Can digital rectal examination be used to detect cauda equina compression in people presenting with acute cauda equina syndrome? A systematic review and meta-analysis of diagnostic test accuracy studies
Can digital rectal examination be used to detect cauda equina compression in people presenting with acute cauda equina syndrome? A systematic review and meta-analysis of diagnostic test accuracy studies
Background: digital rectal examination (DRE) is a commonly used test to help identify people with cauda equina compression (CEC). Objective: To determine the diagnostic accuracy of DRE in assessment of anal tone, squeeze, sensation and reflexes, as predictors of CEC.
Design: a systematic review to investigate the diagnostic accuracy of DRE to detect CEC compared with lumbar Magnetic Resonance Imaging (MRI). Method: Six electronic databases were searched from inception to 6 July 2020 for studies published in English. Two assessors independently performed screening, data extraction and risk of bias assessment (QUADAS-2). Meta-analysis was performed using STATA-16.
Results: six studies were included (n = 741). The sensitivity of anal tone was low across all studies (range: 0.23 to 0.53) with moderate quality evidence against the use of DRE of anal tone. One study on anal sensation found no correlation with CEC using Kendall's tau test: p = 0.102 and another found sensation had low test accuracy. One study identified sensitivity: 0.29 and specificity: 0.96 for anal squeeze, while another identified sensitivity: 0.38 and specificity: 0.6 for anal reflexes.
Conclusion: the diagnostic accuracy of DRE of anal tone to detect CEC is low and carries a high risk of false reassurance. It is therefore not recommended in any clinical setting. More research is needed to determine the diagnostic accuracy of DRE of anal squeeze, sensation and reflexes and if done the results should be interpreted with caution.
Anal squeeze, Anal tone, Cauda equina compression, Cauda equina syndrome, Diagnostic accuracy, Digital rectal examination
102523
Tabrah, Julia
ef2f23d4-79b6-4d84-b284-312c0428744c
Wilson, Nicky
7df34065-883c-43ac-8fc7-1d1ae2a08a39
Phillips, Dean
0294b4eb-9f6d-4033-ba65-9e245c96fdca
Böhning, Dankmar
1df635d4-e3dc-44d0-b61d-5fd11f6434e1
April 2022
Tabrah, Julia
ef2f23d4-79b6-4d84-b284-312c0428744c
Wilson, Nicky
7df34065-883c-43ac-8fc7-1d1ae2a08a39
Phillips, Dean
0294b4eb-9f6d-4033-ba65-9e245c96fdca
Böhning, Dankmar
1df635d4-e3dc-44d0-b61d-5fd11f6434e1
Tabrah, Julia, Wilson, Nicky, Phillips, Dean and Böhning, Dankmar
(2022)
Can digital rectal examination be used to detect cauda equina compression in people presenting with acute cauda equina syndrome? A systematic review and meta-analysis of diagnostic test accuracy studies.
Musculoskeletal Science and Practice, 58, , [102523].
(doi:10.1016/j.msksp.2022.102523).
Abstract
Background: digital rectal examination (DRE) is a commonly used test to help identify people with cauda equina compression (CEC). Objective: To determine the diagnostic accuracy of DRE in assessment of anal tone, squeeze, sensation and reflexes, as predictors of CEC.
Design: a systematic review to investigate the diagnostic accuracy of DRE to detect CEC compared with lumbar Magnetic Resonance Imaging (MRI). Method: Six electronic databases were searched from inception to 6 July 2020 for studies published in English. Two assessors independently performed screening, data extraction and risk of bias assessment (QUADAS-2). Meta-analysis was performed using STATA-16.
Results: six studies were included (n = 741). The sensitivity of anal tone was low across all studies (range: 0.23 to 0.53) with moderate quality evidence against the use of DRE of anal tone. One study on anal sensation found no correlation with CEC using Kendall's tau test: p = 0.102 and another found sensation had low test accuracy. One study identified sensitivity: 0.29 and specificity: 0.96 for anal squeeze, while another identified sensitivity: 0.38 and specificity: 0.6 for anal reflexes.
Conclusion: the diagnostic accuracy of DRE of anal tone to detect CEC is low and carries a high risk of false reassurance. It is therefore not recommended in any clinical setting. More research is needed to determine the diagnostic accuracy of DRE of anal squeeze, sensation and reflexes and if done the results should be interpreted with caution.
Text
Can digital rectal examination be used to detect cauda equina compression in people presenting with acute cauda equina syndrome
- Accepted Manuscript
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Accepted/In Press date: 27 January 2022
e-pub ahead of print date: 9 February 2022
Published date: April 2022
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Diagnosing CEC is challenging because characteristic signs, symptoms and routinely used clinical tests do not reliably predict the condition (Dionne et al., 2019). Early symptoms are often subtle and vague (Greenhalgh et al., 2018) and progression of symptoms is unpredictable (Sun et al., 2014). People with CES often present to primary care services where clinicians typically work in time pressured environments without access to specialist spinal support. The National Backpain Pathway - Clinical Network (2020) have created a CES assessment and referral framework to support clinicians in primary care, but there remains a need to ensure that locally agreed pathways are integrated across settings.
Publisher Copyright:
© 2022 Elsevier Ltd
Copyright:
Copyright 2022 Elsevier B.V., All rights reserved.
Keywords:
Anal squeeze, Anal tone, Cauda equina compression, Cauda equina syndrome, Diagnostic accuracy, Digital rectal examination
Identifiers
Local EPrints ID: 455213
URI: http://eprints.soton.ac.uk/id/eprint/455213
ISSN: 2468-7812
PURE UUID: d0eb27ac-9e65-45d6-8204-e82d637c2ce3
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Date deposited: 15 Mar 2022 17:35
Last modified: 17 Mar 2024 07:09
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Author:
Julia Tabrah
Author:
Nicky Wilson
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