Review Question - QID 1190

This patient has classic symptoms of Cauda Equina Syndrome (CES). The most important next step is identifying a source of compression in the lumbar spine. The study of choice is an MRI, however in patient who cannot have an MRI such as those with pacemakers, a CT myelogram should be performed.

Cauda equina syndrome has been described as a complex of low back pain, bilateral or unilateral sciatica, saddle anesthesia, and motor weakness that can progress to paraplegia and permanent bowel/bladder dysfunction. Cauda equina is an ABSOLUTE indication for surgical treatment of lumbar disc disease. Historically the recommendation was to proceed with surgical decompression within six hours, however new data supports surgery within 48 hours.

Kostuik et al. compared patient treated with surgery at 1.1 days compared to those treated at 3.3 days and found no correlation of these times with return of function. Therefore, they feel even though early surgery should be performed, decompression does not have to be performed in less than six hours.

Ahn et al, in a meta study of 322 patients, found significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.

Incorrect Answers:
Answer 1: MRI of the lumbar spine would not be possible due to pacemaker.
Answer 3: Epidural steroid injection would not be indicated.
Answer 4: Ultimately this patient will require an emergent lumbar decompression, but the source of compression must be identified first.
Answer 4: High dose methylprednisone is only indicated in spinal cord injuries that present within 8 hours of presentation.