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]
Overview
The cauda equina is a collection of nerves at the end of the spinal cord. Cauda equina syndrome is due to compression of these nerves. 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.
Historical perspective
Classification
Cauda equina syndrome may be classified into complete and incomplete.[1][2]
- 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
Cauda equina syndrome is caused by compression of the lumbar and sacral nerves roots arising below the conus medullaris.[2] The proximal region of the cauda equina is relatively hypovascular leading to neuroischemic symptoms with compression [3]
Causes
Cauda equina syndrome may be caused by[4]
- Lumbar disc herniation[4]
- conus medullaris infarction[5]
- Complication of lumbar spinal surgery[6]
- Lumbar spinal stenosis[6]
- Vertebrae fracture/trauma[7]
- Spinal lesions or tumor[8]
- Epidural venous plexus engorgement/thrombosis[9][10][11]
- Primary lumbosacral and pelvic hydatid cyst[12]
- Infections/abscess[10]
Differentiating cauda equina syndrome from other Diseases
Cauda equina syndrome must be differentiated from spinal disc herniation, epidural hematoma, spinal tumor, spinal stenosis, and diabetic amyotrophy.
Epidemiology and Demographics
- The incidence of cauda equina syndrome is 2 per 100,000 /year.[1][10]
- Patients of all age groups may develop cauda equina syndrome.
- There is no racial predilection to cauda equina syndrome.
- Cauda equina syndrome affects men and women equally.
Risk Factors
Screening
Natural History, Complications, and Prognosis
If left untreated, 100% progress to permanent nerve damage and neurological deficit.
Common complications of cauda equina syndrome include[10]
- 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 and the degree of nerve damage at the time of surgery. Following surgery, the extent of recovery is variable.[10]
Diagnosis
Diagnostic Study of Choice
History and Symptoms
The most common symptoms of cauda equina syndrome include
- Intermittent Lower back pain radiating to the lower extremities. [2][4][6][13]
- Decreased muscle strength bilaterally.[4][2][6]
- Fecal incontinence/retention[4][2][5][6][13]
- Urinary incontinence/ retention[1][4][2][6][13]
- Unilateral or bilateral sciatica[2][6][13]
- Saddle anesthesia[2][6][13]
- Paraparesis[5]
- Sexual dysfunction[5][13]
Physical Examination
- Hypesthesia[4][5]
- Saddle dysesthesia[5]
- Lasegue sign[4]
- Decreased knee and ankle reflex bilaterally. [4][5]
- Asymmetric calf wasting[5]
- Lower limb weakness[5]
- Positive Babinski sign[5]
- Impaired proprioception[5]
Laboratory findinds
X-ray
Ultrasound
CT Scan
Lumbosacral CT scan may be helpful in the diagnosis of cauda equina syndrome. Findings on CT scan suggestive of/diagnostic of cauda equina syndrome include
- CT scans show herniated nucleus pulposus at the L4/5 level.
MRI
Lumbosacral MRI is the gold standard in the diagnosis of cauda equina syndrome.[4][2] Findings on MRI suggestive of/diagnostic of cauda equina syndrome include
- In Lumbar disc herniation, MRI shows a disc mass filling most of the spinal canal compressing the cauda equina.
Other Imaging Findings
Other Diagnostic Findings
- Myelogram
- 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.[14]
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.[6]
- 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
Surgery
Surgery is the mainstay of treatment for cauda equina syndrome.[2][4] Immediate surgical decompression is the best intervention associated with positive patient outcome.[15] Procedures used include
- Laminectomy and discectomy (most common)
- Hemilaminectomy
- Transforaminal lumbar interbody infusion
- Microdiscectomy
Long term outcomes postsurgery are bladder, sexual, and motor dysfunction especially in patients with cauda equina syndrome complete with urinary retention.[16]
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
- ↑ 1.0 1.1 1.2 Srikandarajah N, Noble A, Clark S, Wilby M, Freeman BJC, Fehlings MG; et al. (2020). "Cauda Equina Syndrome Core Outcome Set (CESCOS): An international patient and healthcare professional consensus for research studies". PLoS One. 15 (1): e0225907. doi:10.1371/journal.pone.0225907. PMC 6953762 Check
|pmc=value (help). PMID 31923259. - ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T (2018). "Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review". Spine (Phila Pa 1976). 43 (17): E1005–E1013. doi:10.1097/BRS.0000000000002605. PMC 6104724. PMID 29432394.
