Cauda equina syndrome

Cauda equina syndrome
Cauda equina and filum terminale seen from behind.
ICD-10	G83.4
ICD-9	344.6
DiseasesDB	31115
MeSH	C10.668.829.800.750.700

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Joanna Ekabua, M.D. [2]

WikiDoc Resources for Cauda equina syndrome
Articles
Most recent articles on Cauda equina syndrome Most cited articles on Cauda equina syndrome Review articles on Cauda equina syndrome Articles on Cauda equina syndrome in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Cauda equina syndrome Images of Cauda equina syndrome Photos of Cauda equina syndrome Podcasts & MP3s on Cauda equina syndrome Videos on Cauda equina syndrome
Evidence Based Medicine
Cochrane Collaboration on Cauda equina syndrome Bandolier on Cauda equina syndrome TRIP on Cauda equina syndrome
Clinical Trials
Ongoing Trials on Cauda equina syndrome at Clinical Trials.gov Trial results on Cauda equina syndrome Clinical Trials on Cauda equina syndrome at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Cauda equina syndrome NICE Guidance on Cauda equina syndrome NHS PRODIGY Guidance FDA on Cauda equina syndrome CDC on Cauda equina syndrome
Books
Books on Cauda equina syndrome
News
Cauda equina syndrome in the news Be alerted to news on Cauda equina syndrome News trends on Cauda equina syndrome
Commentary
Blogs on Cauda equina syndrome
Definitions
Definitions of Cauda equina syndrome
Patient Resources / Community
Patient resources on Cauda equina syndrome Discussion groups on Cauda equina syndrome Patient Handouts on Cauda equina syndrome Directions to Hospitals Treating Cauda equina syndrome Risk calculators and risk factors for Cauda equina syndrome
Healthcare Provider Resources
Symptoms of Cauda equina syndrome Causes & Risk Factors for Cauda equina syndrome Diagnostic studies for Cauda equina syndrome Treatment of Cauda equina syndrome
Continuing Medical Education (CME)
CME Programs on Cauda equina syndrome
International
Cauda equina syndrome en Espanol Cauda equina syndrome en Francais
Business
Cauda equina syndrome in the Marketplace Patents on Cauda equina syndrome
Experimental / Informatics
List of terms related to Cauda equina syndrome

Overview

The cauda equina is a collection of nerves at the end of the spinal cord. These nerves consist of the spinal nerves L2-L5, S1-S5 and the coccygeal nerve. Cauda equina syndrome first described by Hutchinson in 1889 is due to compression of the cauda equina in the lumbosacral region of the spinal canal. It is an emergency medical condition requiring acute intervention in the form of acute decompression surgery to prevent permanent neurological damage to the urinary bladder, Intestine, sex organs and lower limbs. The most common cause of cauda equina syndrome is lumbar disc herniation. It can be classified into two major groups, cauda equina syndrome complete with urinary retention and cauda equina syndrome incomplete. Prognosis of cauda equina syndrome depends on time from onset of symptoms to decompression and the degree of nerve damage at the time of surgery.

Historical perspective

• Cauda equina was named by the French anatomist Andreas Lazarius (André du Laurens) in the 17th century after its resemblance to a horse's tail (Latin: cauda equina).
• Cauda equina syndrome was first discovered by Jonathan Hutchinson, a British dermatologist and surgeon in 1889, following a hemorrhoidectomy in a 42-year-old man in which general anesthesia of ether and a crushing clamp was used. Postop, the patient had painless urinary retention and constipation. During catheterization, he felt no pain, by postop day 3, he was fecal incontinent without knowledge. The patient was seen by Hutchinson 6 months later, where examination showed the anus to be patulous and acontractile. An enema or manual evacuation had to be used to empty bowel. The patient was unaware of the passage of feces. When patient self-catheterized three times a day, he had no sensation on catheter passage. He, however, could empty his bladder by straining. The patient had partial anesthesia around the anus and buttocks. He had no problems with his bladder or bowels before the operation, but he did have a past medical history of alternating sciatica bilaterally which was not very common. During the sciatica attacks, he felt numb on the buttocks. There is no record of the state of the muscles of his lower limbs. Hutchinson diagnosed a form of ascending neuritis induced by crushing of his pile. He was unhappy with these findings since there was no interval between the operation and the development of the urinary retention. Hutchinson could not establish a diagnosis. Evidence is presented to suggest that this was the first case of disc prolapsed, causing a cauda equina syndrome because of anesthesia and manipulation.
• In 1977/1978, MRI was developed by Raymond Damadian to diagnose cancer. It has since been used to diagnose other pathologies and is the gold standard for the diagnosis of cauda equina syndrome.

