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1 · SNAPSHOT

Cauda Equina Syndrome (CES) body chart — Illustrative, not diagnostic. Canva body chart for Cauda Equina Syndrome (CES).

This entire page is free, permanently — all seven sections. Red flag content is never gated in CliniStudy, and on this pattern every section is red flag content: the questions you ask, the threshold you refer at, the letter you write and the words you say on the way out the door are all the same decision. Putting any of it behind a paywall would put a missed diagnosis behind a paywall.

Who: Anyone with low back pain. There is no demographic that protects them.
What: Acute compression of the lumbar and/or sacral nerve roots — bladder, bowel, saddle, sexual function and both legs, in any combination, at any speed.
How it behaves: Sudden or gradual. Most patients do not present with the full symptom set [1].

The one thing to take from this page:

Your job is not to diagnose it. Your job is to notice it and get it out of your hands the same day.

Figure	Population
CES as a share of primary-care low back pain	0.08% — 1 study
Pooled share in secondary care	0.27% — 4 studies
Cord or cauda equina compression in the emergency department	0.1–1.9% — 22 studies, 41,320 patients
Community incidence	0.3–0.5 per 100,000/yr
Adults with suspected CES who actually had it	19% — 18 studies
Modern consecutive series, tertiary ED	60/530 = 11.3% · 117/1,005 = 11.6%
Urgent referrals to a tertiary spinal centre that were confirmed and operated	6/353 = 1.7%
Mean operative rate across 12 years of urgent MRI	5.1%, against a 10-fold rise in scan demand

[2][3][4][5][6][7]

Read those two blocks together, because the calibration is the whole page

The base rate is tiny. The confirmation rate among the people you refer is roughly one in five to one in ten. Both numbers are true at once, and a student who holds only one of them gets this wrong in a predictable direction.

Refer four people who turn out not to have it and you have done the job correctly. That is what a properly calibrated threshold looks like on a condition this destructive. A student who refers nobody is dangerous. A student who refers everybody is useless. The target is the ratio, not zero false positives.

✅ Australia has a standard, and it names this condition. The ACSQHC Low Back Pain Clinical Care Standard (2022), Quality statement 1: "Emergency assessment or referral is indicated for clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs or symptoms, suspected spinal infection or cauda equina syndrome, spinal tumour, trauma or fracture." Quality statement 8: "Patients with severe or progressively deteriorating neurological signs and symptoms should be immediately referred for urgent imaging and surgical review."

⚠️ And it stops there. There is no CES-specific pathway in Australia — no symptom checklist, no post-void residual threshold, no MRI timeframe, no surgical window, no post-operative guidance. There is no Australian equivalent of the UK GIRFT/BASS national pathway. Everything on this page beyond "refer now, and write it down properly" is anchored to primary evidence and, where labelled, to UK national guidance.

Patterns > Labels. And here the label is contested too: 17 different definitions of CES were in circulation across 212 papers [8].

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order. One deviation, and it is deliberate: on an acute presentation your course takes HISTORY before BEHAVIOUR, and on this pattern behaviour is the least useful thing you will ask about. It is kept in position below so the sequence stays familiar — but it is thin on purpose.

The special questions are not the last box on this pattern. They are the pattern.

MAIN PROBLEM

"My back went, and now I can't feel myself wee."
"I've gone numb between my legs."
"Both legs have gone funny."

And often, nothing that alarming. Onset can be sudden or gradual, and most patients do not present with all of the symptoms [1].

BODY CHART

P1, P2 as usual — and draw the saddle. S3–S5: the perineum, the genitals, the inner thighs, the area you sit on.
If you have not drawn it, you have not asked about it.
Mark both legs. Bilateral leg symptoms are the distribution that matters here.

BEHAVIOUR

This is the one pattern on the whole site where mechanical behaviour tells you nothing useful. Record aggs and eases because your notes need them, then move on.

