Assessment and early investigation of cauda equina syndrome- a systematic review of existing international guidelines and summary of the current evidence.

Background Context: Cauda Equina Syndrome (CES) is an emergency clinical syndrome with correlating radiological evidence of spinal compression. Urgent recognition and treatment is key. In many units, it lacks a clear pathway of investigation and referral, despite a constantly expanding evidence base for its management.

Purpose: The aim of this article is to provide a systematic review of currently available guidelines internationally, and also an up-to-date review of current key evidence on topics central to the accurate assessment and investigation of CES.

Study Design: A systematic review of the literature was carried out to identify all previously published or proposed pathways internationally for CES.

Methods: Included articles were reviewed and data extracted and collected in excel format. Data extracted included year of publication, author, time to MRI in pathway, inclusion or exclusion of post void residual measurement and specific cauda equina red flags used. An evidentiary review was also carried out on key topics including digital rectal examination.

Results: Following removal of duplicates a total of 307 articles underwent title and abstract screening from which 9 were eventually included for data extraction. All included papers recommended urgent MRI with the presence of red flag findings. Red flags included in all papers were perianal/perineal/saddle sensory disturbance and bladder or bowel dysfunction of varying specifications. 8/9 papers included radicular/sciatic pain, 5/9 included new motor weakness, 4/9 included DRE findings and PVR was included in 5/9 papers. PVR and DR examinations retain clinical significance.

Conclusion: While specific guidelines show minor variability, overall the current literature presents a consensus that in cases of suspected cauda equina syndrome MRI should be carried out on an urgent basis.