RED FLAGS & CAUDA EQUINA Stuart Fraser Physiotherapist Wessex Neuro Department Good afternoon everyone, I have been invited here today to talk to you about red flags and CES. For those of you that do not know me, and I think that is nearly all of you, I thought I would just tell you a bit about where I work. I currently work as a physiotherapist in the wessex neurological centre at SGH. This is a regional neurology and neurosurgical centre serving a population of approximately 3 million. We have a team of 10 physios working in the unit and our work load is varied! Southampton University Hospitals NHS Trust

We deal with any insults to your nervous system We deal with any insults to your nervous system. So that can be an acute head injury such as this unfortunate patient to your GBS, parks, facial palsies, or any intra cranial or spinal pathologies such as SOL. And it’s the spinal pathologies that fuelled my interest in red flags. We were having patients in who had had previous physio, chiropractic, osteopathy or DGH consultations for a considerable time before their serious spinal pathology was identified. So this led to a simple question Where red flags being missed

Background WHAT IS A RED FLAG ? In order to answer this you have to look at what a red flag is And im sure that if I were to ask any of you today you would be very comfortable in answering this question. Well we thought we would answer this quetsion by looking at the evidence base for red flags!

Background Patient response or finding on history taking and physical examination that are associated with a serious spinal pathology. A commonly used description of a red flag is a response or finding on questioning and examining your patient that may indicate a serious spinal pathology. So the importance for us as clinicians is that what we ask our patients, what we examine, could indicate a serious pathological processs,

Background LITERATURE SEARCH 40 Papers Specifying Red Flags INTERNATIONAL GUIDELINES 8 International Guidelines So myself and two other physios conducted a literature search on red flags using electronic databases. We identified 40 papers specifiying red flags. We also decided to look at the international guidelines as surely serious spinal pathologies are universal and so a red flag should be the same wherever you are in the world. We managed to obtain 8 of the international guidelines and were missing the finnish and one other.

Source: CSP Guidelines Development Group Red Flags 100% Unanimity 75 – 99% Consensus 51 – 74% Majority view 0 – 50% No consensus Source: CSP Guidelines Development Group Once we had the papers and guidelines we applied the CSP guidelines development group format, whereby 100% of the articles would give a unanimous decision on any aspect of red flags. So what did we find.

Guideline Findings Unanimity 100% Weight Loss Previous History of Cancer Systemic Steroids Well if we look at the guidelines first, there was unanimity that weight loss, a history of Cancer and the use of systemic steroids were all red flags in patients with back pain. But lets just think about this for a minute. Red flags are associated with serious spinal pathology. How many of your patients with serious spinal pathology initially presented with any of the above three. Most of my patients are actually over weight, young with no past medical history and no drug history.

Guideline Findings Consensus 75 – 99% Violent trauma Difficulty with micturition Reduced anal tone Saddle anaesthesia Widespread/progressive neuro Interestingly, if you think about how red flags are taught today and documented in text books, these three commonly referrred to as CES are an absolute red flag, yet there is no unanimity in the guidelines, nor on progressive neurology!!! Where I work one of the key things that would ring alarm bells!!!!

Guideline Findings Majority view 51 – 74% Age <20 or > 55 Constant progressive pain IV drug use / HIV Systemically unwell Gait disturbance Structural deformity If we look at where there was less consensus within the guidelines, there was only a majority view, so just over half of the guidelines documeneted …………

What do Red Flags Signify ? Possible serious spinal pathology Tumour / malignancy Infection Fracture So what sort of serious pathologies are we talking about. Well the big three are tumour infection and fracture. If you pick infection though, there is no consensus, only a majority view in the guidelines so less than three quarters of the guidelines identify progressive pain,or being systemically unwell as red flags to be alert for. For fracture, there is no unanimous decision that trauma and back pain may be indicative of this!

And here are just a few pretty pictures of some of our patients with serious pathologies.

Literature Consensus 75 – 99% Weight loss Previous history of cancer So if we look at the literature, the findings are different to the international guidelines. There is no unanimous decision on any aspect, there is a consensus on weight loss and history of canacer

Literature Majority view 51 – 74% Night pain Age > 50 years Violent trauma Fever Saddle anaesthesia Difficulty with micturition IV drug abuse Progressive neuro Systemic steroids And even less consensus, only a majority view on the above. Think about it, according to the current literature, less than 3 quarters and in some aspects only half of the papers reviewed thought that any of the above were red flags.

Conclusion Inconsistency in the literature as to what red flags signify Inconsistency in identifying true red flags So in conclusion, with our findings identifying over 100 individual red flags. There is a marked inconsistency within the literature and also within the guidelines.

Cauda Equina Syndrome So with all the inconsistencies on red flags as a whole we were a little lost and confused, we decided to take just one red flag, that of CES and apply the same process to that.

What is Cauda equina syndrome ? The evidence from the red flags search was inconsistent, so we decided to ask the simple question what was CES.

Heres just a little picture of your CES, for those of unclear as to what it looks like

Literature 118 PAPERS REVIEWED Again we searched the electronic databases using the key search words, CES and definition, clinical presentation, signs and symptoms, pathology and aetiology. The search identified a very painfull 118 papers.

Definition “A complex of low back pain, bilateral sciatica, saddle anaesthesia, motor weakness in the lower extremities with bowel and bladder incontinence.(Kostuik1986)”

Definition General Statement Pathomechanical Clinical presentation

Source: CSP Guidelines Development Group Cauda Equina 100% Unanimity 75 – 99% Consensus 51 – 74% Majority view 0 – 50% No consensus Source: CSP Guidelines Development Group

Pathology 86% No Consensus (0 – 50%) Disc 45% Tumour 29% Infection 28%

Pathology 65 Pathologies identified Metastatic - vertebral SOL - medullary / dural Specific - chordoma - sarcoma - chondroblastoma

Literature Findings Interview Examination Majority View (51 – 74%) Bladder 74% Bowels 57% Pain 57% Sensation 66% Power 53% No Consensus (0 – 50%) Sexual Function 13% Reflexes 33%

Bladder Retention 41% Incontinence 36% Dysfunction 32% 40 – Subcategories Retention 41% Incontinence 36% Dysfunction 32%

Sensation 42 - Subcategories Specific Location 59% Non Specific 17%

Bowels Sphincter Tone 34% Dysfunction 25% Incontinence 21% 15 – Subcategories Sphincter Tone 34% Dysfunction 25% Incontinence 21%

Pain 42 – Subcategories Specific Location 42% Nature 13%

Power 35 – Subcategories Non Specific 29% Bilateral 18% Specific muscle / location 14%

Summary of Findings Category Consensus (75 – 99%) Majority View (51 – 74%) Pathology Bladder Sensation Specific Location Bowels Pain Power

Clinical implications Acute or Chronic Pathological process

Clinical Implications So what can you do? Should you change your clinical practice?

Any Questions ? Stuart.Fraser@suht.swest.nhs.uk Thank You Any Questions ? Stuart.Fraser@suht.swest.nhs.uk