Rising suspicion, stable disease: an 8-year analysis of suspected and confirmed cauda equina syndrome
Elie Najjar1, Shahbaz Khan1, Rawan Masarwa1
1Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK.
Background Context:
Suspected cauda equina syndrome (CES) referral pathways are designed to maximise sensitivity, often prompting urgent MRI based on single red-flag features. Rising referral volumes have raised concern that pathway-driven behaviour may not reflect true disease incidence. Longitudinal analyses anchored to robust diagnostic adjudication remain limited.
Purpose:
To evaluate temporal trends in suspected CES referrals over 8 years within a regional tertiary spinal service, using multidisciplinary team (MDT) clinico-radiological consensus as the diagnostic gold standard.
Study Design/Setting:
Retrospective observational cohort study at a regional tertiary spinal centre.
Patient Sample:
Consecutive adult patients referred with suspected CES between 2016 and 2023.
Outcome Measures:
Confirmed CES (CES+) based on MDT consensus; referral volume, red-flag prevalence, objective bladder metrics, and diagnostic yield.
Methods:
Temporal trends were analysed across the study period. Objective urinary retention was defined as postvoid residual (PVR) >200 mL or catheterisation at presentation.
Results:
A total of 1,188 referrals were included, of which 163 (13.7%) were confirmed as CES+. Referral volume increased significantly over time (p<.001) with substantial inter-annual variability, whereas confirmed CES incidence and demographic characteristics remained stable. The prevalence of individual red-flag features showed no consistent directional change, and diagnostic yield did not improve over time. Measured bladder volumes (prevoid>500 mL and PVR>200 mL) declined significantly (p=.0165 and p=.0238, respectively); however, composite objective urinary retention demonstrated no significant linear trend (p=.120). Among confirmed CES+ cases, symptom profiles varied nondirectionally across years, and objective urinary retention remained a common feature.
Conclusions:
MDT-confirmed CES demonstrates epidemiologic and phenotypic stability despite substantial fluctuation in suspected referral activity. Referral volume appears highly sensitive to pathway structure and system-level factors and should not be interpreted as a surrogate for disease incidence. Declining bladder volumes do not indicate earlier detection, and CES remains a heterogeneous neurological syndrome not defined by isolated red-flag features.
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