Do not use pain severity as a discriminator. "Worst ever" back pain was reported by 70% of scan-negative patients versus 41% of scan-positive (p=0.005), and panic symptoms at onset by 70% versus 37% (p=0.001) [9]. Severe pain gets people scanned. It does not predict what the scan shows.
Irritability does not gate this decision. Three-part irritability — resting symptoms, vigour of the provoking activity, time to settle — changes your dosage on every other pattern. Here it changes nothing about whether you refer.

HISTORY

What changed, and when. Duration of neurological symptoms is the single field that changes what happens to them downstream, because the timing literature runs off symptom onset, not off arrival.
Trajectory: better, same, or getting worse. A dropping myotome across visits is a referral, not a rehab progression.
Known stenosis, previous lumbar surgery, recent heavy lifting, recent trauma.
Medications — opioids and anticholinergics cause retention — plus recent surgery, childbirth, UTI, constipation, prostate history.

SPECIAL / SCREENING QUESTIONS

Ask these on every lumbar patient, not just the ones you suspect. Record the answers, including the negatives.

Bladder — ask it properly. Not "any bladder problems?" That question gets a no from someone in retention.

Ask	Why
Has anything changed, and when?	Change is the finding, not the absolute state
Can you feel it filling?	Loss of filling sensation is early
Can you feel the flow as it comes out?	Reduced awareness of flow is early
Do you have to strain or wait to start?	Hesitancy and poor stream
Are you leaking without knowing?	Painless retention with overflow is the presentation people miss — the patient describes it as incontinence

Bowel: any change in control, any loss of the urge, any incontinence.
Saddle and perineum: numbness or altered sensation — wiping, sitting, sex, using toilet paper.
Sexual function: new erectile or arousal change, altered genital sensation. Ask it. It is on the list for a reason.
Both legs: bilateral leg pain is the item with the evidence behind it — OR 2.6 (95% CI 1.2–5.8, p=0.02) for confirmed compression, 4.7 (1.7–12.8, p=0.003) where the canal was >75% occupied [4]. Alone it is still weak: bilateral sciatica ran sensitivity 32.4%, PPV 17.2% [10]. Ask about it. Do not decide on it.
Getting weaker: progressive motor loss, in either leg.

Record that you asked, including when the answer was no. Documentation is the protective behaviour, and it is the one the litigation literature keeps pointing at [11][12].

The slow version, which is the one you will actually meet

On an outpatient placement the CES you meet is not the dramatic one. It is an older adult with known lumbar spinal stenosis whose numbness has quietly reached the saddle, or whose voiding has changed over weeks. Degenerative change can compromise the same roots gradually; the presentation is unclear; no standardised diagnostic criteria or management pathway exist for this group, and slow "grumbling" symptoms get absorbed into the stenosis diagnosis that is already on the file [13].

Assessing this region? Download the Lumbar Spine & SIJ assessment template →

3 · HYPOTHESIS RANKING

This pattern inverts the usual ranking. Everywhere else you rank the likely patterns and rule out the dangerous one. Here CES is the dangerous one and it is the least likely thing on the list. So the question is not "what is this most likely to be" — it is "what else explains these exact symptoms, and does any of them let me stop worrying?"

The answer to the second half is always no. Nothing on this table clears CES. Only an MRI does.

#	Competing pattern	The one discriminating feature
1	Scan-negative CES — the most likely outcome by a distance	Positive clinical signs of a functional neurological disorder: 68% of scan-negative versus 11% of scan-positive (p<0.0001). With, in the same cohort, "worst ever" back pain 70% vs 41%, panic at onset 70% vs 37%, and preserved bilateral ankle jerks (12% reduced/absent vs 78%). You still refer. You refer expecting this, which changes how you talk to the patient before the scan
2	Lumbar radicular pain, single root	Unilateral, one dermatome, no bladder, no bowel, no saddle, no bilateral change. The moment it becomes bilateral, or the saddle is involved, or voiding changes, it stops being that page and becomes this one. See lumbar radicular pain
3	Lumbar spinal canal stenosis with slow cauda equina compromise	An older patient, and a change measured in weeks rather than hours — neurogenic claudication that has quietly acquired saddle numbness or altered voiding. No standardised diagnostic criteria exist for this group, and the symptoms get dismissed as part of the stenosis

