Is scan‐negative cauda equina syndrome a functional neurological disorder? A pilot study, 2020, Gibson et al

[Andy]

One of the co-authors is Anthony David, the 'esteemed psychiatrist' from the article discussed here, UK Times:'What if the thing that’s making you physically ill is your mind?', Feb 2020, Rumbelow [includes ME]

Abstract
Background

Cauda equina syndrome (CES) is a neurosurgical emergency which warrants a lumbar MRI. Many patients with suggestive symptoms of CES have no radiological correlate. A functional (non‐organic) aetiology has been proposed in some, but currently little is known about this patient group and their clinical outcomes.

Methods
At a tertiary referral centre, 155 adult patients underwent urgent lumbar MRI for suspected CES in one year from December 2014. Data regarding clinical symptoms and follow‐up were obtained from records. Patients were divided into CES (n=25), radiculopathy (n=68) and scan‐negative (SN) groups (n=62) from scans. Up to 3 years post‐discharge, postal questionnaires were sent to patients with Owestry Disability Index, Pain Catastrophising score, PHQ‐9, GAD‐7, PHQ‐15 and WSAS measures.

Results
No clinical symptoms were found to differentiate CES from SN patients. Functional co‐morbidities were significantly more common in SN patients but mental health diagnosis frequency did not differ. Follow‐up was variable with no consistent referral pathways, particularly for the SN group. 33% (n=47) responded to postal questionnaires; high levels of pain, symptom chronicity and disability were ubiquitous but self‐reported mental health diagnoses and PHQ‐15 were higher for SN patients.

Conclusions
Conflicting data suggests further research is needed to investigate the prevalence of mental illness and somatic symptoms in SN cases. SN patients have higher rates of co‐morbid functional disorders and inconsistent referral pathways. Self‐report measures indicate impaired quality of life across all groups. The low response rate limits the generalisability of findings but neuropsychiatric assessment and care pathway optimisation should be considered.

Paywall, https://onlinelibrary.wiley.com/doi/abs/10.1111/ene.14182
Sci hub, https://sci-hub.se/10.1111/ene.14182

 

[chrisb]

While historically a psychological aetiology has been assumed to underpin FND, this has now largely been replaced by more nuanced biopsychosocial models (7).

I was amused by this. I could not help myself. Does anyone recall the PVFS: time for a new approach of 1988. Then it was time to set aside old unhelpful ideas of hysteria and adopt the modern, forward-looking, approach of "abnormal illness behaviour" as described by Pilowski. So far as one can tell the idea was never again mentioned in the voluminous outpourings of the authors on the subject of ME, PVFS or CFS. Whether it was utilised as a basis for MUS I know not.

 

[Cheshire]

mental health diagnosis frequency did not differ

Which is exactly what happens each time a correct control group (ie similar type of symptoms) is used instead of healthy controls... But it's a biopsychosocial problem...

 

[Kitty]

'Many patients with suggestive symptoms of CES have no radiological correlate.'

This is hardly astounding, though, given that doctors and physios know very well how devastating the consequences can be. They send anyone suddenly developing symptoms that could indicate CES off to A&E, knowing that most of them won't actually have it – but better safe than sorry.

 

[cassava7]

A recent article from HSJ on CE: https://www.hsj.co.uk/service-desig...ery-costs-23m-in-compensation/7024296.article

Exclusive: Delayed spinal surgery costs £23m in compensation

• Delays to spinal surgery lead to £23m being paid a year in compensation
• Time-critical cauda equina treatment delayed by workforce shortage, GIRFT report says
• Some units “reluctant” to interrupt elective scans for late night CE admission

The NHS spends roughly £100m a year on clinical negligence payments for spinal patients, 23 per cent of which relate to cauda equina, which is when a bundle of nerves at the base of the spine get compressed.

The report published today said standards set by the professional associations were “not currently being met, with potentially life-changing impacts on patients”.

The report continued: “This is unacceptable. Evidence collected during visits indicates that the principal reason for patients with suspected CE not receiving timely MRI scans is a lack of out-of-hours radiography support in referring units. Even though MRIs are switched on out-of-hours, in many instances a radiographer may not be available to operate the scanner.”

The GIRFT team visited 127 spinal units across England.

Davies & Partners medical law specialists said the “industry accepted norm” for compensation was between £600,000 and £800,000.

The firm said: “In around half of [CE] cases, the die is cast within the first four to six hours.”

Given the complications caused by cauda equina and the compensation pays mentioned above, the NHS certainly won't stop screening for it. Too risky.