University of Edinburgh
Title: What is the Incidence of Cauda Equina Syndrome? A Systematic ReviewAuthors: Ingrid Hoeritzauer MRCP,2,3 Matthew Wood BSc,1,2, Phillip C Copley MRCS 1,2,3, Andreas K Demetriades FRCSEd*1,3 Julie Woodfield MSc*1,2*AK Demetriades and J Woodfield oversaw this project and are joint last authorsAffiliations1. Department of Clinical Neurosciences, Western General Hospital, Edinburgh UK 2. Centre for Clinical Brain Sciences, University of Edinburgh, UK3. Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, UKCorresponding AuthorJulie WoodfieldDepartment of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, UKT: +44 (0)131 5371000, F: +44 (0) 131 537 1132 , E:Julie.woodfield@ed.ac.ukKey Words: Cauda Equina Syndrome; Incidence; Systematic Review; Epidemiology; PopulationRunning Title: Incidence of Cauda Equina SyndromeAbstract word count: 349Text word count: 3,034Number of references: 50Number of tables and figures: 7Number of videos: 0Abstract Presentation: At the Society of British Neurological Surgeons, April 11th 2018 in poster form.AbstractObjectCauda equina syndrome (CES) is a surgical emergency requiring timely operative intervention to prevent symptom progression. Accurately establishing the incidence of CES is required to inform healthcare service design and delivery including out of hours imaging arrangements. MethodsA systematic literature search of MEDLINE, EMBASE, and Scopus was undertaken to identify original studies stating the incidence of CES, and estimates were combined in a meta-analysis as described in the protocol registered with PROSPERO (CRD42017065865) and reported using the PRISMA guidelines.Results1281 studies were identified and 26 studies were included in the review. Data about CES incidence was available from three different populations: asymptomatic community populations, patients with non-traumatic lower back pain and patients presenting to an emergency setting with suspected CES. The incidence of CES was 0.3-0.5 per 100,000 per year in two asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working age population. CES occurred in 0.08% of those with lower back pain presenting to primary care in one study and a combined estimate of 0.27% was calculated for four studies of those with lower back pain presenting to secondary care. Across 18 studies of adults with suspected CES, 19% had radiological and clinical CES. Difficulties in comparison between studies resulted from the heterogenous definitions of CES and lack of separation of more advanced CES with retention which is unlikely to be reversible (CES-R). In the studies of patients with suspected CES the small sample size, high number of single centre studies (18/18), high number of studies from the UK (17/18), retrospective nature of the studies and high number of abstracts rather than full texts (9/18) reduced the quality of the data.ConclusionsFrom current studies it appears that CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Determining accurate incidence figures and designing a bespoke service for investigation of patients with suspected CES would require a consensus clinical and radiological definition of CES and international multi-site studies of patient pathways of investigation and management. IntroductionCauda equina syndrome (CES) is an emergency with potentially significant consequences including bladder, bowel or sexual dysfunction, numbness, weakness, or pain.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmFzZXI8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 2,9,46 Due to the high medical, personal, social, and legal costs, prompt investigation with MRI is recommended when CES is suspected.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub2RkPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 26 which complicates planning service design and delivery. Establishing the incidence of CES and the likelihood of a diagnosis of CES, in those presenting with symptoms consistent with CES, would facilitate planning imaging and operative pathways for patients with suspected CES. This systematic review aims to identify studies reporting the incidence of CES, describe the populations in which the incidence of CES has been studied, and any differences in incidence between these populations. Materials and MethodsA systematic review was undertaken as described in the study protocol ‘Incidence of Cauda Equina Syndrome: Systematic Review Protocol’ registered with the International Prospective Register of Systematic Reviews (PROSPERO), reference number CRD42017065865, available at: . Studies were included if they reported original data and assessed human subjects with CES. For inclusion, studies had to state the incidence of CES or the proportion of the studied population with CES, or provide sufficient figures for this to be calculated. We defined CES as a clinical diagnosis of CES with radiological cauda equina compression. Studies including only patients with a clinical CES type syndrome without radiological cauda equina compression were excluded. Studies of radiological lesions of the cauda equina or cauda equina compression without clinical features of CES were also excluded. Reference populations could be either asymptomatic or symptomatic populations.. Case series or studies without a reference population where the incidence of CES could not be established were excluded. Case series of operated lumbar discs, spinal stenosis, or iatrogenically caused CES were also excluded to ensure all included studies were applicable to an initial presentation with suspected CES. There were no restrictions on the language or year of publication, the type, location, or age of the population studied, or whether the study was published or unpublished. The final database search was carried out on the 30th July 2018 in Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily 1946 to July 27, 2018, Ovid,EMBASE 1980 to 2018 Week 31 and Scopus. The MEDLINE search strategy was: Polyradiculopathy/cauda equina.ti,ab.Cauda Equina/1 OR 2 OR 3Incidence/ or Prevalence/Epidemiology/(incidence* or prevalen* or epidemiolog* or frequenc* or rate* or occurrence*).ti,ab5 OR 6 OR 74 AND 8 No limits were