[9][13]

Also on the list, and all of them go to the same place

Pattern	Discriminator
Conus medullaris syndrome	Upper motor neurone signs — hyperreflexia, extensor plantar, early symmetrical bladder. CES is lower motor neurone, areflexic, more asymmetrical. Same destination, same speed — do not spend time separating them
Metastatic cord compression / spinal tumour	Constant unremitting pain, worse at night or lying down, cancer history, unexplained weight loss. Named alongside CES in the ACSQHC trigger
Spinal infection / epidural abscess	Fever, IV drug use, indwelling vascular catheter, another infection site, immunosuppression — the flags that actually raised likelihood in the ED review [3]
Retention from something that is not the spine	Opioids and anticholinergics, UTI, constipation, prostatic obstruction, post-partum or post-operative retention. It does not remove the referral — it changes what the ED is being asked. This is why the history records what changed and when

The overlap you have to handle: perineal numbness

Perineal numbness is a cardinal CES symptom AND one of the six findings that shift the post-test probability of lumbar spinal canal stenosis by more than 25%. Same symptom, opposite urgency, and the lumbar spinal canal stenosis pattern carries the other half of it.

Which way do you jump? CES first, every time. Perineal numbness is treated as cauda equina until an MRI says otherwise — because stenosis is a diagnosis you have weeks to make and CES is a diagnosis you have hours to make. Filing perineal numbness under "part of the stenosis picture" is exactly the error Comer et al. describe [13].

The rule that sits over the whole table

CES is best understood not as one condition but as a spectrum of severe radiculopathy from acute compression of the lumbar and/or sacral nerve roots, comprising multiple separate indications for investigation and intervention with variable urgency ([14], Australian, AJGP, written for exactly this confusion).

Jones' hypothesis categories that change your plan here: precautions and contraindications — which override everything else on the list — and pathophysiology. Not management and treatment selection, because there isn't any.

Never output a diagnosis. Output the pattern, the discriminator, and the escalation.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

The whole page is the red flag. This section is the sentence that has to survive everything else.

The red flags are specific, not sensitive — and their absence does not clear it

Pooled across 7 studies and 569 participants against an MRI reference standard, for reduced anal tone, saddle anaesthesia, urinary retention, urinary incontinence, bowel incontinence, leg pain and back pain:

	Pooled range
Sensitivity	0.19 (95% CI 0.09–0.33) to 0.43 (0.30–0.56)
Specificity	0.62 (0.59–0.73) to 0.88 (0.85–0.92)

([15]. The authors' own conclusion: red flags "appear to be more specific than sensitive… when present, they should be considered justification for prompt diagnostic workup.")

Read it as a rule: a red flag that is present earns an MRI. A red flag that is absent earns nothing.

The consequence is the most important operational fact on this page. CES is never excluded at the end of a session. It is excluded by an MRI, or it is carried forward on a safety net. There is no negative finding anywhere in your assessment that closes it.

⚠️ And this review carries two corrigenda, neither of which has been read. Two corrections on the profession's single most-cited CES accuracy review is itself worth saying out loud ([16] and [17] — both PubMed records are bibliographic only, with no abstract and no description of what changed). Only the pooled ranges above are quoted on this page. No individual red flag carries a figure.

The framework agrees, and it is the position that licenses this whole page. There is "an absence of high-quality evidence for the diagnostic accuracy of most red flags", and they should be treated as a clinical reasoning pathway rather than a checklist [18]. A red flag raises your index of suspicion. It does not make or exclude a diagnosis.

