Updated: 9/26/2020

Cauda Equina Syndrome

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Questions
10 10
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Evidence
7 7
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Cases
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https://upload.orthobullets.com/topic/2065/images/large disc herniation copy.jpg
https://upload.orthobullets.com/topic/2065/images/saddle.jpg
Introduction
  • Overview
    • cauda equina syndrome is a serious condition caused by severe compression of nerve roots in the thecal sac in the lumbar spine, usually caused from an acute lumbar disc herniation.
    • it presents with the acute onset of numbness in the perianal region (saddle anesthesia), leg pain, and bladder dysfunction
    • it is considered one of the few true medical emergencies in orthopaedics and requires urgent thecal sac decompression with a microdiscectomy.
  • Epidemiology
    • 1-6% of lumbar disc herniations
  • Pathophysiology
    • space-occupying lesion within lumbosacral canal, including
      • disc herniation (most common)
      • spinal stenosis
      • tumors
      • trauma (retropulsion of fracture fragment, dislocation or collapse)
      • spinal epidural hematoma
      • epidural abscess
  • Associated conditions
    • deep vein thrombosis (DVT)
      • is a well known complication after spinal trauma or spine surgery
  • Prognosis
    • presence of saddle anesthesia or bladder dysfunction is associated with poorer outcomes
    • surgical decompression after 48 hours is associated with poorer outcomes
Anatomy
  • Spinal cord
    • conus medullaris
      • tapered, terminal end of the spinal cord  
      • terminates at T12 or L1 vertebral body
    • filum terminale
      • non-neural, fibrous extension of the conus medullaris that attaches to the coccyx 
    • cauda equina (horse's tail) 
      • collection of L1-S5 peripheral nerves within the lumbar canal
      • compression considered to cause lower motor neuron lesions 
  • Bladder
    • receives innervation from 
      • parasympathetic nervous system (pelvic splanchnic nerves and the inferior hypogastric plexus) and 
      • sympathetic plexus (hypogastric plexus)
    • external sphincter of the bladder is controlled by the pudendal nerve
    • lower motor neuron lesions of cauda equina will interrupt the nerves forming the bladder reflex arcs
Presentation
  • Symptoms 
    • back pain
    • unilateral or bilateral leg pain is the most common presenting symptom after back pain 
    • saddle anesthesia  
    • impotence
    • sensorimotor loss in lower extremity
    • neurogenic bladder dysfunction
      • disruption of bladder contraction and sensation leads to urinary retention and eventually to overflow incontinence 
    • bowel dysfunction is rare
  • Physical exam
    • inspection
      • lower extremity muscle atrophy with insidious presentations (e.g. spinal stenosis)
      • fasciculations are rare
    • palpation
      • lower back pain/tenderness is not a distinguishing feature
      • palpation of the bladder for urinary retention
    • neurovascular examination
      • bilateral lower extremity weakness and sensory disturbances
      • decreased or absent lower extremity reflexes
    • rectal/genital examination
      • reduced or absent sensation to pinprick in the perianal region (S2-S4 dermatomes), perineum, and posterior thigh
      • decreased rectal tone or voluntary contracture
      • diminished or absent anal wink test and a bulbocavernosus reflex 
Imaging
  • MRI
    • study of choice to evaluate neurologic compression 
  • CT myelography
    • study of choice if patient unable to undergo MRI 
Treatment
  • Operative
    • urgent surgical decompression within 48 hours 
      • indications
        • significant suspicion for CES
        • severity of symptoms will increase the urgency of surgical decompression
      • techniques
        • diskectomy 
        • laminectomy
      • outcomes
        • studies have shown improved outcomes in bowel and bladder function and resolution of motor and sensory deficits when decompression performed within 48 hours of the onset of symptoms
Surgical Techniques
  • Surgical decompression of neural elements 
    • approach
      • posterior midline approach to lumbar spine 
    • diskectomy vs. wide laminectomy and diskectomy  
      • no comparison studies between microdiskectomy alone and wide decompression combined with microdiskectomy.
Complications
  • Delayed presentation or decompression
    • sexual dysfunction
    • urinary dysfunction requiring catheterization
    • chronic pain
    • persistent leg weakness
 

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Questions (10)
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(SBQ12SP.72) A 32-year-old male presents with back pain and saddle anesthesia after lifting a heavy object. Figures A and B show T-2 MRI sagittal and axial images, respectively. Which of the following most accurately lists the additional symptoms or physical exam findings this patient may have from most common to least common? Tested Concept

QID: 3770
FIGURES:
1

Leg pain > urinary retention > urinary incontinence

57%

(1527/2657)

2

Urinary retention > leg pain > absent ankle jerk

6%

(151/2657)

3

Urinary retention > leg pain > urinary incontinence

6%

(151/2657)

4

Leg pain > urinary incontinence > urinary retention

12%

(331/2657)

5

Reduced rectal tone > urinary retention > leg pain

18%

(477/2657)

L 4 B

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(SBQ12SP.38) A 32-year-old woman presents to the emergency department with two days of worsening back and leg pain after feeling a sharp pop in her low back after an episode of coughing. She complains of numbness in her perianal region and bilateral buttocks that she notices when wiping herself with toilet paper after urinating. She also reports she is having difficulty urinating and had some episodes of incontinence. She complains of bilateral leg pain that is worse on the left in the region of the anterolateral calf. On physical exam she has weakness to big toe extension of 3/5 and is unable to walk on her heels with the toes elevated. MRI of her spine is shown in figures A through C. After surgical intervention, which of her symptoms is least likely to improve? Tested Concept

QID: 3736
FIGURES:
1

Big toe extension weakness

13%

(510/3827)

2

Bladder dysfuction

66%

(2530/3827)

3

Loss of perianal sensation

6%

(213/3827)

4

Numbness in the left foot

8%

(303/3827)

5

Burning pain in left leg

7%

(250/3827)

L 4 B

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(SAE09SN.15) A 56-year-old man with a history of chronic lower back pain from lumbar spondylosis reports a 2-day history of acute incapacitating back pain. He denies any history of acute trauma, although he reports the pain starting after a coughing spell. He also reports difficulty urinating and some fecal incontinence. Examination reveals generalized lower extremity weakness, saddle paresthesia, hyporeflexia in the lower extremities, and loss of rectal tone. What is the most appropriate management at this time? Tested Concept

QID: 6803
1

Immediate MRI of the lumbar spine

98%

(389/398)

2

General reassurance, anti-inflammatory drugs, and an early home exercise program

0%

(0/398)

3

Immediate radiographs of the lumbar spine and pain medications with 2 days of bed rest if the radiographs are normal

1%

(3/398)

4

Office caudal epidural steroid injection with follow-up in 1 week

0%

(0/398)

5

Outpatient MRI of the lumbar spine with follow-up in 1 week for test results

0%

(0/398)

L 1 D

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(OBQ04.101) A 49-year-old male presents with saddle anesthesia, lower extremity weakness, and urinary retention. When must surgical decompression be done to improve bladder and motor recovery? Tested Concept

QID: 1206
1

less than 24 hours after symptom onset

36%

(1269/3505)

2

less than 48 hours after symptom onset

62%

(2172/3505)

3

less than 60 hours after symptom onset

1%

(23/3505)

4

less than one week after symptom onset

1%

(18/3505)

5

less than two weeks after symptom onset

0%

(5/3505)

L 3 C

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Evidences (15)
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CASES (1)
Topic COMMENTS (13)
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