Back Pain, Bladder Dysfunction and Lower Limb weakness in Older Adults: Improving Recognition of Cauda Equina Syndrome

Introduction

Cauda Equina Syndrome (CES) is a time-critical neurosurgical emergency in which delayed diagnosis may cause irreversible neurological disability. Diagnosis in older adults is challenging because back pain, bladder dysfunction and reduced mobility commonly coexist with age-related comorbidities. This quality improvement initiative evaluated the clinical characteristics of MRI-confirmed CES in older adults and the effect of introducing routine post-void residual (PVR) measurement.

Methods

A retrospective clinical audit reviewed adults undergoing lumbosacral MRI for suspected CES at a tertiary neurosurgical referral centre in Ireland (University Hospital). Clinical presentation, MRI findings and PVR documentation were analysed. Following the initial audit, routine PVR measurement before MRI was incorporated into the local CES pathway. A re-audit assessed compliance.

Results

A total of 118 adults (≥18 years) underwent MRI for suspected CES, including 29 aged ≥65 years. Twenty (17.0%) had MRI-confirmed CES, of whom eight (40%) were aged ≥65 years. Older adults had a higher MRI confirmation rate than younger adults (27.6% vs 13.5%).

Back pain was present in all MRI-confirmed cases. Lower limb weakness occurred in 19/20 (95%) overall and 8/8 (100%) of older adults. Saddle paraesthesia occurred in 17/20 (85%) overall and in 6/8 (75%) older adults. Urinary and/or faecal incontinence occurred in 15/20 (75%) overall and in 7/8 (87.5%) older adults. PVR was documented in 10% during the initial audit. Following multiple education sessions, a re-audit of 85 patients found PVR documentation in 78/85 (92%); 3/12 (25%) MRI - confirmed cases had abnormal PVR.

Conclusion

Universal back pain, and frequent lower limb weakness and incontinence among older adults emphasise the need for a high index of suspicion for CES. Routine PVR assessment markedly improved adherence to the diagnostic pathway, demonstrating that a simple intervention can enhance assessment of this time-critical neurosurgical emergency.