British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: https://www.tandfonline.com/loi/ibjn20

‘Scan-negative’ cauda equina syndrome: Evidence

of functional disorder from a prospective case
series

Ingrid Hoeritzauer, Carolynne M. Doherty, Stacey Thomson, Rachel Kee, Alan

Carson, Niall Eames & Jon Stone

To cite this article: Ingrid Hoeritzauer, Carolynne M. Doherty, Stacey Thomson, Rachel Kee, Alan
Carson, Niall Eames & Jon Stone (2015) ‘Scan-negative’ cauda equina syndrome: Evidence of
functional disorder from a prospective case series, British Journal of Neurosurgery, 29:2, 178-180,
DOI: 10.3109/02688697.2014.1003032

To link to this article: https://doi.org/10.3109/02688697.2014.1003032

Published online: 03 Feb 2015.

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British Journal of Neurosurgery, April 2015; 29(2): 178–180
© 2015 The Neurosurgical Foundation
ISSN: 0268-8697 print / ISSN 1360-046X online
DOI: 10.3109/02688697.2014.1003032

SHORT REPORT

‘Scan-negative’ cauda equina syndrome: Evidence of functional disorder

from a prospective case series
Ingrid Hoeritzauer1, Carolynne M. Doherty1, Stacey Thomson2, Rachel Kee1, Alan Carson3,
Niall Eames2 & Jon Stone3
1Department of Neurology, Royal Victoria Hospital, Belfast, UK, 2Department of Spinal Orthopaedics, Royal Victoria Hospital,

Belfast, UK, and 3Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, UK

causes CES), scan-negative CES (normal MRI or changes

Abstract
In the first prospective comparison of ‘scan-negative’ (n ⫽ 11)
and ‘scan-positive’ (n ⫽ 7) patients with cauda equina syndrome
(CES) we found that Hoover’s sign of functional leg weakness
but not routine clinical features differentiated the two groups
(p ⬍ 0.02). This offers a new direction of study in this area,
although magnetic resonance imaging is still required for all
patients with possible CES.
Keywords: aetiology; cauda equina syndrome; functional
disorders; urinary retention
Introduction
Cauda equina syndrome (CES) is a devastating condition
which requires urgent surgery and has serious potential
morbidity and medico-legal consequences.1 However,
despite the high profile of CES correlation between clinical
assessment and magnetic resonance imaging (MRI) findings
is often poor, even amongst experienced clinicians. In previ-
ous neurosurgical series, nearly 50% of patients presenting
with possible CES had MRI scans which did not explain their
symptoms, the so-called ‘scan-negative’ patients.1,2 This
interesting ‘scan-negative’ group is not well studied and,
given their heavy resource utilisation, certainly warrants
scrutiny. We investigated these patients prospectively for
the first time in a pilot study and compared them with ‘scan-
positive’ patients with MRI confirmed CES.
Methods
At the Royal Victoria Hospital Belfast, patients with a pos-
sible diagnosis of CES are typically admitted to the care of
orthopaedic team. We recruited prospective consecutive
cases from weekday orthopaedic meetings over a six-month
period in 2013/4, whose history and examination were sug-
gestive enough of CES for the orthopaedic team to request
urgent MRI lumbosacral spine imaging. We divided them
into those with scan-positive CES (changes seen on MRI that
seen on MRI that were not causing CES, e.g. L5 nerve root
entrapment), and ‘other’ (with an alternative explanation for
symptoms). We aimed to see all patients were blind to the
diagnosis.
We collected data on age; sex; symptoms (back pain, leg
weakness and numbness, urinary and bladder dysfunction
and saddle anaesthesia); presence of dissociation (using Per-
itraumatic Dissociative Experiences Questionnaire [PDEQ]);
whether there were symptomatic criteria for a panic attack
(using Diagnostic and Statistical Manual of Mental Disorders,
IVth Edition [DSM-IV]); physical examination (tone, power,
sensation, reflexes and plantars); a specific sign of functional
(also called ‘psychogenic/non-organic’) limb weakness
was performed (Hoover’s sign: weakness of hip extension
that returns to normal with contralateral hip flexion against
resistance)3; residual bladder volume on bladder scan or vol-
ume on initial catheterisation if recorded; lumbosacral MRI
scan reported by a consultant radiologist; length of in-patient
stay; length of follow-up and clinical outcome through infor-
mation on their Electronic Care Record which documents
all A&E, out-patient hospital attendances, admissions and
mortalities in Northern Ireland. Statistical significance was
determined using Fisher’s exact test and unpaired t-test.
Results
Twenty patients were seen as part of the prospective study,
of whom eighteen were suitable for inclusion. Two patients
were excluded as other diagnoses were made to explain the
presentation (n ⫽ 1 thoracic malignant lesion, n ⫽ 1 neuro-
sarcoidosis). Of the 18 included patients, 11 (61%) were ‘scan
negative’ (7 females, mean age: 38 years) for CES and 7 (39%)
were ‘scan positive’ for CES (4 females, mean age: 57 years).
They are described in Table I.
The most striking differences between the ‘scan-negative’
and ‘scan-positive’ groups were found in the frequency of
Hoover’s sign of functional leg weakness (9/10 scan negative
and 0/3 scan positive), 100% seen blind to the diagnosis: no

