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Crocker and colleagues reported a total of 125 patients. Eighty-two patients had emergency admission for suspected cauda equina syndrome of whom 27 (33%) required a surgical procedure. Only five patients (6%) required emergency surgery.
Forty-three patients in the same 2-year period had a lumbar discectomy because of a cauda equina syndrome. Did those 43 patients include the 27 patients who required surgery following emergency magnetic resonance imaging (MRI)? It is difficult to reconcile the numbers. For example, 27 patients of the 82 who had emergency MRI required surgery which ought to leave only 16 patients (43–27) who required surgery following diagnostic imaging at another hospital whereas the paper quotes 32 of the 43 patients had diagnostic imaging from another hospital. Some of these difficulties clearly relate to the retrospective nature of this study which the authors recognise.
This study is an important contribution to the literature because the issues of (i) when and where to image patients with symptoms that might be a consequence of cauda equina compression (ii) when, or if, such patients should be assessed by neurosurgeons and (iii) when, or if, such patients should have a surgical operation is much debated and this is significant in relation to practice for all surgeons who see such patients.
Given the retrospective nature of their study, Crocker and co-workers were unable to identify the neurological status of their patients in any detail. This is understandable but, in fact, management decisions in this area are crucially related to the patient' neurological status at the time of primary diagnosis. May I offer the following facts at least as so far as we understand them together with some conclusions which I hope would enhance the authors' observations and conclusions?
Taking all of this into account, the following algorithm may be helpful:
I do hope that this clinical algorithm adds strength to the conclusions set out by Crocker and colleagues. I agree that many patients can appropriately have imaging performed promptly within the DGH but it is important that we have a selective approach to: (i) patients who should be initially managed at the DGH; (ii) patients who require urgent or emergency MRI; and (iii) patients who require urgent or emergency treatment.