Review Criteria for the Diagnosis and Treatment of Acute Cauda Equina Syndrome (CES)
|A request may be appropriate for||If the patient has||AND the diagnosis is supported by these clinical findings||AND this has been done (if recommended)|
|Lumbar decompression||Cauda equina syndrome||Partial or complete loss of bladder and/or bowel function (incontinence or retention not otherwise explained)
Acute low back pain
|Diminished or absent anal sphincter tone
Numbness and/or weakness involving both legs or multiple nerve roots in one leg is present
Urinary retention, incontinence, and/or patulous anus
Reduced or absent bulbo cavernosus reflex
|A lesion with mass effect on the cauda equina is present in the spinal canal, compressing multiple lumbo-sacral nerve roots (usually large mass effect) as documented by:
Lumbar magnetic resonance imaging (MRI) (the diagnostic procedure of choice)
Computed tomography (CT) or CT myelography may provide useful information, especially when MRI cannot be done or is limited by hardware artifact
|Conservative care alone is rarely indicated|
Acute cauda equina syndrome
Advanced Practice Nurses
Health Care Providers
Managed Care Organizations
- To provide an educational resource for physicians who treat injured workers in the Washington workers' compensation system under Title 51 Revised Code of Washington (RCW) and review criteria for the Department's utilization review team to help ensure diagnosis and treatment of cauda equina syndrome is of the highest quality
- To provide standards that ensure a uniformly high quality of care for injured workers in Washington State
- To summarize information from the available medical literature and expert clinical opinion to help physicians make an accurate diagnosis quickly and deliver the appropriate care as soon as possible
The injured worker with cauda equina syndrome
- Evaluation of subjective (sensory symptoms) and objective (neurological deficits) clinical findings
- Diagnostic tests, including magnetic resonance imaging (MRI), computed tomography (CT) scan or CT myelography, x-rays, ultrasound, or urodynamic tests
- Conservative treatment (not generally recommended)
- Decompression surgery (e.g., micro discectomy, wide laminectomy with discectomy)
- Incidence of work-related cauda equina syndrome (CES)
- Appropriate authorization of CES surgeries by the utilization review team and claim adjudicators
- Incidence of CES by cause (disc herniation, trauma, etc.)
- Degree of recovery following treatment
Searches of Electronic Databases
The literature search was conducted in February and March of 2014. PubMed was the main database searched for peer reviewed articles. The search terms used in PubMed were: cauda equina syndrome, cauda equina syndrome and treatment, cauda equina syndrome and diagnosis, cauda equina syndrome and evidence-based medicine. The search was filtered to select English language and humans, in the past five years. The studies reviewed were case articles, case reports, and case series studies (of class III/IV evidence). Cauda equina syndrome is not appropriate for randomized controlled studies.
Filters: 5 years, abstract available, English and humans
|Search Date||Search Term||Results||*Selected Based on Title|
|02/20/2014||Cauda Equina Syndrome||281||20|
|02/21/2014||Cauda Equina Syndrome and treatment||222||19|
|02/24/2014||Cauda Equina Syndrome and diagnosis||179||36|
|02/24/2014||Cauda Equina Syndrome and evidence based medicine||111||17|
*Some of these articles overlapped.
Weighting According to a Rating Scheme (Scheme Given)
The quality and strength of the evidence were assessed using the American Academy of Neurology (AAN) clinical guideline process manual rating scheme. More information about the Industrial Insurance Medical Advisory Committee (IIMAC) guideline process is included in a separate document (see the "Availability of Companion Documents" field). Refer to the AAN Clinical Practice Guideline Process Manual .
The process for guideline development is contained in a separate document, titled Medical Treatment Guidelines in Washington Workers' Compensation, June 2010 (see the "Availability of Companion Documents" field). A formal subcommittee was not convened for this review of the carpal tunnel syndrome guideline. The review was conducted by Washington State Department of Labor and Industries (L&I) staff, and discussed with the Industrial Insurance Medical Advisory Committee (IIMAC) members who worked on the previous guideline, then discussed and voted on in a meeting of the full IIMAC on April 25, 2014.
