An evaluation of individuals who repeatedly present with suspected cauda equina syndrome

Cauda Equina Syndrome (CES) is a surgical emergency and an intimidating medico-legal challenge. Poor clinical specificity leads to a high rate of negative (normal/No-CES) MRI scans, placing additional burden on emergency services. A proportion of patients re-present with CES-like symptoms. The aim of this study was to assess this cohort of patients and identify the incidence, clinical risk factors, comparative MRI-findings and predictive factors for subsequent True-CES.

Retrospective review of prospective data of patients aged 18-65 years, who first attended with suspected-CES with a normal MRI, between January 2019-December 2022; and re-presented with suspected-CES within one year. Patients with True-CES or abnormal MRI pathology at first attendance were excluded. Clinical, bladder scan and MRI findings from first and re-presentation visits were recorded and statistically analysed.

922 patients were included, 56 (6%) had True-CES on MRI and 356 met exclusion criteria, leaving 510 patients with normal MRI on initial presentation. 43 patients (8%) re-presented within one year (mean interval 152 days), and 7 presented a third time (mean interval 126 days). There was no significant difference in clinical symptoms, gender and bladder scans between presentations. No patient showed True-CES on re-presentation MRI, all demonstrating the same MRI findings as the initial scan.

This is the largest series of patients that evaluates re-presentations of suspected-CES after initial attendance with normal/No-CES MRI. There were no significant clinical/radiological differences between presentations. No patient showed True-CES on re-presentation MRI, and therefore, no predictive factors were identified.