[14] Cauda Equina Syndrome Flashcards
What is cauda equina syndrome?
A surgical emergency caused by a compression of the cauda equina
What can cauda equina lead to if untreated?
Debilitating complications
What is the result of the potential for the development of debilitating complications from cauda equina syndrome?
A high level of suspicion and rapid intervention is required
What is the peak age of onset of cauda equina syndrome?
40-50 years old
What is the cauda equina?
A bundle of nerves situated inferior to the spinal cord
Where does the spinal cord taper to an end?
At approximately the first lumbar vertebrae
What is the tapering end of the spinal cord called?
The conus medullaris
How do nerve roots L1-S5 leave the spinal cord?
They pass down the spinal canal (as the cauda equina) to exit at their respective foramina
What does the cauda equina contain?
Lower motor neurones, containing motor and sensory impulses to the lower limbs, motor innervation to the anal sphincter, and parasympathetic innervation from the bladder
What is cauda equina syndrome caused by?
Compression of cauda equina
What can cause compression of the cauda equina?
- Disc herniation
- Trauma
- Neoplasm
- Infection
- Chronic spinal inflammation
- Iatrogenic
At what level does disc herniation most commonly cause cauda equina syndrome?
L5/S1 and L4/5
What trauma can cause cauda equina syndrome?
- Vertebral fracture
- Subluxation
What are the common metastatic cancers that spread to spinal vertebrae?
- Thyroid
- Breast
- Lung
- Renal
- Prostate
What infections can cause compression of the cauda equina?
- Discitis
- Pott’s disease
What disease can cause chronic spinal inflammation leading to cauda equina?
Ankylosing spondylitis
What are the iatrogenic causes of cauda equina compression?
Haematoma secondary to spinal anaesthesia
What can cauda equina syndrome be divided into?
Complete or incomplete
Of what nature will most cases of cauda equina syndrome be?
Progressive, and will not immediately cause complete compression of the cauda equina
Why is the classification of complete or incomplete cauda equina syndrome important?
Because incomplete cauda equina syndrome has a greater potential for neurological recovery
What are the symptoms of cauda equina syndrome?
Lower motor neurone signs and symptoms, including;
- Reduced lower limb sensation (often bilateral)
- Bladder or bowel dysfunction
- Lower limb motor weakness
- Severe back pain
- Impotence
What is an important feature to assess in cauda equina syndrome?
Bladder dysfunction, specifically the presence of retention
What is the importance of assessing bladder dysfunction in cauda equina syndrome?
Confirmed retention or reduced ability to void (loss of desire, reduced urinary sensation) suggests complete or incomplete CES respectively
What are the features of cauda equina syndrome on examination?
- Saddle anaesthesia or lower limb anaesthesia
- Loss of anal tone
- Urinary retention
- Lower limb weakness and hyporeflexia
What is saddle anaesthesia?
Anaesthesia of the lower sacral dermatomes (perianal area)
What should be done as part of the examination for suspected CES, regardless of symptoms?
- PR examination
- Post-void bladder scan
What are the differential diagnoses of cauda equina syndrome?
- Radiculopathy
- Cord compression
How is radiculopathy differentiated from cauda equina syndrome?
There will be no faecal, urinary, or sexual dysfunction in radiculopathy
What is cord compression?
A surgical emergency with similar pathophysiology to CES
What is cord compression characterised by?
Upper motor neurone signs
What investigations should be done for suspected cases of cauda equina syndrome?
An emergency whole spine MRI
What % of patients suspected to have CES from clinical assessment have an abnormality found on MRI?
60%
Is further imaging required in CES?
It may be required depending on underlying cause, but if CES is confirmed then urgent surgical intervention is the priority
How is cauda equina syndrome managed?
- An early neurosurgical review for urgent decompression must be initiated
- Most patients will initially be started on high-dose steroids
- In trauma, immobilisation is often employed
In whom is it particularly important that an early neurosurgical review is important?
Those with incomplete CES
Why is especially important that those with incomplete CES undergo early neurosurgical review?
As the prognosis is potentially more favourable
Give an example of a steroid used in CES
Dexamethasone
What is the purpose of high dose steroids in CES?
Reduce any swelling
What is done for cases of CES deemed suitable for neurosurgical intervention?
The neurosurgical team will discuss plans for surgical decompression
How can CES be managed in cases caused by malignancy?
Radiotherapy and chemotherapy, especially if hte patient is not suitable for surgery
What is the prognosis of CES variable depending on?
- Aetiology
- Time taken from symptom onset to surgery