applied. EMBASE and Scopus search strategies are in the supplementary material. Duplicate studies were eliminated and then all abstracts and titles were screened by two reviewers independently (JW, IH, PC, or MW). Where reviewers disagreed, discussion with a third or fourth reviewer was undertaken to provide a consensus. The full text of all included abstracts was retrieved and independently reviewed by two reviewers (JW, IH, PC, or MW). Any disagreements were resolved through discussion with a third or fourth reviewer. The reference lists of all included studies were screened independently by two reviewers to identify any additional relevant papers. Studies citing the included studies were identified using Scopus and also screened by two reviewers independently. Multiple papers or abstracts reporting the same study were treated as a single study. Data were extracted from each included paper by two reviewers independently and all instances where data did not match were checked by a third reviewer (JW, IH, PC, or MW). The data items extracted were: incidence of CES in the population (including confidence intervals and standardised estimates where given); number of cases of CES; size of the reference population; description of the population (location, demographics, time period studied, inclusion criteria); and definition of CES used in the study including any sub-categorisation. Study quality and risk of bias was assessed using the following questions adapted from those used in prior systematic reviews of incidence of neurological conditionsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FdGVtYWRpZmFyPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh
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ADDIN EN.CITE.DATA 8,33 As there are no validated diagnostic criteria for CES, studies were assessed on whether they described the definition of CES used. Was the target population clearly described?Were cases ascertained by survey of the entire population or by probability sampling?Was the sample size >300 subjects?Was the response rate >70%? Were non-responders clearly described?Was the sample representative of the population? Were data collection methods standardised?Were the diagnostic criteria used to assess the presence of disease described? Were estimates of incidence given with confidence intervals?Were standardised estimates reported? The incidence of CES was reported per 100,000 population per year in asymptomatic populations. The percentage with CES was reported in symptomatic populations. Statistical heterogeneity was assessed using the Q statistic and the I2 test. ADDIN EN.CITE <EndNote><Cite><Author>Higgins</Author><Year>2002</Year><RecNum>292</RecNum><DisplayText><style face="superscript">24</style></DisplayText><record><rec-number>292</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540841226">292</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Higgins, J. P. T.</author><author>Thompson, S. G.</author></authors></contributors><auth-address>Inst Publ Hlth, MRC, Biostat Unit, Cambridge CB2 2SR, England</auth-address><titles><title>Quantifying heterogeneity in a meta-analysis</title><secondary-title>Statistics in Medicine</secondary-title><alt-title>Stat Med</alt-title></titles><alt-periodical><full-title>Stat Med</full-title></alt-periodical><pages>1539-1558</pages><volume>21</volume><number>11</number><keywords><keyword>meta-analysis</keyword><keyword>heterogeneity</keyword><keyword>randomized trials</keyword><keyword>clinical-trials</keyword><keyword>metaanalysis</keyword></keywords><dates><year>2002</year><pub-dates><date>Jun 15</date></pub-dates></dates><isbn>0277-6715</isbn><accession-num>WOS:000176016900005</accession-num><urls><related-urls><url><Go to ISI>://WOS:000176016900005</url><url> Proportions were combined using the inverse variance method and a DerSimonian-Laird estimator for τ2. ADDIN EN.CITE <EndNote><Cite><Author>DerSimonian</Author><Year>1986</Year><RecNum>110</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>110</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540840511">110</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>DerSimonian, R.</author><author>Laird, N.</author></authors></contributors><titles><title>Meta-analysis in clinical trials</title><secondary-title>Control Clin Trials</secondary-title></titles><periodical><full-title>Control Clin Trials</full-title></periodical><pages>177-88</pages><volume>7</volume><number>3</number><keywords><keyword>Clinical Trials as Topic/*methods</keyword><keyword>Humans</keyword><keyword>Models, Theoretical</keyword><keyword>Research Design</keyword><keyword>Statistics as Topic</keyword></keywords><dates><year>1986</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>0197-2456 (Print)
0197-2456 (Linking)</isbn><accession-num>3802833</accession-num><urls><related-urls><url> Confidence intervals for individual studies were calculated using Clopper-Pearson confidence intervals. ADDIN EN.CITE <EndNote><Cite><Author>Clopper</Author><Year>1934</Year><RecNum>349</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>349</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540849076">349</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clopper, C. J.</author><author>Pearson, E. S.</author></authors></contributors><titles><title>THE USE OF CONFIDENCE OR FIDUCIAL LIMITS ILLUSTRATED IN THE CASE OF THE BINOMIAL</title><secondary-title>Biometrika</secondary-title></titles><periodical><full-title>Biometrika</full-title></periodical><pages>404-413</pages><volume>26</volume><number>4</number><dates><year>1934</year></dates><isbn>0006-3444</isbn><urls><related-urls><url> All statistics were calculated using the meta package in R version 3.4.0. ADDIN EN.CITE <EndNote><Cite><Author>Schwarzer</Author><Year>2015</Year><RecNum>350</RecNum><DisplayText><style face="superscript">44</style></DisplayText><record><rec-number>350</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540849324">350</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Schwarzer, G.</author><author>Carpenter, J.R.</author><author>Rucker, G.</author></authors></contributors><titles><title>Meta-Analysis with R</title><secondary-title>Use R!