Cauda equina syndrome
Encyclopedia
Cauda equina syndrome is a serious neurologic
condition in which there is acute loss of function of the lumbar plexus, neurologic elements (nerve root
s) of the spinal canal below the termination (conus
) of the spinal cord
.
or "horse-tail") that branches off the lower end of the spinal cord and contains the nerve roots from L1-5 and S1-5. The nerve roots from L4-S4 join in the sacral plexus which affects the sciatic nerve, which travels caudally (toward the feet).
such as knife
wound
s or ballistic trauma
.
) or a developmental defect which is present at birth. In the most severe cases of spondylolisthesis
cauda equina syndrome can result.
and ankylosing spondylitis
can cause it. This is due to the spinal canal narrowing that these kind of syndromes can produce.
), sphincter weaknesses causing urinary
retention and post-void residual incontinence
as assessed by catheterizing after the patient has urinated.
Also, there may be decreased anal
tone and consequent fecal incontinence; sexual dysfunction
; saddle anesthesia
; bilateral leg
pain
and weakness; and bilateral absence of ankle reflexes. Pain may, however, be wholly absent; the patient may complain only of lack of bladder control and of saddle-anaesthesia, and may walk into the consulting-room.
Diagnosis is usually confirmed by an MRI scan or CT scan, depending on availability. If cauda equina syndrome exists, surgery is an option depending on the etiology discovered and the patient's candidacy for major spine surgery.
Cauda equina syndrome of sudden onset is regarded as a medical/surgical emergency. Surgical decompression by fish tail means of laminectomy or other approaches may be undertaken within 48 hours of symptoms developing if a compressive lesion, e.g. ruptured disc, epidural abscess, tumour or haematoma is demonstrated. This treatment may significantly improve the chance that long-term neurological damage will be avoided.
If cauda equina is caused by a trauma then the patient should be immobilized.
Surgery may be required to remove blood, bone fragments, a tumour or tumours, a herniated disc or an abnormal bone growth.If the tumour cannot be removed surgically and it is malignant then radiotherapy may be used as an alternative to relieve pressure, with spinal neoplasms chemotherapy can also be used. If the syndrome is due to an inflammatory condition e.g. ankylosing spondylitis, anti-inflammatory , including steroids can be used as an effective treatment. If a bacterial infection is the cause then an appropriate course of antibiotics can be used to treat it.
Cauda equina can occur during pregnancy due to lumbar disc herniation; age of mother increases the risk. Surgery can still be performed and the pregnancy does not adversely affect treatment. Treatment for those with cauda equina can and should be carried out at any time during pregnancy.
Lifestyle issues may need to be addressed post - treatment. Issues could include the patients need for physiotherapy and occupational therapy due to lower limb dysfunction. Obesity might also need to be tackled.
Damage can be so severe that nerve regrowth is impossible, and the nerve damage will be permanent. In cases where the nerve has been damaged but is still capable of regrowth, recovery time is widely variable. Surgical intervention with decompression of the cauda equina can assist recovery. Delayed or severe nerve damage can mean up to several years' recovery time because nerve growth is exceptionally slow.
Review of the literature indicates that around 50-70% of patients have urinary retention (CES-R) on presentation with 30-50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression. CES-I with its more favourable prognosis may become CES-R at a later stage.
Neurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...
condition in which there is acute loss of function of the lumbar plexus, neurologic elements (nerve root
Nerve root
A nerve root is the initial segment of a nerve leaving the central nervous system. Types include:* A cranial nerve root, the beginning of one of the twelve pairs leaving the central nervous system from the brain stem or the highest levels of the spinal cord;...
s) of the spinal canal below the termination (conus
Conus medullaris
The conus medullaris is the terminal end of the spinal cord. It occurs near lumbar vertebral levels 1 and 2 . After the spinal cord tapers out, the spinal nerves continue as dangling nerve roots called cauda equina. This terminal nerve root tail is referred to as the filum terminale...
) of the spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...
.
Causes
After the conus medullaris, the canal contains a mass of nerves (the cauda equinaCauda equina
The cauda equina is a structure within the lower end of the spinal column of most vertebrates, that consists of nerve roots and rootlets from above...
or "horse-tail") that branches off the lower end of the spinal cord and contains the nerve roots from L1-5 and S1-5. The nerve roots from L4-S4 join in the sacral plexus which affects the sciatic nerve, which travels caudally (toward the feet).
Tumors and lesions
Any lesion which compresses or disturbs the function of the cauda equina may disable the nerves although the most common is a central disc prolapse. Metastatic disease may also be a cause.Trauma
Direct trauma from lumbar puncture can also cause cauda equina syndrome. Other trauma-related causes include burst fractures resulting in posterior migration of fragments of the vertebral body, severe disc herniations, spinal anaesthesia involving trauma from catheters and high local anaesthetic concentrations around the cauda equina. Penetrating traumaPenetrating trauma
Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...
such as knife
Knife
A knife is a cutting tool with an exposed cutting edge or blade, hand-held or otherwise, with or without a handle. Knives were used at least two-and-a-half million years ago, as evidenced by the Oldowan tools...
wound
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...
s or ballistic trauma
Ballistic trauma
The term ballistic trauma refers to a form of physical trauma sustained from the discharge of arms or munitions. The most common forms of ballistic trauma stem from firearms used in armed conflicts, civilian sporting and recreational pursuits, and criminal activity.-Destructive effects:The degree...