Correspondence: Ingrid Hoeritzauer, Department of Neurosciences, Royal Victoria Hospital, Belfast BT12 6AB, UK. E-mail: ahoeritzauer01@qub.ac.uk
Received for publication 15 June 2014; accepted 20 December 2014

178
 ‘Scan-negative’ cauda equina syndrome 179

Table I. Clinical features of scan-positive and scan-negative patients with cauda equina symptoms, n (%) unless otherwise stated.
Significance*
‘Scan negative’ (n ⫽ 11[55%]) ‘Scan positive’ (n ⫽ 7 [35%]) (Comparing scan negative and
n (%) n (%) scan positive; two-tailed p value)
Mean age (whole years, range) 38 (17–62) 57 (34–81) 0.064a
Sex: Female 7 (64) 4 (57) 0.39
Low back pain
Yes 11 (100) 7 (100) 1
Numb saddle
Yes 8 (73) 3 (43) 0.33
No 3 (27) 4 (57)
Sciatica 7 (64) 6 (54) 0.60
Numb leg 7 (64) 4 (57) 1
Incontinence
Urine 3 (27) 3 (43) 0.63
Faeces 0 0
Retention
Urine 8 (73) 6 (54) 1
Faeces 0 0
DSM-IV panic attack criteria 8 (73) 2 (29) 0.14
PDEQ score ⬎ 20 5 (45) 1 (14) 0.32
Opiate use 7 (63) 5 (71) 1
Weakness 9 (82) 3 (43) 0.14
Refused/post op/on way to scan 0 4 (57)
Numbness 4 (36) 2 (29) 0.59
Refused/post op/on way to scan 1 (9) 3 (43)
Hoover’s sign Positive 9 (82) 0/3 0.014*
Unable to assess 2/11 (n ⫽ 1 refused, n ⫽ 1 full power) 4/7 (n ⫽ 2 post op, n ⫽ 1 left for
urgent scan, n ⫽ 1 refused)
PDEQ, Peritraumatic Dissociative Experiences Questionnaire
aUnpaired t-test.

*Significance Fisher’s exact test.