Classification

Cauda equina syndrome may be classified into complete and incomplete.

• Cauda equina syndrome complete with urinary retention
• Cauda equina syndrome incomplete

Cauda equina syndrome

Complete with urinary retention

Incomplete

Lumbar +/- leg pain, sensory and motor deficency in lower extremities, painless urine retention with overflow incontinence, total perianal sensory loss, and fecal incontinece.

Lumbar +/- leg pain, sensory and motor deficency in lower extremities, loss of micturition reflex, altered urinary sensation and hesitancy, partial saddle anesthesia, and decreased anal sphinter tone.

Pathophysiology

• It is thought that cauda equina syndrome is the result of direct mechanical compression of the lumbar and sacral nerves roots arising below the conus medullaris and venous congestion or ischemia.
• Mechanical compression can be due to space-occupying lesion such as
  • Spinal disc herniation
  • Infections/abscess
  • Hematoma
  • Fractured vertebrae
  • Metastasis
  • Lumbosacral and pelvic hydatid cyst within lumbosacral region of the spinal canal
• The proximal region of the cauda equina is relatively hypovascular leading to neuroischemic symptoms with compression.

Causes

Cauda equina syndrome may be caused by

• Lumbar disc herniation
• Conus medullaris infarction
• Complication of lumbar spinal surgery
• Lumbar spinal stenosis
• Vertebrae fracture/trauma
• Spinal lesions or tumor
• Epidural venous plexus engorgement/thrombosis
• Primary lumbosacral and pelvic hydatid cyst
• Infections/abscess

Differentiating cauda equina syndrome from other Diseases

• Cauda equina syndrome must be differentiated from spinal disc herniation, epidural hematoma, spinal tumor/metastasis, spinal stenosis, and diabetic amyotrophy.

Epidemiology and Demographics

• The incidence of cauda equina syndrome is 2 in 100,000/year.
• Patients of all age groups may develop cauda equina syndrome.
• Cauda equina syndrome usually affects individuals of all races, although African American individuals are less likely to develop cauda equina syndrome.
• Cauda equina syndrome affects men and women equally.

Risk Factors

• The most potent risk factor in the development of cauda equina syndrome is spinal disc herniation.
• Other risk factors include trauma, a spinal tumor, severe infection, spinal stenosis, spinal anesthesia, obesity and female sex.

Screening

• There is insufficient evidence to recommend routine screening for cauda equina syndrome.

Natural History, Complications, and Prognosis

• If left untreated, 100% progress to permanent nerve damage and neurological deficit.

• Common complications of cauda equina syndrome include
  • Micturition dysfunction 48%
  • Defecation dysfunction 42%,
  • Sexual dysfunction 53%
  • Sciatica 48%
  • Altered sensation of the saddle area 57%.

• Prognosis of cauda equina syndrome depends on a number of factors, example time from onset of symptoms to decompression, the degree of nerve damage at the time of surgery and the type of cauda equina syndrome; with incomplete being more favourable. Following surgery, the extent of recovery is variable. Long term outcomes postsurgery are bladder, sexual, and motor dysfunction especially in patients with cauda equina syndrome complete with urinary retention.

Diagnosis

Diagnostic Study of Choice

• There are no established criteria for the diagnosis of cauda equina syndrome. However, in the presence of Lower back pain, urinary retention, decreased muscle strength, and saddle anesthesia, MRI should be ordered to rule out cauda equina syndrome.

Radiological imaging	Sensitivity	specificity	PPV	NPV
CT	98%	86%	72%	99%
MRI	68%	78%	84%	58%

• Although CT is shown to be more sensitive and specific for the diagnosis of cauda equina syndrome, MRI is considered the goal standard because it can depict soft tissue clearer.