A formal cost analysis was not performed and published cost analyses were not reviewed.
External Peer Review
Internal Peer Review
This guideline was carefully reviewed by Labor & Industries' epidemiology and health policy staff, and then by the Industrial Insurance Medical Advisory Committee (IIMAC), which included the main author of the previous acute cauda equina syndrome (CES) guideline.
The type of supporting evidence is not specifically stated for each recommendation.
This guideline was based on the weight of the best available clinical and scientific evidence from a systematic review of the literature and on a consensus of expert opinion. Due to the emergent nature of acute cauda equina syndrome (CES), controlled studies are not feasible and the literature is limited to case series, case studies and narrative reviews.
Appropriate diagnosis and treatment of work-related acute cauda equina syndrome (CES)
This guideline is intended as an educational resource for physicians who treat injured workers in the Washington workers' compensation system under Title 51 Revised Code of Washington (RCW). The guideline serves as a review criteria for the Department's utilization review team to help ensure diagnosis and treatment of cauda equina syndrome is of the highest quality. The emphasis is on accurate diagnosis and treatment that is curative or rehabilitative.
Most guidelines are implemented within the utilization review (UR) program. Labor and Industries (L&I) guidelines have priority over other proprietary guidelines and criteria that may exist. Where L&I guidelines are not available, proprietary ones may be used. Reviewers apply each guideline as a standard for the majority of requests in the Washington workers' compensation program. For the minority of workers who appear to fall outside of the guideline and whose complexity of clinical findings exceeds the specificity of the guideline, further review by a physician is conducted.
When a surgical procedure is requested for a patient who meets the guideline criteria, the reviewer will recommend approval to the claim manager. If the criteria are not met, the request will be referred to a physician consultant who will review the patient's file, offer to discuss the case with the requesting physician, and make a recommendation to the claim manager. The flexibility built into this decision-making process helps legitimize the work of the subcommittee in the eyes of practicing physicians in Washington.
Completed guidelines will be communicated to practicing physicians via L&I's website and through its provider listserv . Education and training will be provided to reviewers and staff to ensure their proper application within the UR program. Where possible, continuing medical education (CME) credits may be offered.
|Washington State Department of Labor and Industries. Work-related acute cauda equina syndrome (CES) diagnosis and treatment. Olympia (WA): Washington State Department of Labor and Industries; 2014 Apr 26. 5 p. [12 references]|
Not applicable: The guideline was not adapted from another source.
1991 Jan (revised 2014 Apr 26)
Washington State Department of Labor and Industries - State/Local Government Agency [U.S.]
Washington State Department of Labor and Industries (L&I)
Washington State Department of Labor and Industries (L&I), Industrial Insurance Medical Advisory Committee (IIMAC)
This is the current release of the guideline.
This guideline updates a previous version: Washington State Department of Labor Industries. Work-related acute cauda equina syndrome (CES) diagnosis and treatment. Olympia (WA): Washington State Department of Labor and Industries; 2009 Aug 1. 5 p. [11 references]
Electronic copies: Available from the Washington State Department of Labor and Industries Web site .
The following is available:
- Medical treatment guidelines for Washington Workers' Compensation. Washington State Department of Labor and Industries. Guideline process. 2010 Jun. 4 p. Electronic copies: Available from the Washington State Department of Labor and Industries Web site .
This summary was completed by ECRI on February 14, 2000. It was sent to the guideline developer for review on February 15, 2000; however, to date, no comments have been received. The guideline developer has given NGC permission to publish the NGC summary. This summary was updated by ECRI on May 27, 2004. The information was verified by the guideline developer on June 14, 2004. This summary was updated by ECRI Institute on November 16, 2009. The information was verified by the guideline developer on December 16, 2009. This summary was updated by ECRI Institute on July 15, 2014.
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