copley, M. Arora, S.A. Glasmacher, M. Abdelsadg, G. Scicluna, M.T.C. Poon, S. Pronin, A.H.C. Leung, S. Darwish, J. Brown, and N. Eames have no conflicts of interest to declare. I. Hoeritzauer declares honoraria for speaking about functional neurological disorders and has received payment for expert testimony on idiopathic urinary retention. P.F.X. Statham has received payment for expert testimony, acting for a number of both claimants and defenders in cases of CES, roughly in the proportion 2/3 defender, 1/3 claimant over about 20 years. A.K. Demetriades declares payment or honoraria for speaking for Integra, Stryker, and Safe Orthopaedics and declares unpaid leadership board roles for Global Neuro Foundation and European Association of Neurosurgical Societies.

Figures

Fig. 1
Fig. 1
Flow diagram of patient identification. Initial patient identification was by the local clinical team during the emergency admission with CES. Case ascertainment was checked using diagnostic coding data for the study period for the ICD-10 code G83.4 Cauda Equina Syndrome. Additional eligible patients were added to the study database. ICD-10 coding for CES for the whole of Scotland was also sourced. Clinical notes were reviewed for all the 211 patients admitted at hospitals with spinal surgery but could not be reviewed for those admitted at hospitals without spinal surgery. As hospital sites with spinal surgery also have other specialties, it was possible that patients admitted at the hospital were not admitted to the spinal surgery centre. Notes were reviewed for the 28 patients admitted at the hospital site but not admitted to the spinal surgery centre. None had clinical CES and radiological compression of the cauda equina. Patients with causes of CES other than degenerative spine disease were excluded from this study but were initially included in the UCES database. Patients without clinical signs and symptoms of CES or without radiological cauda equina compression were excluded. One patient erroneously included in the UCES database did not have clinical CES and was not included in this study. Clinical CES was defined as back and or leg pain and any of: altered perianal or perineal sensation; bladder dysfunction; bowel dysfunction; sexual dysfunction; or bilateral sciatica. (CES: cauda equina syndrome; UCES: Understanding Cauda Equina Syndrome Study).
Fig. 2
Fig. 2
Age and gender of patients with CES. All cases of CES in Scotland by 10 years age group and gender. All cases have clinical CES and radiological cauda equina compression. Raw numbers are presented with no correction for the underlying population structure. Orange bars to the right represent males. Green bars to the left represent females. CES, cauda equina syndrome.
Fig. 3
Fig. 3
Incidence of CES by socioeconomic status. Patients are divided into the quintiles of the Scottish Index of Multiple Deprivation (SIMD) where the most deprived fall into quintile one and the least deprived into quintile five. Incidence is presented as a point estimate per 100,000 population per year, with error bars representing 95% confidence intervals.
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