SHADES of grey – The challenge of 'grumbling' cauda equina symptoms in older adults with lumbar spinal stenosis. (February 2020)

• Record Type: Journal Article
• Authors: Comer, Christine; Finucane, Laura; Mercer, Chris; Greenhalgh, Susan
• Is Part Of: Musculoskeletal science and practice. Volume 45(2020)
• Publication Date: 2020-02
• Subjects: Lumbar spinal stenosis -- Neurogenic claudication -- Cauda equina syndrome -- Red flags -- Signs and symptoms; Manipulation (Therapeutics) -- Periodicals; Physical therapy -- Periodicals; Neuromuscular diseases -- Treatment -- Periodicals; Musculoskeletal system -- Diseases -- Periodicals; Manipulation (Therapeutics); Neuromuscular diseases -- Treatment; Physical therapy; Manipulation, Orthopedic; Musculoskeletal Diseases -- therapy; Neuromuscular Diseases -- therapy; Physical Therapy Modalities; Electronic journals; Periodicals; 615.82
• DOI: 10.1016/j.msksp.2019.102049
• Languages: English
• ISSNs: 2468-8630

Abstract

Abstract: Diagnosing cauda equina syndrome is challenging in older adults with lumbar spinal stenosis. Understanding these challenges is vital for clinicians who are faced with difficult decisions about when to refer for investigation or surgical management. This is a growing clinical issue because of the escalating prevalence of lumbar spinal stenosis in our ageing population, and increasing demands on healthcare services including imaging and surgical services. This professional issue explores the challenges and evidence gaps relating to cauda equina syndrome in older adults with lumbar spinal stenosis. The degenerative patho-anatomical changes in the lumbar spine that are responsible for lumbar spinal stenosis also have the potential to lead to a gradual compromise of the cauda equina nerve roots. The clinical presentation may be unclear. As a result, there is a risk that slow-onset 'grumbling' cauda equina symptoms may be overlooked or dismissed in older patients with lumbar spinal stenosis. Furthermore, a lack of standardised diagnostic criteria and management pathways add to the challenges for clinicians diagnosing and managing potential cauda equina compromise associated with lumbar spinal stenosis. We recommend careful assessment, appropriate safety netting, and ongoing clinical monitoring and vigilance when assessing and managing this potentially vulnerable patient group. Highlights: Lumbar Spinal Stenosis (LSS) is increasingly prevalent in our ageing population. 'Grumbling' cauda equina syndrome (CES) may be overlooked in this population. Clinicians face considerable challenges in the differential diagnosis of CES in LSS. Careful assessment, clinical reasoning and vigilance are essential. We recommend a safety first approach incorporating safety netting those at risk.