.
Spinal stenosis
CES can be caused by lumbar spinal stenosis, which is when the diameter of the spinal canal narrows. This could be the result of a degenerative process of the spine (such as osteoarthritisOsteoarthritis
Osteoarthritis also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion...
) or a developmental defect which is present at birth. In the most severe cases of spondylolisthesis
Spondylolisthesis
Spondylolisthesis describes the anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. It was first described in 1782 by Belgian obstetrician, Dr. Herbinaux. He reported a bony prominence anterior to the sacrum that obstructed the vagina of a...
cauda equina syndrome can result.
Inflammatory conditions
Chronic spinal inflammatory conditions such as Paget disease, chronic inflammatory demyelinating polyneuropathyChronic inflammatory demyelinating polyneuropathy
Chronic inflammatory demyelinating polyneuropathy is an acquired immune-mediated inflammatory disorder of the peripheral nervous system. The disorder is sometimes called chronic relapsing polyneuropathy. CIDP is closely related to Guillain-Barré syndrome and it is considered the chronic...
and ankylosing spondylitis
Ankylosing spondylitis
Ankylosing spondylitis , previously known as Bekhterev's disease, Bekhterev syndrome, and Marie-Strümpell disease is a chronic inflammatory disease of the axial skeleton with variable involvement of peripheral joints and nonarticular structures...
can cause it. This is due to the spinal canal narrowing that these kind of syndromes can produce.
Signs
Signs include weakness of the muscles of the lower extremeties innervated by the compressed roots (often paraplegiaParaplegia
Paraplegia is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek: παραπληγίη "half-striking". It is usually the result of spinal cord injury or a congenital condition such as spina bifida that affects the neural elements of the spinal canal...
), sphincter weaknesses causing urinary
Urine
Urine is a typically sterile liquid by-product of the body that is secreted by the kidneys through a process called urination and excreted through the urethra. Cellular metabolism generates numerous by-products, many rich in nitrogen, that require elimination from the bloodstream...
retention and post-void residual incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...
as assessed by catheterizing after the patient has urinated.
Also, there may be decreased anal
Anus
The anus is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, unwanted semi-solid matter produced during digestion, which, depending on the type of animal, may be one or more of: matter which the animal cannot digest,...
tone and consequent fecal incontinence; sexual dysfunction
Sexual dysfunction
Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm....
; saddle anesthesia
Saddle anesthesia
Saddle anesthesia is a loss of sensation restricted to the area of the buttocks and perineum.It is frequently associated with cauda equina syndrome....
; bilateral leg
Human leg
The human leg is the entire lower extremity or limb of the human body, including the foot, thigh and even the hip or gluteal region; however, the precise definition in human anatomy refers only to the section of the lower limb extending from the knee to the ankle.Legs are used for standing,...
pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
and weakness; and bilateral absence of ankle reflexes. Pain may, however, be wholly absent; the patient may complain only of lack of bladder control and of saddle-anaesthesia, and may walk into the consulting-room.
Diagnosis is usually confirmed by an MRI scan or CT scan, depending on availability. If cauda equina syndrome exists, surgery is an option depending on the etiology discovered and the patient's candidacy for major spine surgery.
Treatment/management
The management of true cauda equina syndrome frequently involves surgical decompression.When cauda equina is caused by a herniated disk early surgical decompression is recommended.Cauda equina syndrome of sudden onset is regarded as a medical/surgical emergency. Surgical decompression by fish tail means of laminectomy or other approaches may be undertaken within 48 hours of symptoms developing if a compressive lesion, e.g. ruptured disc, epidural abscess, tumour or haematoma is demonstrated. This treatment may significantly improve the chance that long-term neurological damage will be avoided.
If cauda equina is caused by a trauma then the patient should be immobilized.
Surgery may be required to remove blood, bone fragments, a tumour or tumours, a herniated disc or an abnormal bone growth.If the tumour cannot be removed surgically and it is malignant then radiotherapy may be used as an alternative to relieve pressure, with spinal neoplasms chemotherapy can also be used. If the syndrome is due to an inflammatory condition e.g. ankylosing spondylitis, anti-inflammatory , including steroids can be used as an effective treatment. If a bacterial infection is the cause then an appropriate course of antibiotics can be used to treat it.
Cauda equina can occur during pregnancy due to lumbar disc herniation; age of mother increases the risk. Surgery can still be performed and the pregnancy does not adversely affect treatment. Treatment for those with cauda equina can and should be carried out at any time during pregnancy.
Lifestyle issues may need to be addressed post - treatment. Issues could include the patients need for physiotherapy and occupational therapy due to lower limb dysfunction. Obesity might also need to be tackled.
Prognosis
The prognosis for complete recovery is dependent upon many factors. The most important of these is the severity and duration of compression upon the damaged nerve(s). Generally, the longer the time before intervention to remove the compression causing nerve damage, the greater the damage caused to the nerve(s).Damage can be so severe that nerve regrowth is impossible, and the nerve damage will be permanent. In cases where the nerve has been damaged but is still capable of regrowth, recovery time is widely variable. Surgical intervention with decompression of the cauda equina can assist recovery. Delayed or severe nerve damage can mean up to several years' recovery time because nerve growth is exceptionally slow.
Review of the literature indicates that around 50-70% of patients have urinary retention (CES-R) on presentation with 30-50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression. CES-I with its more favourable prognosis may become CES-R at a later stage.