Compartment and Cauda Equina syndromes Flashcards
What’s compartment syndrome?
What happens?
It’s a critical pressure increase within a confined space (compartment)
perfusion pressure to the tissues in the compartment is reduced -> ischaemia and necrosis
What are the complications of untreated compartment syndrome?
- limb loss
- multiorgan failure
- death
Possible causes of compartment syndrome
- trauma to the affected area
- fractures that cause vascular injury
- iatrogenic causes (e.g. vascular injury post-op)
- tight casts or splints
- DVT
- post-reperfusion syndrome swelling
Characteristic presenting features of Compartment Syndrome
- pain (worsening despite treatment, disproportionate to the injury, worse on passive movement)
- paraesthesia - in a cutaneous distribution of a nerve that is compressed
- generalised muscular tenderness
- swelling
*as a disease progresses -> features of acute arterial insufficiency develop (5’ Ps)
Features of arterial insufficiency (6 ‘Ps)
- pallor
- pulseless
- paraesthesia
- perishingly cold
- pain
- paralysis
DIagnosis of compartment syndrome
- it is usually clinical
- suspicion in a post-op patient
- MRI of affected compartment -> if diagnosis is in doubt
Initial management of Compartment Syndrome (prior to definitive intervention)
- early recognition is important
- inform plastic/genera/orthopaedic surgeon
- keep the limb at neutral level (do not elevate or lower)
- increase blood pressure -> crystalloid fluids
- high flow oxygen
- remove any constricting dressings, splits, casts
- opioid analgesia and anti-emetics
Definitive management of Compartment Syndrome
Emergency Open Fasciectomy -> to relieve the pressure inside the compartment
What happens after open fasciectomy?
What needs to be monitored?
- the skin incisions are left open -> re-looked at after 24-48 hours
- monitor renal function and electrolytes closely -> risk of rhabdomyolysis and reperfusion syndrome
What signs (lower or upper motor neurone) does cauda equina produce?
Cauda Equina = lower motor neurone signs
Examples: hypotonia, hyporeflexia, downgoing plantars
Gold standard investigation for Cauda Equina syndrome
Whole spine MRI
How common cauda equina is? What’s peak age onset?
Peak age onset is 40-50 years old
4 in 10 000 people this age, presenting with lower back pain will have it
What nerve roots can be affected by Cauda Equina?
L1 - S5
What the cauda equina innervates?
Sensory and motor impulses -> lower limbs
Motor -> anal sphincter
Parasympathetic -> bladder
Pathophysiology (and causes) of Cauda Equina
Cauda equina syndrome is caused by compression of the cauda equina:
- Disc herniation – most common at L5/S1 and L4/L5 level
- Trauma – including vertebral fracture and subluxation
- Neoplasm
- Infection – e.g. discitis or Potts disease
- Chronic spinal inflammation – e.g. ankylosing spondylitis
- Iatrogenic – e.g. haematoma secondary to spinal anaesthesia
Symptoms of Cauda Equina
- reduced lower limbs sensation (often bilateral)
- bladder and anal sphincter dysfunction
- importance
- lower limb muscular weakness
- severe back pain
*lower motor neurone signs
What may be seen on examination of a patient with Cauda Equina Syndrome?
- perianal (the lower sacral dermatomes, termed “saddle” anaesthesia)
- lower limb anaesthesia
- loss of anal tone
- urinary retention
- lower limb weakness and hyporeflexia
What clues may be there in the history of a patient presenting with cauda equina syndrome?
- weight loss
- signs of malignancy/ metastatic disease
- living in area of endemic TB
What (2) elements should be involved in the examination of every patient presenting with suspected cauda equina syndrome?
- PR
- post-voiding bladder scan
Differential diagnosis of Cauda Equina Syndrome (2)
*how to distinguish these from CES?
- Radiculopathy – presents with radiating back pain, however there will be no faecal, urinary, or sexual dysfunction in these patients
- Cord compression – a surgical emergency with a similar pathophysiology to CES, however is characterised by upper motor neurone signs
Management of Cauda Equina Syndrome
- early neuro-surgical review -> for early decompression
- high dose steroids e.g. Dexamethasone -> to reduce localised swelling
- immobilisation -> in case of trauma
- surgical decompression -> if neuro-surgeons opinion is to do so
- management of malignancy (if that is the case) -> radiotherapy, chemotherapy etc
Prognosis for Cauda Equina Syndrome
- variable
- depends on the time between the first onset of autonomic dysfunction to the treatment
