Developing Consensus on the Diagnosis and Management of Cauda Equina Syndrome: A Modified Delphi Study

Cauda equina syndrome (CES) necessitates urgent intervention to prevent permanent neurological damage. Current literature calls for decompression within 48 hours of symptom onset. Great heterogeneity exists in criteria informing surgical decision-making. Unified consensus statements may provide clarity in these topics.

We performed a modified Delphi study to investigate CES diagnosis and management. A 30-question survey was distributed to 18 spine surgeons, addressing diagnosis, sensorimotor/bladder/bowel findings, and surgical decision-making. Consensus was ≥ 80% agreement (agree/strongly agree) or ≤ 20% agreement (consensus to opposite statement) on a 4-point Likert scale. Teleconferences and final survey followed to clarify contentious statements.

18 responses were received (15 neurosurgeons, 3 orthopedic surgeons). 17 statements achieved final consensus, pertaining to diagnosis (4), sensorimotor findings (4), bowel/bladder function (1), and surgical management (8). In our practice, 100% consensus was achieved for sensorimotor findings in CES comprising a constellation of symptoms, including pain and/or paresthesia and/or lower extremity motor weakness, and for time to decompression to be informed by duration and severity of symptoms. 94% consensus was achieved on one of the following symptoms required to diagnose CES: lower extremity motor dysfunction, bowel/bladder dysfunction, or saddle anesthesia, in addition to confirmatory MRI.

We present institutional consensus on key factors in CES symptom identification and operative management. Our local findings highlight the importance of recognizing the heterogeneous presentation of CES and the utility of combining symptom acuity with clinical context for operative planning. We hope they spur further discussion in CES management on a national scale.