</secondary-title></titles><pages>XII, 252</pages><edition>1</edition><dates><year>2015</year></dates><publisher>Springer International Publishing</publisher><isbn>978-3-319-21415-3</isbn><urls></urls><electronic-resource-num>10.1007/978-3-319-21416-0</electronic-resource-num></record></Cite></EndNote>44 Results The studies identified and excluded at each stage and reasons for exclusion are shown in the PRISMA flow diagram ADDIN EN.CITE <EndNote><Cite><Author>Moher</Author><Year>2009</Year><RecNum>65</RecNum><DisplayText><style face="superscript">36</style></DisplayText><record><rec-number>65</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540837491">65</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moher, D.</author><author>Liberati, A.</author><author>Tetzlaff, J.</author><author>Altman, D. G.</author><author>Prisma Group</author></authors></contributors><auth-address>Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. dmoher@ohri.ca</auth-address><titles><title>Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement</title><secondary-title>PLoS Med</secondary-title></titles><periodical><full-title>PLoS Med</full-title></periodical><pages>e1000097</pages><volume>6</volume><number>7</number><keywords><keyword>Evidence-Based Practice/standards</keyword><keyword>Humans</keyword><keyword>*Meta-Analysis as Topic</keyword><keyword>Periodicals as Topic/standards</keyword><keyword>Publication Bias</keyword><keyword>Publishing/*standards</keyword><keyword>Quality Control</keyword><keyword>*Review Literature as Topic</keyword><keyword>*Terminology as Topic</keyword></keywords><dates><year>2009</year><pub-dates><date>Jul 21</date></pub-dates></dates><isbn>1549-1676 (Electronic)
1549-1277 (Linking)</isbn><accession-num>19621072</accession-num><urls><related-urls><url> in Figure One. Of the 1281 studies identified after removal of duplicates, 26 were included. Four studies reported the incidence of CES occurring in asymptomatic community populations.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdXJtZTwvQXV0aG9yPjxZZWFyPjE5ODM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 40 Table 1.Population Incidence of CESStudy details and incidence figures for the four studies reporting the incidence of CES in community dwelling asymptomatic populations are shown in Table 1. Hurme et al ADDIN EN.CITE <EndNote><Cite><Author>Hurme</Author><Year>1983</Year><RecNum>1</RecNum><DisplayText><style face="superscript">28</style></DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540835993">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hurme, M.</author><author>Alaranta, H.</author><author>Torma, T.</author><author>Einola, S.</author></authors></contributors><titles><title>Operated lumbar disc herniation: epidemiological aspects</title><secondary-title>Annales Chirurgiae et Gynaecologiae</secondary-title><alt-title>Ann Chir Gynaecol</alt-title></titles><periodical><full-title>Annales Chirurgiae et Gynaecologiae</full-title><abbr-1>Ann Chir Gynaecol</abbr-1></periodical><alt-periodical><full-title>Annales Chirurgiae et Gynaecologiae</full-title><abbr-1>Ann Chir Gynaecol</abbr-1></alt-periodical><pages>33-6</pages><volume>72</volume><number>1</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Finland</keyword><keyword>Humans</keyword><keyword>*Intervertebral Disc Displacement/ep [Epidemiology]</keyword><keyword>Intervertebral Disc Displacement/su [Surgery]</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reoperation</keyword></keywords><dates><year>1983</year></dates><isbn>0355-9521</isbn><accession-num>6847111</accession-num><urls><related-urls><url> Technologies</remote-database-provider><language>English</language></record></Cite></EndNote>28 and Podnar et alPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb2RuYXI8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 37 investigated European community dwelling populations and identified similar incidence figures of 0.48 and 0.34 cases per 100,000 population per year respectively despite different methods of case ascertainment. Hurme et al ADDIN EN.CITE <EndNote><Cite><Author>Hurme</Author><Year>1983</Year><RecNum>1</RecNum><DisplayText><style face="superscript">28</style></DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540835993">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hurme, M.</author><author>Alaranta, H.</author><author>Torma, T.</author><author>Einola, S.</author></authors></contributors><titles><title>Operated lumbar disc herniation: epidemiological aspects</title><secondary-title>Annales Chirurgiae et Gynaecologiae</secondary-title><alt-title>Ann Chir Gynaecol</alt-title></titles><periodical><full-title>Annales Chirurgiae et Gynaecologiae</full-title><abbr-1>Ann Chir Gynaecol</abbr-1></periodical><alt-periodical><full-title>Annales Chirurgiae et Gynaecologiae</full-title><abbr-1>Ann Chir Gynaecol</abbr-1></alt-periodical><pages>33-6</pages><volume>72</volume><number>1</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Finland</keyword><keyword>Humans</keyword><keyword>*Intervertebral Disc Displacement/ep [Epidemiology]</keyword><keyword>Intervertebral Disc Displacement/su [Surgery]</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reoperation</keyword></keywords><dates><year>1983</year></dates><isbn>0355-9521</isbn><accession-num>6847111</accession-num><urls><related-urls><url> Technologies</remote-database-provider><language>English</language></record></Cite></EndNote>28 identified cases of CES using surgical records, whilst Podnar et alPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb2RuYXI8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 42,43 studied an American military personnel healthcare database and found a higher incidence of 7 per 100,000 population per year in this working age population. Reito et alPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWl0bzwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 40 was the only study to divide CES into sub-categories. Two patients had CES with retention and two patients had incomplete CES making the incidence of each subtype 0.30 per 100,000 per adult population per year. Both Reito et alPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWl0bzwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 40l also reviewed clinical notes of the identified cases. Meta-analysis of the incidence estimates was not undertaken due to the heterogeneity in the reference populations studied and the methods of CES case ascertainment. Table 2.Incidence of CES in Patients with Back PainFive studies reported the proportion of patients presenting with non-traumatic lower back pain who were found to have CES.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZW5zY2hrZTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+