The escalation table

Finding	Action
Any change in bladder function — filling, flow, hesitancy, painless leaking, retention	Emergency department, same day
Any bowel change or new saddle / perineal sensory change	Emergency department, same day
New sexual dysfunction with back or leg pain	Emergency department, same day
Bilateral leg symptoms, new	Emergency department, same day
Progressive motor weakness, any distribution	Emergency department, same day
Suspicion, with every question answered "no"	Escalate anyway if the picture worries you — sensitivity 0.19–0.43 is exactly what "the questions cannot exclude it" looks like
Every other lumbar patient you discharge	The safety-netting script below. Verbally, in writing, and in the notes

And the standard has moved. UK national guidance now requires that any patient with a history of CES symptoms be referred for urgent MRI even with no objective signs at all — symptom-only referral [19]. That is UK, not Australian law, and it is on this page because it tells you which way the profession is travelling: waiting for signs is no longer the standard anywhere.

Do not wait for the full picture

"Bladder + saddle = surgical emergency" is a good memory hook and it describes the LATE presentation. Waiting for bladder plus saddle means waiting for CES with retention — which is precisely the group in whom the timing of surgery makes no measurable difference to bladder outcome [20][21]. The pearl is the emergency. It is not the referral threshold.

The safety net — what you say to EVERY low back pain patient you discharge

The standard writes this for you, in plain Australian English, in the consumer section of Quality statement 1:

"See your clinician urgently if new symptoms appear, such as problems with controlling urine or bowel movements, or numbness or weakness in your legs, back or genitals."

Use those words. They are Australian, they are plain, and they sit on a government website you can point a patient to.

Three things, all of them, every time:

Say it — out loud, before they leave.
Give it in writing — they will not remember it.
Write in your notes that you did. The documented version is the only one that exists after the fact.

Name the destination: emergency department, same day. Not "call me". Not "see how it goes over the weekend".

And repeat it at every review in anyone with lumbar radicular pain or spinal stenosis. In older adults with stenosis, slow "grumbling" cauda equina symptoms are the ones that get absorbed into the existing diagnosis [13].

⚠️ Be honest about what safety netting is. It is recommended by every source on this page, it is applied inconsistently, with limited guidance and limited evidence, and physiotherapists describe fear of missed diagnosis, poor referral pathways and ambiguous presentations as what drives their practice [22]. We teach it because it is defensible and humane, not because it is proven.

Why everyone around you is tense about this

2,496 CES claims in the UK between 2012 and 2020, 51 of them attributed to physiotherapists — a figure the authors say is probably an undercount [12]. The same group's earlier scoping review reports 15 claims from 2009–2021, 0.7% of all CES claims [23].

Both figures are here because the discrepancy is the finding. CES claims against physiotherapists are not recorded consistently enough to count. Do not quote either number as a rate.

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Guideline anchor

Low Back Pain Clinical Care Standard (ACSQHC 2022) — read live from safetyandquality.gov.au on 2 Sep 2026.

Quality statement 1 names cauda equina syndrome by name in the emergency-referral trigger; Quality statement 3 sets the imaging position and the Medicare fact; Quality statement 8 and its Box 6 specify what goes in the urgent referral; the consumer sections carry the safety-netting words. Supplemented for the surgical pathway by the UK GIRFT 2025 suspected-CES pathway as reported in Conte et al. 2026 (PMID 42053010), which is NOT an Australian document and is labelled as such on the page.

PubMed Source

Australia HAS a standard, it names cauda equina syndrome explicitly, and it covers the only two decisions a physiotherapy student actually makes — escalate now, and what to tell every low back pain patient on the way out the door. What it does NOT contain is a CES-specific pathway: no symptom checklist, no post-void residual threshold, no MRI timeframe, no surgical window, no post-operative rehabilitation guidance. There is no Australian equivalent of the UK GIRFT/BASS national CES pathway. Those elements are anchored to primary evidence and to UK national guidance, and the page says so out loud.

