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Introduction
  • Cauda equina syndrome is defined by a constellation of symptoms that result from terminal spinal nerve root compression in the lumbosacral region
    • considered one of the few true medical emergencies in orthopaedics
    • key features
      • bilateral leg pain
      • bowel and bladder dysfunction
      • saddle anesthesia
      • lower extremity sensorimotor changes
  • 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
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 (8)
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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? Review Topic

QID: 1206
1

less than 24 hours after symptom onset

35%

(955/2746)

2

less than 48 hours after symptom onset

63%

(1742/2746)

3

less than 60 hours after symptom onset

1%

(17/2746)

4

less than one week after symptom onset

1%

(15/2746)

5

less than two weeks after symptom onset

0%

(4/2746)

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PREFERRED RESPONSE 2

(OBQ04.85) A 51-year-old male with a pacemaker reports difficulty with urination and numbness in his bilateral buttock. His symptoms began 12 hours ago. What is the next most appropriate step in management? Review Topic

QID: 1190
1

MRI of the lumbar spine

11%

(357/3162)

2

CT myelogram of the lumbar spine

84%

(2658/3162)

3

Epidural steroid injection

0%

(10/3162)

4

Emergent lumbar decompression

3%

(87/3162)

5

High dose methylprednisone

1%

(37/3162)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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