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ADDIN EN.CITE.DATA 23 found 0.08% of adults presenting to primary care in Australia with lower back pain were diagnosed with CES by the study rheumatologist using clinical assessment and investigation. The other four studies investigated patients presenting to secondary care and reported proportions between 0.15-0.54%.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaGlydWdhbmFzYW1iYW5kYW1vb3J0aHk8L0F1dGhvcj48
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ADDIN EN.CITE.DATA 48 and the method was not reported in one study.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaWJlcmQ8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 30 Study estimates for the proportion with CES in those presenting to secondary care with non traumatic lower back pain were combined using a random effects model to give an estimated proportion of 0.27% (95% CI: 0.14-0.54%). Study estimates and confidence intervals are shown in the forest plot in Figure 2. There was a high level of statistical heterogeneity with I2=85.2% (95% CI: 63.3%-94.0%) and Q=20.2 (p<0.001). Table 3.Incidence of Confirmed CES in Patients Suspected of CES Eighteen studies reported the proportion of patients presenting with signs and symptoms suspicious for CES who had clinical and radiological confirmation of CES. The study details are shown in Table 3. Eleven studies included only patients undergoing MRI for suspected CES.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWxsPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 5 studied only children. All other studies included adult populations but did not state whether they specifically excluded paediatric patients. A diagnosis of CES was established by cauda equina compression on MRI or operative intervention for CES. The imaging type in all studies was MRI. Only two studies described findings on MRI defining a diagnosis of CES and this was more than 50% canal compromise in one studyPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdXNzYWluPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48
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ADDIN EN.CITE.DATA 1,7,11,15,20 One study discussed subtypes of CES (with urinary symptoms, or incomplete) but did not report the numbers in each group.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CbGFkZXM8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 7 None of the other studies used subcategories or descriptors. Four studies provided information on symptom duration. Urinary symptoms in two studies were present for an average of 4 and 5.8 days in two studies and symptoms not further specified were present for between 24hours to six months and a median of 11 days in two other papers. Two studies containing small numbers of patients with CES investigated whether any symptoms or signs were predictive of CES. In the six patients assessed with bladder scanning Domen et al found urinary retention of >500mls plus at least two of: bilateral sciatica, subjective urinary retention or rectal incontinence had an odds ratio of 48 for predicting cauda equina compression on MRI. In five patients with CES Ahad et al did not find any predictive symptoms but found that patients with an abnormal MRI spine for back pain prior to CES presentation were significantly more likely to have radiological compression. These results are limited in their generalisability by the small numbers of patients involved. The proportion with confirmed CES in those presenting with suspected CES ranged from 0% to 40% in the eighteen studies. We excluded the study that included only children,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYW5lcmplZTwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+
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ADDIN EN.CITE.DATA 5 and combined the other estimates using a random effects model to give an overall estimate of confirmed CES in 18.9% (95% CI:13.6-25.6%). The forest plot is shown in Figure Three. There was a high level of heterogeneity in the study designs and the statistical heterogeneity was high with I2 = 91.9% (95% CI 88.6-94.3%) and Q = 197 (p<0.001). Table 4.Study Quality Study quality assessment is shown in Table 4. All studies described the population being studied and had representative samples. However, definitions of CES and methods used to ascertain the diagnosis of CES varied between studies and many studies did not adequately describe their methods in a way that could be easily reproduced. Only two studies reported excluded patients,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWl0bzwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 23,40 and none reported population standardised estimates. Of the 26 studies included in this review, nine were published only in abstract form.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaWJlcmQ8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 4,5,7,13,22,27,30,32,45 Studies of patients with suspected CES were of particularly poor quality. They were limited by; small sample sizes, only three (17%) studies included more than 300 participants.