What is the diagnostic accuracy of red flags related to cauda equina syndrome (CES), when compared to Magnetic Resonance Imaging (MRI)? A systematic review. (July 2019)

• Record Type: Journal Article
• Authors: Dionne, Nathalie; Adefolarin, Abiodun; Kunzelman, Dena; Trehan, Nitin; Finucane, Laura; Levesque, Lenerdene; Walton, David M.; Sadi, Jackie
• Is Part Of: Musculoskeletal science and practice. Volume 42(2019)
• Page Start: 125
• Page End: 133
• Publication Date: 2019-07
• Subjects: Cauda equina syndrome -- Low back pain -- Signs and symptoms -- Red flags -- Accuracy -- MRI; 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.2019.05.004
• Languages: English
• ISSNs: 2468-8630

Abstract

Abstract: Objective: To review and statistically pool available evidence on the diagnostic accuracy of red flags to clinically identify MRI confirmed Cauda Equina Syndrome (CES). Study design: Systematic review. Data sources: Embase, Scopus, Ovid Medline, Ovid Healthstar, Amed and CINAHL from inception to January 30, 2018 and a grey literature search. Inclusion criteria: Primary diagnostic studies, published in English; comparing red flags for CES; to Magnetic Resonance Imaging (MRI) as reference standard; in humans; older than 18 years. Methods: Data extraction, assessment of study quality using a modified QUADAS-2 tool and the use of GRADE to synthesize the results for each test was performed by three independent assessors. Diagnostic accuracy statistics applied to the identified data andpooled analysis performed using Meta-DiSc, version 1.4. Moderator analyses planned for pooled results. Results: Seven studies (total N = 569 participants) were included. Potential signs or symptoms of CES were compared to MRI findings. Diagnostic data could be pooled for reduced anal tone, leg pain, back pain, saddle anaesthesia, urinary retention, urinary incontinence and bowel incontinence from six of seven studies. The pooled sensitivity for the signs and symptoms ranged from 0.19 (95% CI 0.09 to 0.33) to 0.43 (95% CI 0.30 to 0.56) while the pooled specificity ranged from 0.62 (95% CI 0.59 to 0.73) to 0.88 (95% CI 0.85 to 0.92). Conclusion: Red flags used to identify potential CES appear to be more specific than sensitive. As such, when these are present, they should be considered justification for prompt diagnostic workup. Highlights: Diagnostic accuracy of red flags used to identify cauda equina syndrome is poor. Most of the pooled red flags showed heterogeneity for sensitivity and specificity. Saddle anesthesia had the best overall diagnostic value of the red flags. Bilateral leg pain had the highest pooled sensitivity of the red flags. Back pain was the red flag with the best negative likelihood ratio.