Cauda Equina Syndrome

Cauda equina syndrome is a medical emergency and it must be diagnosed quickly, as well as treated urgently in order to avoid long term complications. It occurs at the level of the lower roots, causing lower motor neuron injury. The cauda equina is multiple nerve roots within the lower end of the spinal canal, beginning at the level of L1, and L1-S5 peripheral nerve roots are inside the lumbar canal.

The symptoms of cauda equina syndrome usually present bilaterally and symmetrically. The symptoms will have a sudden onset, and include back pain, more so than radicular pain, and sensation over the perianal area is affected.

Cauda equina syndrome usually occurs due to a space occupying lesion such as a disc herniation, tumor, fracture, epidural hemorrhage, or an abscess. However, central disc herniation is the most common cause of cauda equina syndrome. A disc herniation can be posterolateral, central, or foraminal, but the posterolateral disc herniation is the most common type of disc herniation seen in cauda equina syndrome.

With a posterolateral disc herniation, there will be a nerve root injury, as well as changes in the sensory distribution. There may also be motor and reflex changes. With this type of herniation, the foot and ankle are usually affected. It is usually treated conservatively, at least at first. Posterolateral disc herniation commonly causes unilateral leg pain and weakness, and will produce a positive straight leg raising test.

A central disc herniation will affect the cauda equina as well. In the cervical and thoracic spine, compression causes involvement of the spinal cord and an upper motor neuron lesion. On the other hand, compression in the lower lumbar spine causes injury to the nerve roots and lower motor neuron lesions.

With cauda equina syndrome, the patient will have back pain, buttock pain, saddle anesthesia, bilateral leg pain, weakness in the lower extremity, urinary retention followed by urinary incontinence, and bowel dysfunction. Saddle anesthesia occurs from involvement of S2-S5 nerve roots- these nerve rots provide sensory innervation to the anal area, the perineum, and the inner thigh. There will be reduced or absent sensation to pinprick in the perianal region from S2-S5 dermatomes, as well as decreased rectal tone or voluntary contraction.

There are some red flags to watch out for with cauda equina syndrome, which include low back pain, sciatica, either unilateral or bilateral, sudden sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory changes. Even with knowing these red flags, early diagnosis is challenging, as the initial signs and symptoms are subtle. In this way, it is important to suspect cauda equina syndrome. When it is suspected, a digital rectal exam should be done and perianal sensation should be tested. With suspicion, an emergency MRI should be ordered to diagnose cauda equina syndrome. Then, the patient will probably need to be admitted for completion of the workup. If the patient has a pacemaker, then a CT myelogram will need to be done instead. In any way, if there is suspicion of cauda equina syndrome, a study should be ordered, as the source of the compression in the lumbar spine needs to be identified.

Cauda equina syndrome is a surgical emergency with maximum chance of recovery of the urinary and bowel function with adequate, early surgery. Additionally, the bladder dysfunction symptoms are the least likely to improve following cauda equina syndrome, so it is important that the surgery is done early. Ultimately, the timing of surgery decides the outcome.

Surgery for cauda equina syndrome includes early decompression with removal of the disc or bony fragments that are compressing the nerve roots. The patient should be taken to surgery urgently in order to provide the best chance of symptoms resolution.

The prognosis of cauda equine syndrome is usually improvement in pain and weakness. However, the results are less predictable for recovery of the urinary bladder and bowel dysfunction. If a patient presents after more than 48 hours of onset, there will be less than a 40% chance of improvement in bladder or bowel function. 60% of patients with cauda equina syndrome will have chronic bowel and bladder dysfunction if the surgery is delayed more than 48 hours.

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