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Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 36

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2020Long et al. (2020). Evaluation and management of cauda equina syndrome in the emergency department. The American journal of emergency medicine, 38(1), 143-148. https://doi.org/10.1016/j.ajem.2019.158402
2020Hoeritzauer et al. (2020). What is the incidence of cauda equina syndrome? A systematic review. Journal of neurosurgery. Spine, 32(6), 832-841. https://doi.org/10.3171/2019.12.SPINE19839
2020Galliker et al. (2020). Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags. The American journal of medicine, 133(1), 60-72.e14. https://doi.org/10.1016/j.amjmed.2019.06.005
2024Wood et al. (2024). Can clinical presentation predict radiologically confirmed cauda equina syndrome: retrospective case review of 530 cases at a tertiary emergency department. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 33(11), 4243-4252. https://doi.org/10.1007/s00586-024-08474-5
2024Curtis Lopez et al. (2024). Evaluation of the role of anal tone and perianal sensation examination in the assessment of suspected cauda equina syndrome. British journal of neurosurgery, 38(4), 923-927. https://doi.org/10.1080/02688697.2021.2005775
2025Rao & Chitgopkar (2025). Cauda equina syndrome-most frequent referral diagnosis to a tertiary spinal centre: a retrospective study. Journal of spine surgery (Hong Kong), 11(4), 906-912. https://doi.org/10.21037/jss-25-112
2025Stoddart et al. (2025). No turning back: a long-term retrospective analysis of urgent magnetic resonance imaging (MRI) performed for suspected cauda equina compression in a tertiary referral centre. Clinical radiology, 86, 106923. https://doi.org/10.1016/j.crad.2025.106923
2022Lavy et al. (2022). Cauda equina syndrome-a practical guide to definition and classification. International orthopaedics, 46(2), 165-169. https://doi.org/10.1007/s00264-021-05273-1
2021Hoeritzauer et al. (2021). Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study. Neurology, 96(3), e433-e447. https://doi.org/10.1212/WNL.0000000000011154
2020Katzouraki et al. (2020). A prospective study of the role of bladder scanning and post-void residual volume measurement in improving diagnostic accuracy of cauda equina syndrome. The bone & joint journal, 102-B(6), 677-682. https://doi.org/10.1302/0301-620X.102B6.BJJ-2020-0195.R1
2018Greenhalgh et al. (2018). Assessment and management of cauda equina syndrome. Musculoskeletal science & practice, 37, 69-74. https://doi.org/10.1016/j.msksp.2018.06.002
2022Yeowell et al. (2022). Medico-legal litigation of UK physiotherapists in relation to cauda equina syndrome: a multimethods study. BMJ open, 12(7), e060023. https://doi.org/10.1136/bmjopen-2021-060023
2020Comer et al. (2020). SHADES of grey - The challenge of 'grumbling' cauda equina symptoms in older adults with lumbar spinal stenosis. Musculoskeletal science & practice, 45, 102049. https://doi.org/10.1016/j.msksp.2019.102049
2025Stuart et al. (2025). Cauda equina syndrome and severe lumbar-sacral radiculopathy in general practice: Finding the needle in the haystack. Australian journal of general practice, 54(7), 439-443. https://doi.org/10.31128/AJGP-08-24-7389
2019Dionne et al. (2019). What is the diagnostic accuracy of red flags related to cauda equina syndrome (CES), when compared to Magnetic Resonance Imaging (MRI)? A systematic review. Musculoskeletal science & practice, 42, 125-133. https://doi.org/10.1016/j.msksp.2019.05.004
2019Dionne et al. (2019). Corrigendum to "What is the diagnostic accuracy of red flags related to cauda equina syndrome (CES), when compared to Magnetic Resonance Imaging (MRI)? A systematic review" [Musculoskelet. Sci. Pract. 42 (2019) 125-133]. Musculoskeletal science & practice, 43, 128. https://doi.org/10.1016/j.msksp.2019.07.001
2021Dionne et al. (2021). Corrigendum to "What is the diagnostic accuracy of red flags related to cauda equina syndrome (CES), when compared to Magnetic Resonance Imaging (MRI)? A systematic review" [Musculoskeletal Science and Practice 42 (2019) 125-133]. Musculoskeletal science & practice, 53, 102355. https://doi.org/10.1016/j.msksp.2021.102355
