Cauda Equina Syndrome

The caudal nerve roots located at the terminus of the spinal cord form what is known as the cauda equina.  Compression of these nerves can cause cauda equina syndrome which can affect:
  • sensation in the perineal area
  • bladder and bowel function
  • sexual function
  • neurological deficit in the lower limbs
Cauda Equina Syndrome requires immediate referral for urgent investigation as it is a medical emergency. The majority of patients with CES will need decompression surgery as early as possible (recommended within the first 48 hours of presentation) in order to ensure the best possible outcome.

Presentation

It is not easy to diagnose cauda equina syndrome and the only way to eliminate the diagnosis is with an emergency MRI scan.  A thorough history and clinical examination assisted by appropriate radiological examination will provide the primary basis for a diagnosis.
The majority of CES cases are of sudden onset and progress extremely quickly within days, or even a matter of hours.  It is also possible for some patients to develop CES slowly and these patients may also experience no pain whatsoever.
Patients most commonly present with:
  • Low back pain, with pain in the legs and unilateral or bilateral lower limb motor and/or sensory abnormality.
  • Lower limb motor weakness and sensory deficits: usually asymmetrical weakness with loss of reflexes dependent on the affected nerve root
  • Bowel and/or bladder dysfunction with saddle and perineal anaesthesia.
  • Urinary dysfunction may include retention, difficulty starting or stopping a stream of urine, overflow incontinence and decreased bladder and urethral sensation.
  • Bowel disturbances may include faecal incontinence and constipation. Rectal examination may reveal loss of anal tone and sensation.
  • Sexual dysfunction

Management

Refer the patient for a neurosurgical consultation immediately.
Urgent spinal decompression surgery is necessary to provide the patient the best chance of avoiding permanent neurological damage.
  • Immobilise the spine if CES is due to trauma.
  • Surgery is indicated to remove blood, bone fragments, tumour, herniated disc or abnormal bone growth.
  • Lesion debulking is required for space-occupying lesions - eg, tumours, abscess.
  • If surgery cannot be performed, radiotherapy may relieve cord compression caused by malignant disease.
  • Other treatment options may be useful in certain patients, depending on the underlying cause of the CES:
    • Anti-inflammatory agents, including steroids, can be effective in patients with inflammatory causes - eg, ankylosing spondylitis.
    • Infection causes should be treated with appropriate antibiotic therapy.
    • Patients with spinal neoplasms should be evaluated for chemotherapy and radiation therapy.
  • Postoperative care includes addressing lifestyle issues (eg, obesity), and also physiotherapy and occupational therapy, depending on residual lower limb dysfunction.

Useful Articles

Cauda equina syndrome 2016
Sciatica (lumbar radiculopathy) 2015
Common questions about chronic low back pain 2015
Cauda equina syndrome: implications for primary care 2014
Cauda equina syndrome: evaluation of the clinical outcome 2014
Current management review of thoracolumbar cord syndromes 2011
Causes and outcomes of cauda equina syndrome in medico-legal practice… 2011
Cauda equina syndrome: a review of the current clinical and medico-legal position 2010
Low back pain in adults: early management 2009
Cauda equina syndrome: a literature review of its definition and clinical presentation 2009
Cauda equina syndrome: a review of clinical progress 2009
Cauda equina syndrome: a clinical review for the frontline clinician 2009
Cauda equina syndrome 2009
Cauda equina syndrome: a comprehensive review 2008
Epidural abscess causing cauda equina syndrome 2005
Nonvascular complications following spinal manipulation 2005
This page is a summary of an article on Cauda Equina Syndrome authored by Dr Colin Tidy and reviewed by Dr John Cox written for https://Patient.info.