- ↑ Parke WW, Gammell K, Rothman RH (1981). "Arterial vascularization of the cauda equina". J Bone Joint Surg Am. 63 (1): 53–62. PMID 7005240.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Luo D, Ji C, Xu H, Feng H, Zhang H, Li K (2020). "Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report". Medicine (Baltimore). 99 (7): e19025. doi:10.1097/MD.0000000000019025. PMC 7035013 Check
|pmc=value (help). PMID 32049799 Check|pmid=value (help). - ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Weng YC, Chin SC, Wu YY, Kuo HC (2019). "Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction". BMC Neurol. 19 (1): 328. doi:10.1186/s12883-019-1566-1. PMC 6916224 Check
|pmc=value (help). PMID 31847829. - ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Yuan T, Zhang J, Yang L, Wu J, Tian H, Wan T; et al. (2019). "Cauda equina syndrome without motor dysfunction following lumbar spinal stenosis surgery: A case report". Medicine (Baltimore). 98 (29): e16396. doi:10.1097/MD.0000000000016396. PMC 6709168 Check
|pmc=value (help). PMID 31335689. - ↑ Li P, Qiu D, Shi H, Song W, Wang C, Qiu Z; et al. (2019). "Isolated Decompression for Transverse Sacral Fractures with Cauda Equina Syndrome". Med Sci Monit. 25: 3583–3590. doi:10.12659/MSM.916483. PMC 6532556 Check
|pmc=value (help). PMID 31089068. - ↑ Wu HY, Xu WB, Lu LW, Li HH, Tian JS, Li JM; et al. (2018). "Imaging features of spinal atypical teratoid rhabdoid tumors in children". Medicine (Baltimore). 97 (52): e13808. doi:10.1097/MD.0000000000013808. PMC 6314652. PMID 30593171.
- ↑ Tello Díaz C, Allegue Allegue N, Gil Sala D, Gonçalves Martins G, Boqué Torremorell M, Bellmunt Montoya S (2019). "Cauda Equina Syndrome Caused by Epidural Venous Plexus Engorgement in a Patient with May-Thurner Syndrome". Ann Vasc Surg. 60: 480.e7–480.e11. doi:10.1016/j.avsg.2019.04.002. PMID 31200048.
- ↑ 10.0 10.1 10.2 10.3 10.4 "StatPearls". 2020. PMID 30725885.
- ↑ Lavy C, James A, Wilson-MacDonald J, Fairbank J (2009). "Cauda equina syndrome". BMJ. 338: b936. doi:10.1136/bmj.b936. PMID 19336488.
- ↑ Adilay U, Tuğcu B, Gunes M, Günaldi O, Gunal M, Eseoglu M (2007). "Cauda equina syndrome caused by primary lumbosacral and pelvic hydatid cyst: a case report". Minim Invasive Neurosurg. 50 (5): 292–5. doi:10.1055/s-2007-973822. PMID 18058646.
- ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Long B, Koyfman A, Gottlieb M (2020). "Evaluation and management of cauda equina syndrome in the emergency department". Am J Emerg Med. 38 (1): 143–148. doi:10.1016/j.ajem.2019.158402. PMID 31471075.
- ↑ Venkatesan M, Nasto L, Tsegaye M, Grevitt M (2019). "Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome". Spine (Phila Pa 1976). 44 (18): 1303–1308. doi:10.1097/BRS.0000000000003152. PMID 31479434.
- ↑ Hogan WB, Kuris EO, Durand WM, Eltorai AEM, Daniels AH (2019). "Timing of Surgical Decompression for Cauda Equina Syndrome". World Neurosurg. 132: e732–e738. doi:10.1016/j.wneu.2019.08.030. PMID 31415897.
- ↑ Hazelwood JE, Hoeritzauer I, Pronin S, Demetriades AK (2019). "An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome". Acta Neurochir (Wien). 161 (9): 1887–1894. doi:10.1007/s00701-019-03973-7. PMC 6704093 Check
|pmc=value (help). PMID 31263950.
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