Author Response: “Scan-negative” cauda equina syndrome: A prospective cohort study
IngridHoeritzauer,Neurologist,1. Centre for Clinical Brain Sciences, University of Edinburg, UK 2. Department of Clinical Neurosciences, Royal Infirmary
AlanCarson,Professor of Neuropsychiatry,1. Centre for Clinical Brain Sciences, University of Edinburgh 2. Department of Clinical Neurosciences, Royal Infirmary Hospital
PatrickStatham,Consultant Neurosurgeon,1. Department of Neurosurgery, Royal Infirmary Hospital Edinburgh, UK 2. Department of Clinical Neurosciences, Royal Infirmary
AndreasDemetriades,Consultant Neurosurgeon,1. Department of Neurosurgery, Royal Infirmary Edinburgh, UK
JonStone,Professor of Neurology,1. Centre for Clinical Brain Sciences, University of Edinburg, UK 2. Department of Clinical Neurosciences, Royal Infirmary
Submitted January 04, 2021
We thank Dr. Amelot et al. for the response to our article.1
We are aware that in other centers only patients with positive scans are referred to neurosurgeons. In our center, and in most of the UK NHS system, “suspected CES” cases are seen by out-of-hours neurosurgery services for urgent transfer and MRI scanning. The proportion of patients with a scan positive CES–47/198 or 24%–was consistent with a systematic review (19%)2我们回顾性研究(28%)。3
We think the authors have possibly misunderstood the primary purpose of the paper which was especially focused on describing what is wrong with the large majority of such patients with ‘scan-negative’ CES presentations.4
We do not agree that follow up with a specific spinal specialist might have altered our outcome data. All patients were referred to a neurosurgeon who assessed their clinical and radiological findings for evidence of ‘scan positive’ CES. The 137 patients in the mixed and ‘scan negative’ CES groups had follow up for an average of 24 months, looking for any new neurological or neurosurgical diagnoses which fully or partially explained their CES symptoms. Our patients with persisting neurological symptoms continued to have spinal specialist input from a neurosurgeon or neurologist. No patients in the mixed or ‘scan negative’ CES groups had a presentation with ‘scan positive’ CES during follow-up, which is meaningful given that nearly all patients would present to local NHS services.
We do not agree with the framing of functional neurological disorder or somatization as reattributed distress. Functional disorders are distinct entities in their own right, to which pathophysiological and predictive cognitive processes, medications and iatrogenic factors contribute.5,6
In our article we hypothesize that pain, panic, medications, prior bladder dysfunction, or functional neurological disorders may cause patients to present with ‘scan negative’ CES.
We recently created a patient factsheet, available onwww.neurosymptoms.org(see bladder symptoms), that explains our current thinking about ‘scan negative’ CES. This may be helpful for patients who are left wondering what has caused their symptoms when their scans are normal.
Further research into this neglected group is required. We are glad to have interest from neurosurgeons as we try to increase awareness and optimize treatment of this group.
Disclosure
The authors report no relevant disclosures. Contact journal@neurology.org for full disclosures.
References
Hoeritzauer I, Carson A, Statham P, et al. Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study.首页. 2021;96(3):e433-e447. doi:10.1212/WNL.0000000000011154
Hoeritzauer I, Wood M, Copley PC, Demetriades AK, Woodfield J. What is the incidence of cauda equina syndrome? A systematic review [published online ahead of print, 2020 Feb 14].J Neurosurg Spine. 2020;1-10. doi:10.3171/2019.12.SPINE19839
Hoeritzauer I, Pronin S, Carson A, Statham P, Demetriades AK, Stone J. The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients.J Neurol. 2018;265(12):2916-2926. doi:10.1007/s00415-018-9078-2
Gibson LL, Harborow L, Nicholson T, Bell D, David AS. Is scan-negative cauda equina syndrome a functional neurological disorder? A pilot study.Eur J Neurol. 2020;27(7):1336-1342. doi:10.1111/ene.14182
Begue我,亚当斯C,石头,Perez DL. Structural alterations in functional neurological disorder and related conditions: a software and hardware problem?.Neuroimage Clin. 2019;22:101798. doi:10.1016/j.nicl.2019.101798
Van den Bergh O, Witthöft M, Petersen S, Brown RJ. Symptoms and the body: Taking the inferential leap.Neurosci Biobehav Rev. 2017;74(Pt A):185-203. doi:10.1016/j.neubiorev.2017.01.015
We thank Dr. Amelot et al. for the response to our article.1
We are aware that in other centers only patients with positive scans are referred to neurosurgeons. In our center, and in most of the UK NHS system, “suspected CES” cases are seen by out-of-hours neurosurgery services for urgent transfer and MRI scanning. The proportion of patients with a scan positive CES–47/198 or 24%–was consistent with a systematic review (19%)2我们回顾性研究(28%)。3
We think the authors have possibly misunderstood the primary purpose of the paper which was especially focused on describing what is wrong with the large majority of such patients with ‘scan-negative’ CES presentations.4
We do not agree that follow up with a specific spinal specialist might have altered our outcome data. All patients were referred to a neurosurgeon who assessed their clinical and radiological findings for evidence of ‘scan positive’ CES. The 137 patients in the mixed and ‘scan negative’ CES groups had follow up for an average of 24 months, looking for any new neurological or neurosurgical diagnoses which fully or partially explained their CES symptoms. Our patients with persisting neurological symptoms continued to have spinal specialist input from a neurosurgeon or neurologist. No patients in the mixed or ‘scan negative’ CES groups had a presentation with ‘scan positive’ CES during follow-up, which is meaningful given that nearly all patients would present to local NHS services.
We do not agree with the framing of functional neurological disorder or somatization as reattributed distress. Functional disorders are distinct entities in their own right, to which pathophysiological and predictive cognitive processes, medications and iatrogenic factors contribute.5,6
In our article we hypothesize that pain, panic, medications, prior bladder dysfunction, or functional neurological disorders may cause patients to present with ‘scan negative’ CES.
We recently created a patient factsheet, available onwww.neurosymptoms.org(see bladder symptoms), that explains our current thinking about ‘scan negative’ CES. This may be helpful for patients who are left wondering what has caused their symptoms when their scans are normal.
Further research into this neglected group is required. We are glad to have interest from neurosurgeons as we try to increase awareness and optimize treatment of this group.
Disclosure
The authors report no relevant disclosures. Contact journal@neurology.org for full disclosures.
References