History and Symptoms

The most common symptoms of cauda equina syndrome include

• Intermittent Lower back pain radiating to the lower extremities.
• Decreased muscle strength bilaterally.
• Fecal incontinence/retention
• Urinary incontinence/ retention
• Unilateral or bilateral sciatica
• Saddle anesthesia
• Paraparesis
• Sexual dysfunction

Physical Examination

Common physical examination findings of cauda equina syndrome include

• Hypesthesia
• Saddle dysesthesia
• Lasegue sign
• Decreased knee and ankle reflex bilaterally.
• Asymmetric calf wasting
• Lower limb weakness
• Positive Babinski sign
• Impaired proprioception

Laboratory findinds

• There are no diagnostic laboratory findings associated with cauda equina syndrome.

Echocardiography

• There are no ECG findings associated with cauda equina syndrome.

X-ray

• There are no x-ray findings associated with cauda equina syndrome.

Ultrasound

• There are no ultrasound findings associated with cauda equina syndrome.

CT Scan

• Lumbosacral CT scan may be helpful in the diagnosis of cauda equina syndrome.

• CT scan sensitivity for cauda equina syndrome has been estimated to be 98%; specificity, 86%; positive predictive value, 72%; and negative predictive value, 99%.

• Findings on CT scan suggestive of/diagnostic of cauda equina syndrome include
  • This CT scan shows compression of the spinal cord due to a fractured Vertebra.

Sagittal view CT demonstrates spinal cord compression due to Vertebra fracture after fall from a height (yellow arrow). Case courtesy of Dr Ian Bickle (Picture courtesy: Radiopedia)

MRI

• Lumbosacral MRI is the gold standard in the diagnosis of cauda equina syndrome.

• MRI sensitivity for cauda equina syndrome has been estimated to be 68%, specificity 78%, positive predictive value 84% and negative predictive value 58%.

• Findings on MRI suggestive of cauda equina syndrome include
• In Lumbar disc herniation, MRI shows a disc mass filling most of the spinal canal compressing the cauda equina.

T2-weighted images in non-contrast MRI of the lumbar region at L4/5 level demonstrating a huge isointense lesion (herniated disc) compressing the spinal cord. Sagittal view (Left/yellow arrow) and axial view (Right/yellow arrowhead) (Picture courtesy: Medicine)

• In Pott's disease, MRI shows spinal cord compression by destroyed bone.

Sagittal view MRI of the spine demonstrating a lumbar vertebra destruction due to TB and spinal cord compression (yellow arrowhead). Case courtesy of Dr Rishi Ramaesh (Picture courtesy: Radiopedia)

Other Imaging Findings

• There are no other imaging findings associated with cauda equina syndrome.

Other Diagnostic Findings

• Myelogram which demonstrates spinal cord compression due to Spinal disc herniation

Sagittal view of CT myelogram demonstrates spinal cord compression due to Spinal disc herniation (white arrow). (Picture courtesy: Thebmj)

• Electromyography
• Pre and post-void bladder scan; if the post-void residual volume is >200ml, the probability of cauda equina syndrome is 43% (P < 0.000003) making bladder scan an adjunct in the diagnosis of cauda equina syndrome.

Treatment

Medical Treatment

Cauda equina syndrome is a medical emergency and requires prompt treatment. Although the mainstay of treatment is surgery, The following medications are used.

• 5.4 mg/kg·h of methylprednisolone (intravenous) for 2 days
• 5 mg of dexamethasone (intravenous) every 12 h for 3 days
• 0.5 mg of mecobalamin tablets (oral) every 8 h
• Chemotherapy for cases due to tumors
• Antibiotics for cases due to infection

Surgery

• Surgery is the mainstay of treatment for cauda equina syndrome. Immediate surgical decompression is the best intervention associated with positive patient outcome. Procedures used include
  • Laminectomy and discectomy (most common)
  • Hemilaminectomy
  • Transforaminal lumbar interbody infusion
  • Microdiscectomy
• positive outcomes in bladder and bowel functions, sensory and motor deficit are seen if decompresssion is performed within 48hours of symptoms.

Primary Prevention

• There are no established measures for the primary prevention of cauda equina syndrome.

Secondary Prevention

• There are no established measures for the secondary prevention of cauda equina syndrome.

References

Template:Neuroscience-stub Template:Cerebral palsy and other paralytic syndromes [{Category:Needs patient information]] de:Cauda-equina-Syndrom