T&O: Cauda Equina Syndrome

Question 1

Outline the pathophysiology of CES.

Answer 1

Surgical emergency = compression of the corda equina (L2-5)

Peak onset between 40-50 years of age

Results in LMN signs and symptoms

Question 2

Outline the aetiology of CES.

Answer 2

Disc herniation = most common at L5/S1 and L4/L5 level

Trauma = vertebral fracture and subluxation

Neoplasm = either primary or metastatic (most common cancers that spread to spinal vertebrae are thyroid, breast, lung, renal and prostate)

Infection = discitis or Potts disease

Chronic spinal inflammation = ankylosing spondylitis

Iatrogenic = haematoma secondary to spinal anaesthesia

Question 3

What are the symptoms of CES?

Answer 3

Reduced lower limb sensation (often bilateral)

Bladder or bowel dysfunction

Lower limb motor weakness

Severe back pain

Impotence

Perianal (the lower sacral dermatomes, termed “saddle” anaesthesia)

Lower limb anaesthesia

Loss of anal tone

Urinary retention

Question 4

What questions should you ask a patient who is suffering with symptoms of CES?

Answer 4

1. Can you feel wiping your back passage?

2. Can you feel your bladder filling?

Question 5

How would you investigate CES?

Answer 5

Whole spine MRI

Lower limb neurological exam

PR exam

Post-void bladder scan

Question 6

How would you manage CES?

Answer 6

Urgent decompression

High-dose steroids (dexamethasone) = reduce any localised swelling

Malignancy = radiotherapy and/or chemotherapy can be used

Question 7

What are the complications of CES?

Answer 7

Residual weakness, incontinence, impotence, and/or sensory abnormalities are potential problems if therapy is delayed

Patients with complete perineal anaesthesia are more likely to have permanent paralysis of the bladder