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaWRlcmlzPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE.DATA 7,32,45 ; by their retrospective (100%) and single centre design (100%) and by the limited information available as so many (50%) were published only as an abstract. Of the 18 studies of patients with suspected CES all but one was from the UK.DiscussionThis is the first systematic review of studies estimating the incidence of CES. 26 studies were included. The incidence of CES is low at fewer than 1 per 100,000 people in asymptomatic populations per year. Only 0.27% of those with lower back pain and only 18.9% of those with signs and symptoms consistent with CES will have a final diagnosis of radiological and clinical CES. This review identified a paucity of literature on the incidence of CES. We included all studies from which incidence of CES could be calculated, but few of the studies had a primary aim to calculate incidence. Many did not meet expected epidemiological standards as can be seen from Table 4. Sample sizes were small in symptomatic populations and estimates did not have confidence intervals and were not standardised for the populations. Few studies described exclusions or missing data. Nine studies were only published in abstract form and provided fewer methodological details and had not been through the peer review process. All abstracts and full text articles were screened by at least two reviewers and we only identified seven further studiesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BaGFkPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 40 Diagnosis was determined through clinical coding, record review, urgent operative intervention, radiology reports, clinical assessment, or any combination of these. The variation in definitions and reporting of diagnostic criteria likely reflects the lack of agreed definitions and multiple classifications of CES in use clinically and in the literatures. ADDIN EN.CITE <EndNote><Cite><Author>Fraser</Author><Year>2009</Year><RecNum>32</RecNum><DisplayText><style face="superscript">18</style></DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540837242">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fraser, S.</author><author>Roberts, L.</author><author>Murphy, E.</author></authors></contributors><auth-address>Southampton University Hospitals Trust, Southampton, Wessex Neurological Centre, Therapy Services Department, Tremona Road, Southampton SO16 6YD, United Kingdom. Stuart.Fraser@suht.swest.nhs.uk</auth-address><titles><title>Cauda equina syndrome: a literature review of its definition and clinical presentation</title><secondary-title>Arch Phys Med Rehabil</secondary-title><alt-title>Archives of physical medicine and rehabilitation</alt-title></titles><periodical><full-title>Arch Phys Med Rehabil</full-title><abbr-1>Archives of physical medicine and rehabilitation</abbr-1></periodical><alt-periodical><full-title>Arch Phys Med Rehabil</full-title><abbr-1>Archives of physical medicine and rehabilitation</abbr-1></alt-periodical><pages>1964-8</pages><volume>90</volume><number>11</number><edition>2009/11/06</edition><keywords><keyword>Evidence-Based Medicine</keyword><keyword>Humans</keyword><keyword>Polyradiculopathy/*diagnosis/etiology/pathology</keyword></keywords><dates><year>2009</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0003-9993</isbn><accession-num>19887225</accession-num><urls></urls><electronic-resource-num>10.1016/j.apmr.2009.03.021</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>18 The lack of specific clinical phenotyping covered by a broad CES definition hampers accurate assessment of incidence and contributes to the statistical heterogeneity as the incidence will likely differ depending on the definition and case ascertainment methods used. Adopting agreed definitions or defining subtypes such as those listed by Todd and Dickson ADDIN EN.CITE <EndNote><Cite><Author>Todd</Author><Year>2016</Year><RecNum>76</RecNum><DisplayText><style face="superscript">50</style></DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540837794">76</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Todd, N. V.</author><author>Dickson, R. A.</author></authors></contributors><auth-address>a Sandyford , Newcastle upon Tyne , UK ;
b University of Leeds , Leeds , UK.</auth-address><titles><title>Standards of care in cauda equina syndrome</title><secondary-title>Br J Neurosurg</secondary-title><alt-title>British journal of neurosurgery</alt-title></titles><periodical><full-title>British Journal of Neurosurgery</full-title><abbr-1>Br J Neurosurg</abbr-1></periodical><alt-periodical><full-title>British Journal of Neurosurgery</full-title><abbr-1>Br J Neurosurg</abbr-1></alt-periodical><pages>518-22</pages><volume>30</volume><number>5</number><edition>2016/05/31</edition><keywords><keyword>Ces</keyword><keyword>Cesc</keyword><keyword>Cesi</keyword><keyword>Cesr</keyword><keyword>Cess</keyword><keyword>Cauda equina syndrome</keyword><keyword>standards of care</keyword></keywords><dates><year>2016</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0268-8697</isbn><accession-num>27240099</accession-num><urls><related-urls><url> might enable more consistent reporting in future studies and allow more accurate incidence figures to be established. One study was carried out in Australia,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZW5zY2hrZTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+
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ADDIN EN.CITE.DATA 30,38,43,48 and the remainder studied European populations. It is not known whether these estimates are relevant outwith the populations and healthcare settings studied. Location may determine availability of imaging and clinical threshold for investigation. All but onePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbjwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 15 study reporting the proportion of patients with CES from those with suspected CES were carried out in the UK. This may reflect the interest in determining the yield of MRI scanning for suspected CES in a healthcare setting where access to out of hours MRI is not always readily available. Guidance from the British Association of Spine Surgeons recommends an emergency MRI for suspected CES and yet only 14% of hospitals in England and Wales surveyed in 2012 reported 24 hour access to MRI. ADDIN EN.CITE <EndNote><Cite><Author>Hauptfleisch</Author><Year>2013</Year><RecNum>353</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>353</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1541428278">353</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hauptfleisch, J.