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Funded by the Orthopaedic Research and Education Fund and the J Robert Gladden Orthopaedic Society, our latest study is a mixed methods exploration of the patient experience factors that underpin disparities in imaging in hopes of developing a solution.
When I was a spine fellow at Washington University in St. Louis, MO, I met a patient who changed my life. She was an African American woman in her mid-30s who had visited multiple emergency rooms in the city seeking help with her back pain.
By the time she reached our team, she had full-blown cauda equina syndrome (CES), in which a herniated disc in the lower back compresses a bundle of nerves at the base of the spine. She had no control of her bowels and bladder, and though we were able to repair her spine and relieve her pain, the incontinence was permanent. This might have been avoided if she had gotten an MRI right away, rather than being bounced from hospital to hospital to get care.
Now, I’m a spine surgeon and researcher at MedStar Washington Hospital Center. I’m working with the MedStar Center for Health Equity and the National Center for Human Factors in Health Care on a study funded by the Orthopaedic Research and Education Fund and the J Robert Gladden Orthopaedic Society to understand the experience of Black patients with CES.
Our goal is to learn how factors like bias, historical trauma, and social determinants of health play a role in creating and perpetuating disparities that result in poorer outcomes for Black patients than their white counterparts.
What is cauda equina syndrome?
The cauda equina is a bundle of nerves at the base of the spinal cord in the lower part of the spine. These nerves communicate to keep the lower limbs and pelvic organs in contact with the brain. CES is relatively rare and can be caused by spinal trauma such as a vehicle accident or a fall, or cancer of the spine. CES causes symptoms such as:
- Disturbances in sensation in the anus, genitals, or buttocks
- Pain in the back and/or legs
- Sexual dysfunction
- Urinary or fecal incontinence
- Urinary retention
- Weakness and paralysis of the legs
When diagnosing CES, providers conduct a physical exam and talk with the patient about their history and symptoms. An MRI can produce images of the spinal cord and nerves, and help create a clear picture of the condition.
Emergency surgery is the best treatment for most patients with CES. Spine surgeons work to reduce pressure on the compressed nerves and allow them to recover. After surgery, continence and weakness can often be resolved. Left untreated, CES can result in permanent paralysis or incontinence.
Black patients have worse outcomes.
Our research has shown that Black patients have significantly poorer outcomes from CES than their white counterparts. To understand why, we analyzed different sets of published data on outcomes based on factors such as gender, race, and ethnicity.
We found that Black patients were more likely than others to have higher rates of complications and a greater likelihood of dying after a diagnosis of CES. New York State data showed that Black patients had a nearly three-fold greater chance of dying within 30 days of diagnosis than patients from other backgrounds and a high risk of being readmitted to the hospital.
It is likely that many of these patients did not get proper imaging to diagnose CES. Unconscious bias can influence treatment decisions, and social determinants of health such as access to timely care can exacerbate disparities.
To make a difference, we are partnering with our colleagues at the MedStar Center for Health Equity Research to conduct a mixed-methods study and create a data-driven clinical decision-support tool that flags patients who could have early CES for proper imaging.
Research to help reduce disparities through action.
First, we’re examining MedStar Health’s extensive data set to identify patients who have been treated for CES. We’ll then interview African American patients to understand their interaction with the health system, experiences of bias (or not), and outcomes, revealing opportunities for improvement.
Then, we’ll conduct a Delphi study to gather perspectives from nurses, emergency room doctors, spine surgeons, and others involved in CES diagnosis and treatment. Working with this combined information, we’ll develop a tool that will help eliminate unconscious bias and inform important clinical decisions like whether to seek imaging.
I’m a clinician first and a researcher second—talking with and examining patients in the clinic provides enormous scientific value. MedStar Health Research Institute is at the forefront of advanced research on spinal trauma that will improve care for all patients.