2020Finucane et al. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy, 50(7), 350-372. https://doi.org/10.2519/jospt.2020.9971
2026Todd (2026). Symptom-only cauda equina syndrome: A medicolegal assessment of new national guidelines. The Medico-legal journal, 94(1), 39-42. https://doi.org/10.1177/00258172251405164
2015Srikandarajah et al. (2015). Does early surgical decompression in cauda equina syndrome improve bladder outcome?. Spine, 40(8), 580-3. https://doi.org/10.1097/BRS.0000000000000813
2026Najjar et al. (2026). Reassessing the clock in cauda equina syndrome: a systematic review and meta-analysis of surgical timing and outcomes. The spine journal : official journal of the North American Spine Society, 26(9), 1653-1670. https://doi.org/10.1016/j.spinee.2026.04.013
2025Rice & Sheeran (2025). How do physiotherapists use Cauda Equina Syndrome safety netting techniques and what influences their practice?. Musculoskeletal science & practice, 78, 103353. https://doi.org/10.1016/j.msksp.2025.103353
2021Leech et al. (2021). A scoping review: Investigating the extent and legal process of cauda equina syndrome claims for UK physiotherapists. Musculoskeletal science & practice, 56, 102458. https://doi.org/10.1016/j.msksp.2021.102458
2022Tabrah et al. (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 & practice, 58, 102523. https://doi.org/10.1016/j.msksp.2022.102523
2015Sherlock et al. (2015). The Evaluation of Digital Rectal Examination for Assessment of Anal Tone in Suspected Cauda Equina Syndrome. Spine, 40(15), 1213-8. https://doi.org/10.1097/BRS.0000000000000902
2010Balasubramanian et al. (2010). Reliability of clinical assessment in diagnosing cauda equina syndrome. British journal of neurosurgery, 24(4), 383-6. https://doi.org/10.3109/02688697.2010.505987
2019Venkatesan et al. (2019). Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome. Spine, 44(18), 1303-1308. https://doi.org/10.1097/BRS.0000000000003152
2023Boktor et al. (2023). Predictive value of post-void residual volume as an adjunctive tool in the clinical evaluation of cauda equina syndrome. The bone & joint journal, 105-B(5), 487-495. https://doi.org/10.1302/0301-620X.105B5.BJJ-2022-0739.R2
2026Conte et al. (2026). Cauda Equina Syndrome-A 2025 Narrative Review. British journal of hospital medicine (London, England : 2005), 87(4), 52970. https://doi.org/10.31083/BJHM52970
2000Ahn et al. (2000). Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine, 25(12), 1515-22. https://doi.org/10.1097/00007632-200006150-00010
2014Chau et al. (2014). Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World neurosurgery, 81(3-4), 640-50. https://doi.org/10.1016/j.wneu.2013.11.007
2022Kumar et al. (2022). Outcomes of cauda equina syndrome due to lumbar disc herniation after surgical management and the factors affecting it: a systematic review and meta-analysis of 22 studies with 852 cases. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 31(2), 353-363. https://doi.org/10.1007/s00586-021-07001-0
2026Najjar et al. (2026). Reassessing bladder recovery in cauda equina syndrome: long-term outcomes after surgical decompression:a systematic review and meta-analysis. The spine journal : official journal of the North American Spine Society. https://doi.org/10.1016/j.spinee.2026.07.005
2026Najjar et al. (2026). Sexual dysfunction after cauda equina syndrome: a systematic review of long-term outcomes. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. https://doi.org/10.1007/s00586-026-10170-5
2021Hazelwood et al. (2021). Long-term mental wellbeing and functioning after surgery for cauda equina syndrome. PloS one, 16(8), e0255530. https://doi.org/10.1371/journal.pone.0255530
2018Hoeritzauer et al. (2018). The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients. Journal of neurology, 265(12), 2916-2926. https://doi.org/10.1007/s00415-018-9078-2

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