</author><author>Meagher, T. M.</author><author>King, D.</author><author>Lopez de Heredia, L.</author><author>Hughes, R. J.</author></authors></contributors><auth-address>Radiology Department, John Radcliffe Hospital, Oxford, UK.</auth-address><titles><title>Out-of-hours MRI provision in the UK and models of service delivery</title><secondary-title>Clin Radiol</secondary-title></titles><periodical><full-title>Clin Radiol</full-title></periodical><pages>e245-8</pages><volume>68</volume><number>5</number><keywords><keyword>After-Hours Care/*statistics & numerical data</keyword><keyword>England</keyword><keyword>Health Care Surveys/methods/*statistics & numerical data</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging/*statistics & numerical data</keyword><keyword>National Health Programs/*statistics & numerical data</keyword><keyword>State Medicine/statistics & numerical data</keyword><keyword>Surveys and Questionnaires</keyword><keyword>United Kingdom</keyword><keyword>Wales</keyword></keywords><dates><year>2013</year><pub-dates><date>May</date></pub-dates></dates><isbn>1365-229X (Electronic)
0009-9260 (Linking)</isbn><accession-num>23352762</accession-num><urls><related-urls><url>(13)00012-3/fulltext</url></related-urls></urls><electronic-resource-num>10.1016/j.crad.2012.12.007</electronic-resource-num></record></Cite></EndNote>21 As clinical symptoms and signs in those with radiological cauda equina compression are very difficult to distinguish from those without cauda equina compression, ADDIN EN.CITE <EndNote><Cite><Author>Fairbank</Author><Year>2011</Year><RecNum>34</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>34</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1540837372">34</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fairbank, J.</author><author>Hashimoto, R.</author><author>Dailey, A.</author><author>Patel, A. A.</author><author>Dettori, J. R.</author></authors></contributors><auth-address>Nuffield Orthopaedic Centre, Oxford, UK.</auth-address><titles><title>Does patient history and physical examination predict MRI proven cauda equina syndrome?</title><secondary-title>Evid Based Spine Care J</secondary-title></titles><periodical><full-title>Evid Based Spine Care J</full-title></periodical><pages>27-33</pages><volume>2</volume><number>4</number><dates><year>2011</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1663-7976 (Print)
1663-7976 (Linking)</isbn><accession-num>23230403</accession-num><urls><related-urls><url> this leads to a situation in which many patients are transferred to specialist centres for an MRI outside office hours and then either transferred back or discharged from locations that can be far from home. In healthcare settings with pressure on MRI services, such as the UK, the threshold for investigating patients with MRI for suspected CES may be higher than in a situation where MRI is quickly and readily available 24 hours a day. It is not known whether easy access to MRI correlates with a lower diagnostic yield of positive scans for cauda equina compression on MRI due to an increased overall number of patients undergoing MRI. Healthcare service planning for the investigation and management of CES needs to balance the needs of the majority population with the few CES cases in whom a missed diagnosis or delayed treatment could have significant health and social care consequences for the patient plus medicolegal consequences for the surgeon and healthcare service. Different medico-legal implications in different countries may affect the threshold for investigating and diagnosing CES, which will ultimately affect estimates of incidence. Between 2013 and 2016, there were 131 claims relating to CES in the UK with a projected value of GBP 68 million. ADDIN EN.CITE <EndNote><Cite><Author>Machin</Author><Year>2018</Year><RecNum>355</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>355</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1569493921">355</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Machin, J. T.</author><author>Hardman, J.</author><author>Harrison, W.</author><author>Briggs, T. W. R.</author><author>Hutton, M.</author></authors></contributors><auth-address>Nottingham University Hospitals NHS Trust, Chesterfield Royal Hospital NHS Foundation Trust, NHS Improvement, London, UK.
Whittington Health NHS Trust, London, UK. John.hardman4@.
Mersey Deanery, Liverpool, UK.
The Royal National Orthopaedic Hospital (Stanmore) NHS Trust, NHS Improvement, London, UK.
Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.</auth-address><titles><title>Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS</title><secondary-title>Eur Spine J</secondary-title><alt-title>European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society</alt-title></titles><periodical><full-title>Eur Spine J</full-title></periodical><pages>2693-2699</pages><volume>27</volume><number>11</number><edition>2018/08/29</edition><keywords><keyword>*Litigation</keyword><keyword>*Malpractice</keyword><keyword>*Medicolegal</keyword><keyword>*Negligence</keyword></keywords><dates><year>2018</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0940-6719</isbn><accession-num>30151803</accession-num><urls></urls><electronic-resource-num>10.1007/s00586-018-5739-1</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>34 These were most commonly due to delay in diagnosis or treatment. ADDIN EN.CITE <EndNote><Cite><Author>Machin</Author><Year>2018</Year><RecNum>355</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>355</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1569493921">355</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Machin, J. T.</author><author>Hardman, J.</author><author>Harrison, W.</author><author>Briggs, T. W. R.</author><author>Hutton, M.</author></authors></contributors><auth-address>Nottingham University Hospitals NHS Trust, Chesterfield Royal Hospital NHS Foundation Trust, NHS Improvement, London, UK.
Whittington Health NHS Trust, London, UK. John.hardman4@.
Mersey Deanery, Liverpool, UK.
The Royal National Orthopaedic Hospital (Stanmore) NHS Trust, NHS Improvement, London, UK.
Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.</auth-address><titles><title>Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS</title><secondary-title>Eur Spine J</secondary-title><alt-title>European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society</alt-title></titles><periodical><full-title>Eur Spine J</full-title></periodical><pages>2693-2699</pages><volume>27</volume><number>11</number><edition>2018/08/29</edition><keywords><keyword>*Litigation</keyword><keyword>*Malpractice</keyword><keyword>*Medicolegal</keyword><keyword>*Negligence</keyword></keywords><dates><year>2018</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0940-6719</isbn><accession-num>30151803</accession-num><urls></urls><electronic-resource-num>10.1007/s00586-018-5739-1</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>34 In the USA the average payout of 15 lawsuits related to CES between 1983 and 2010 was USD 1.57 million. ADDIN EN.CITE <EndNote><Cite><Author>Daniels</Author><Year>2012</Year><RecNum>356</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>356</rec-number><foreign-keys><key app="EN" db-id="ara50apwidfr22ev5adxdppd0frtwzseersp" timestamp="1569493921">356</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Daniels, E. W.</author><author>Gordon, Z.</author><author>French, K.</author><author>Ahn, U. M.</author><author>Ahn, N. U.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.</auth-address><titles><title>Review of medicolegal cases for cauda equina syndrome: what factors lead to an adverse outcome for the provider?</title><secondary-title>Orthopedics</secondary-title><alt-title>Orthopedics</alt-title></titles><periodical><full-title>Orthopedics</full-title></periodical><alt-periodical><full-title>Orthopedics</full-title></alt-periodical><pages>e414-9</pages><volume>35</volume><number>3</number><edition>2012/03/06</edition><keywords><keyword>Health Personnel/*legislation & jurisprudence/*statistics & numerical data</keyword><keyword>Humans</keyword><keyword>Malpractice/*statistics & numerical data</keyword><keyword>Polyradiculopathy/*epidemiology/*surgery</keyword><keyword>Postoperative Complications/*epidemiology</keyword><keyword>United Kingdom/epidemiology</keyword></keywords><dates><year>2012</year><pub-dates><date>Mar 7</date></pub-dates></dates><isbn>0147-7447</isbn><accession-num>22385455</accession-num><urls></urls><electronic-resource-num>10.3928/01477447-20120222-15</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>12 It is unknown whether the frequency of legal action for CES in a country is associated with the clinical threshold for investigation of symptoms with an MRI as all but one study of patients with suspected CES were carried out in the UK. The high legal costs to the health service of a missed case must be weighed against the costs involved in implementing systems to ensure timely MRI scanning in patients with suspected CES. Most patients investigated for suspected CES do not have radiological compression on MRI. Although final diagnoses in patients without cauda equina compression include demyelination, myelitis, and infection, the majority of patients do not have a structural cause found.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2VyaXR6YXVlcjwvQXV0aG9yPjxZZWFyPjIwMTg8L1ll
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ADDIN EN.CITE.DATA 26 could increase the yield of MRI scanning for suspected CES. However, due to the significance of a missed diagnosis, expansion of local out of hours MRI provision is more likely to improve care for those investigated for CES with and without structural radiological cauda equina compression. Local MRI services would avoid unnecessary transfer of patients to tertiary services which they do not require. ConclusionCES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Major limitations in the published literature make it difficult to provide evidence based services for patients with CES. Multi-centre and international studies are required. 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Ann R Coll Surg Engl 93:76-80, 201148.Thiruganasambandamoorthy V, Turko E, Ansell D, Vaidyanathan A, Wells GA, Stiell IG: Risk factors for serious underlying pathology in adult emergency department nontraumatic low back pain patients. J Emerg Med 47:1-11, 201449.Todd NV: Causes and outcomes of cauda equina syndrome in medico-legal practice: a single neurosurgical experience of 40 consecutive cases. Br J Neurosurg 25:503-508, 201150.Todd NV, Dickson RA: Standards of care in cauda equina syndrome. Br J Neurosurg 30:518-522, 2016Figure LegendsFigure 1. PRISMA Flow Diagram. Studies identified, included, and excluded. Figure 2. Forest plot. Proportion and number (events) of patients with cauda equina syndrome amongst those presenting with non traumatic lower back pain to secondary care. Summary proportion calculated using a random effects model. Figure 3. Forest plot. Proportion and number (events) of patients with confirmed cauda equina syndrome amongst those referred to secondary or tertiary care facilities for assessment for possible cauda equina syndrome. Summary proportion calculated using a random effects model. Appendix 1: Search StrategiesOvid EMBASE 1980 to 2018 Week 31 Cauda equina syndrome/ cauda equina.ti,ab.Cauda Equina/1 or 2 or 3Incidence/ or Prevalence/Epidemiology/(incidence* or prevalen* or epidemiolog* or frequenc* or rate* or occurrence*).ti,ab5 or 6 or 74 and 8Scopus 30th July 2018“cauda equina” (incidence* or prevalen* or epidemiolog* or frequenc* or rate* or occurrence*) 1 AND 2 TablesTABLE 1. Incidence of CES in asymptomatic community populationsAuthors & StudyYrs of StudyTime