1. RED FLAGS & CAUDA EQUINA
Stuart Fraser
Physiotherapist
Wessex Neuro Department
Good afternoon everyone, I have been invited here today to talk to you about red flags and CES. For those of you that do not know me, and I think that is nearly all of you, I thought I would just tell you a bit about where I work. I currently work as a physiotherapist in the wessex neurological centre at SGH. This is a regional neurology and neurosurgical centre serving a population of approximately 3 million. We have a team of 10 physios working in the unit and our work load is varied!
Southampton
University Hospitals NHS Trust

2. We deal with any insults to your nervous system
We deal with any insults to your nervous system. So that can be an acute head injury such as this unfortunate patient to your GBS, parks, facial palsies, or any intra cranial or spinal pathologies such as SOL. And it’s the spinal pathologies that fuelled my interest in red flags. We were having patients in who had had previous physio, chiropractic, osteopathy or DGH consultations for a considerable time before their serious spinal pathology was identified.
So this led to a simple question
Where red flags being missed

3. Background WHAT IS A RED FLAG ?
In order to answer this you have to look at what a red flag is
And im sure that if I were to ask any of you today you would be very comfortable in answering this question.
Well we thought we would answer this quetsion by looking at the evidence base for red flags!

4. Background
Patient response or finding on history taking and physical examination that are associated with a serious spinal pathology.
A commonly used description of a red flag is a response or finding on questioning and examining your patient that may indicate a serious spinal pathology.
So the importance for us as clinicians is that what we ask our patients, what we examine, could indicate a serious pathological processs,

5. Background LITERATURE SEARCH 40 Papers Specifying Red Flags
INTERNATIONAL GUIDELINES
8 International Guidelines
So myself and two other physios conducted a literature search on red flags using electronic databases. We identified 40 papers specifiying red flags. We also decided to look at the international guidelines as surely serious spinal pathologies are universal and so a red flag should be the same wherever you are in the world. We managed to obtain 8 of the international guidelines and were missing the finnish and one other.

6. Source: CSP Guidelines Development Group
Red Flags
100% Unanimity
75 – 99% Consensus
51 – 74% Majority view
0 – 50% No consensus
Source: CSP Guidelines Development Group
Once we had the papers and guidelines we applied the CSP guidelines development group format, whereby 100% of the articles would give a unanimous decision on any aspect of red flags. So what did we find.

7. Guideline Findings Unanimity 100% Weight Loss
Previous History of Cancer
Systemic Steroids
Well if we look at the guidelines first, there was unanimity that weight loss, a history of Cancer and the use of systemic steroids were all red flags in patients with back pain.
But lets just think about this for a minute. Red flags are associated with serious spinal pathology. How many of your patients with serious spinal pathology initially presented with any of the above three.
Most of my patients are actually over weight, young with no past medical history and no drug history.

8. Guideline Findings Consensus 75 – 99% Violent trauma
Difficulty with micturition
Reduced anal tone
Saddle anaesthesia
Widespread/progressive neuro
Interestingly, if you think about how red flags are taught today and documented in text books, these three commonly referrred to as CES are an absolute red flag, yet there is no unanimity in the guidelines, nor on progressive neurology!!! Where I work one of the key things that would ring alarm bells!!!!

9. Guideline Findings Majority view 51 – 74% Age <20 or > 55
Constant progressive pain
IV drug use / HIV
Systemically unwell
Gait disturbance
Structural deformity
If we look at where there was less consensus within the guidelines, there was only a majority view, so just over half of the guidelines documeneted …………

10. What do Red Flags Signify ?
Possible serious spinal pathology
Tumour / malignancy
Infection
Fracture
So what sort of serious pathologies are we talking about. Well the big three are tumour infection and fracture.
If you pick infection though, there is no consensus, only a majority view in the guidelines so less than three quarters of the guidelines identify progressive pain,or being systemically unwell as red flags to be alert for. For fracture, there is no unanimous decision that trauma and back pain may be indicative of this!

11. And here are just a few pretty pictures of some of our patients with serious pathologies.

16. Literature Consensus 75 – 99% Weight loss Previous history of cancer
So if we look at the literature, the findings are different to the international guidelines.
There is no unanimous decision on any aspect, there is a consensus on weight loss and history of canacer

17. Literature Majority view 51 – 74% Night pain Age > 50 years
Violent trauma
Fever
Saddle anaesthesia
Difficulty with micturition
IV drug abuse
Progressive neuro
Systemic steroids
And even less consensus, only a majority view on the above. Think about it, according to the current literature, less than 3 quarters and in some aspects only half of the papers reviewed thought that any of the above were red flags.

18. Conclusion
Inconsistency in the literature as to what red flags signify
Inconsistency in identifying true red flags
So in conclusion, with our findings identifying over 100 individual red flags. There is a marked inconsistency within the literature and also within the guidelines.

19. Cauda Equina Syndrome
So with all the inconsistencies on red flags as a whole we were a little lost and confused, we decided to take just one red flag, that of CES and apply the same process to that.

20. What is Cauda equina syndrome ?
The evidence from the red flags search was inconsistent, so we decided to ask the simple question what was CES.

21. Heres just a little picture of your CES, for those of unclear as to what it looks like

22. Literature 118 PAPERS REVIEWED
Again we searched the electronic databases using the key search words, CES and definition, clinical presentation, signs and symptoms, pathology and aetiology. The search identified a very painfull 118 papers.

23. Definition
“A complex of low back pain, bilateral sciatica, saddle anaesthesia, motor weakness in the lower extremities with bowel and bladder incontinence.(Kostuik1986)”

24. Definition
General Statement
Pathomechanical
Clinical presentation

25. Source: CSP Guidelines Development Group
Cauda Equina
100% Unanimity
75 – 99% Consensus
51 – 74% Majority view
0 – 50% No consensus
Source: CSP Guidelines Development Group

26. Pathology 86%
No Consensus
(0 – 50%)
Disc %
Tumour 29%
Infection 28%

27. Pathology 65 Pathologies identified Metastatic - vertebral
SOL - medullary / dural
Specific - chordoma
- sarcoma
- chondroblastoma

28. Literature Findings Interview Examination Majority View (51 – 74%)
Bladder 74%
Bowels 57%
Pain 57%
Sensation 66%
Power 53%
No Consensus
(0 – 50%)
Sexual Function %
Reflexes 33%

29. Bladder Retention 41% Incontinence 36% Dysfunction 32%
40 – Subcategories
Retention 41%
Incontinence 36%
Dysfunction 32%

30. Sensation
42 - Subcategories
Specific Location 59%
Non Specific 17%

31. Bowels Sphincter Tone 34% Dysfunction 25% Incontinence 21%
15 – Subcategories
Sphincter Tone 34%
Dysfunction 25%
Incontinence 21%

32. Pain
42 – Subcategories
Specific Location 42%
Nature %

33. Power 35 – Subcategories Non Specific 29% Bilateral 18%
Specific muscle / location 14%

34. Summary of Findings Category Consensus (75 – 99%) Majority View
(51 – 74%)
Pathology
Bladder
Sensation Specific Location
Bowels
Pain
Power

35. Clinical implications
Acute or Chronic
Pathological process

36. Clinical Implications
So what can you do?
Should you change your clinical practice?

37. Any Questions ? Stuart.Fraser@suht.swest.nhs.uk
Thank You
Any Questions ?