assessment was possible in seven cases [Table I]). There were
also notable differences in the frequency of symptoms com-
patible with a panic attack (8/11 scan negative [72%] vs. 2/7
scan positive [29%], p 0.14) and in Peritraumatic Dissociative
Experiences scores (5/11 scan negative [45%] ⬎ 20 PDEQ vs.
1/7 scan positive [14%] ⬎ 20 PDEQ, p 0.32).
By contrast classical CES symptoms showed poor ability
to discriminate between ‘scan-negative’ and ‘scan-positive’
patients: the frequency and nature of leg pain, weakness and
numbness, urinary retention and/or saddle anaesthesia; use
of opioids (scan negative [63%], scan positive [71%]).
Only four patients had bladder scans, of whom three were
in the ‘scan-negative’ group (600 mls, 900 mls and 1000 mls)
and one in the scan-positive CES group (1200 mls).
Four of the eleven patients in the ‘scan-negative’ group
had definite nerve root impingement on MRI (L4 [n ⫽ 1], L5
[n ⫽ 1], S1 [n ⫽ 2]) but none of the changes explained their
CES symptoms. In the ‘scan-negative’ group the average
length of inpatient stay was one day with only two patient’s
admission lasting more than two days.
Follow-up data were available on all patients (‘scan-
negative’ mean ⫽ 5.7 months, ‘scan-positive’ mean ⫽ 6.8 months).
None of the eleven scan-negative patients represented with
CES. One scan-negative patient had a discectomy three weeks
after initial presentation for back pain, urinary incontinence
and possible S1 root compression on MRI but no CES. All
scan-positive patients had improvement on follow-up.
Discussion
Our prospective study demonstrates that a high propor-
tion of patients with CES symptoms are ‘scan negative’. CES
represents an important disabling disorder and patients con-
sume significant emergency resources.
Two previous retrospective studies found that 43%2 and
48%1 of patients with CES were scan negative but were unable
to determine any discriminating clinical features to help differ-
entiate them from scan-positive patients. Likewise in this study
our ‘scan-negative’ patients had CES symptoms and progres-
sion similar to the patients with imaging-confirmed CES.
However, on the basis of our clinical experience and the
published literature, we propose the hypothesis that some of
the ‘scan-negative’ patients may be experiencing acute func-
tional (non-organic) weakness, numbness and possibly even
urinary retention triggered by acute back pain.1 We know
that functional weakness can present with CES symptoms
and that urinary symptoms are often present in patients with
functional symptoms. Functional limb weakness is com-
monly triggered by injury or pain and is commonly acute
and ‘stroke like’ with symptoms of panic or dissociation like
these in scan-negative CES patients.3 We were able to test this
systematically in our prospective study and found some pre-
liminary evidence to support this hypothesis with the pres-
ence of a blinded assessment of Hoover’s sign of functional
leg weakness (90% vs. 0%), a panic attack (72% vs. 29%) and
symptoms of dissociation (45% vs. 14%) all acting as possible
useful discriminators in the clinical assessment of patients
with CES symptoms.
It could be that some of our ‘scan-negative’ patients may
have had a dynamic problem in the disc, with scanning in
the supine position not demonstrating disc changes present
when standing or flexed. Alternatively, other issues include
incomplete radiology and the presence of a non-structural
cause for CES such as acute inflammatory and infectious
180 I. Hoeritzauer et al.
lumbosacral polyradiculopathy or vasculitis which would
not necessarily appear on imaging.1 Our MRI scans were
reported by a consultant radiologist with an interest in spinal
imaging or a consultant neuro-radiologist. Rapid improve-
ment and quick discharge in the majority of ‘scan-negative’
patients and lack of any new explanation at follow-up sug-
gests that a missed structural or other organic cause of CES
symptoms is unlikely.
In some cases there could be acute on chronic sacral
nerve degeneration. This may only be found using bulbo-
cavernous reflex or anal sphincter EMG testing which is not
commonly performed although could be in patients with
ongoing sacral nerve symptoms.
Limitations of this data include: the small sample size
and ability to detect differences between group; the risk of
non-blinding influencing the data; possible missed alterna-
tive organic causes of CES symptoms in the ‘scan-negative’
group; incomplete data in some cases (e.g. four of the ‘scan-
positive’ CES patients could not be examined for a Hoover’s
sign) and lack of detailed systematic follow-up.
Our preliminary findings were in keeping with two pre-
vious studies, showing that ‘scan-negative’ CES accounts
for up to half of cauda equina emergency admissions and
is associated with similar disabling symptoms1,2. What our
prospective study adds is a new description of some positive
clinical findings which may differentiate ‘scan-negative’ and
‘scan-positive’ patients. MRI will continue to be an essential
part of the investigation of all patients with possible CES,
whether or not they have positive features of a functional
disorder. However, if these findings are confirmed by larger
prospective studies, they may significantly alter the subse-
quent clinical management of those CES patients who are
‘scan negative’. Patients with functional limb weakness ben-
efit from specific explanation and physiotherapy approach
which emphasises the positive nature of the diagnosis.4
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the paper.
References
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correlation between clinical assessment and MRI scanning? Br J
Neurosurg 2007;21:201–3.
3. Stone J, Warlow C, Sharpe M. Functional weakness: clues to
mechanism from the nature of onset. J Neurol Neurosurg Psychiatry
2012;83:67–9.
4. Nielsen G, Stone J, Matthews A , et al. Physiotherapy for functional
motor disorders: a consensus recommendation. J Neurol Neurosurg
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