PeriodReference Population Definition of CESTotal PopulationTotal CasesCases/ 100,000/ Yr (95 %CI)Hurme et al.,19831975–19795 yrsHospital catchment population, Finland Undergoing operation for CES455,000110.48*Podnar, 20071996–20048 yrsPopulation of SloveniaHistory, examination, neurophysiology & radiology1,989,198670.34Schoenfeld & Bader, 20122001–20109 yrsAmerican Military Database, USICD code13,871,384 person-yrs$9767Reito et al., 20182012–20143 yrsHospital catchment population, FinlandICD code; SBNS guideline subcategories based on clinical records661,902 adult person-yrs?40.6 (0.16–1.5)* Calculated from values given in paper. ? Reported as the total number of people in the population in the total number of years during the study time period.TABLE 2. Incidence of CES in patients presenting with back painAuthors & StudyYrs of StudyTime PeriodReference Population Definition of CESTotal PopulationTotal CasesProportion w/ CES (95% CI)Henschke et al., 20092003–200520 mosPrimary care, AustraliaRheumatologist assessment (history, exam, tests)117210.08% (0.0–0.5%)Thiruganasambandamoorthy et al., 20142009-20103 mosAdults, ED, Canada Clinician determined32910.30%Kiberd et al., 2018Not stated7 yrsED, CanadaNot stated38714570.15%Premkumar et al., 20182005–201611 yrsSpinal surgeon, USICD code9940360.36%Reito et al., 20182012–20143 yrsAdults, ED, FinlandICD code; SBNS guideline subcategories – based on clinical records900 visits; 737 patients40.44% per visit; 0.54% per patientED: emergency department; SBNS = Society of British Neurological Surgeons.TABLE 3. Incidence of CES in patients presenting with suspected CESAuthors & StudyYrs of StudyTime PeriodReference Population: Potential CESDefinition of CESImaging TypeTotal PopulationTotal CasesProportion w/ CES Bell et al., 2007Not stated4 mosMRI for ?CES, neurosurgery, UK MRI CE compression MRI23521.7%Crocker et al., 2008Not stated2 yrsOOH MRI for ?CES, Neurosurgery, UKSurgery for CESMRI822732.9%Demetriades et al., 200920081 yrOOH MRI for ?CES, neurosurgery, UKDisc on MRI & surgery for CES MRI331030.3%Domen et al., 20092003–20075 yrsUrgent MRI for ?CES neurology/ED, the Netherlands Radiology report MRI CE compressionMRI58813.8%Rooney et al., 2009200410 mosMRI for ?CES, neurosurgery, UKSurgery for CESMRI661624.2%Balasubramanian et al., 201020081 yrMRI for ?CES, spinal surgery, UK Radiology report >75% canal compromiseMRI801518.8%Thangarajah et al., 20112006–20071 yrUrgent spinal MRI, teaching hospital, UKNot statedMRI8100%Gooding et al., 201320081 yrMRI for ?CES, Hospital w/ Spinal Unit, UKRadiology report CE compression MRI571322.8%Haworth et al., 20132009–20113 yrsOOH MRI for ?CES, neurosurgery, UKMRI CE compressionMRI1623924.1%Sideris et al., 20142010–20134 yrs?CES, neurosurgery, UK Clinical & radiological CESMRI66380+12.0%Ahad et al., 20152012–20138 mosUrgent spinal MRI, hospital, UKMRI CE compressionMRI7956.3%Blades et al., 20152008–20147 yrs?CES, spinal unit, UK MRI CE compression MRI34413740%Hoeritzauer et al., 20152013–20146 mosUrgent MRI for ?CES spinal unit, UKMRI CE compressionMRI18738.9%Hoeritzauer et al., 20172013–201416 mos?CES, neurosurgery, UKMRI CE compressionMRI2909131.4%Kostusiak et al., 20182014–20174 yrsOOH MRI for ?CES, neurosurgery, UKRadiology report CE compressionMRI323154.6%Hussain et al., 20182013–2014 14 mos?CES, neurosurgery, UK >50% canal compromise on MRIMRI2503212.8%Banerjee, 20182014–20163 yrs?CES, district hospital, UKMRI CE compressionMRI43716.3%Banerjee & Jalgaonkar, 20182012– 20175 yrsChildren (0–15 yrs), ?CES, district hospital, UKMRI CE compressionMRI1500%CE = cauda equina; OOH = out of hours.* Calculated from paper.Table 4: Study Quality and Risk of Bias in Included StudiesAuthors & StudyTarget population clearly describedCases from entire population probability sampling Sample size >300Response rate >70%Non-responders clearly describedSample representativeStandardised data collectionDiagnostic criteria describedEstimates given with confidence intervalsStandardised estimates reportedHurme et al., 1983YYY?NYYNNNPodnar, 2007YNY?NYYYNNSchoenfeld & Bader, 2012YYY?NYYYNNReito et al., 2018YYYYYYYYYNHenschke et al., 2009YNY?NYYYYNThiruganasambandamoorthy et al., 2014YYY?NYYNNNKiberd et al., 2018YYY?NY?NNNPremkumar et al., 2018YNY?NYYYNNBell et al., 2007YYN?NYYYNNCrocker et al., 2008YYN?NYYNNNDemetriades et al., 2009YYN?NY?YNNDomen et al., 2009YYN?NYYYNNRooney et al., 2009YYNNNYYYNNBalasubramanian et al., 2010YYN?NYYYNNThangarajah et al., 2011YYN?NYNNNNGooding et al., 2013YYN?NY?YNNHaworth et al., 2013YYN?NY?NNNSideris et al., 2014YYY?NYYNNNAhad et al., 2015YYN?NYYNNNBlades et al., 2015YYY?NYYNNNHoeritzauer et al., 2015YYN?NYYYNNHoeritzauer et al., 2017YYN?NYYNNNBanerjee, 2018YYN?NY?NNNBanerjee & Jalgaonkar, 2018YYN?NY?NNNHussain et al., 2018YYN?NYYYNNKostusiak et al., 2018YYY?NYYNNNStudies were assessed against the 11 pre-specified criteria. Y represents “Yes” and N represents “No”. Where no information is given in the study report there is a question mark. FiguresFigure 1. PRISMA Flow Diagram. Studies identified, included, and excluded. Figure 2. Forest plot. Proportion and number (events) of patients with cauda equina syndrome amongst those presenting with non traumatic lower back pain to secondary care. Summary proportion calculated using a random effects model. Figure 3. Forest plot. Proportion and number (events) of patients with confirmed cauda equina syndrome amongst those referred to secondary or tertiary care facilities for assessment for possible cauda equina syndrome. Summary proportion calculated using a random effects model. ................
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