T&O: Spine and Cauda equina

Question 1

Herniation at which level of the spinal discs can lead to caudal equine syndrome?

Answer 1

Lumbar discs

Question 2

Definition of cauda equina syndrome?

Answer 2

A prolapsed intervertebral disc fills the spinal canal. This compresses the lumbar and sacral nerve roots within the spinal canal

Question 3

How does CES present? What are red flags?

Answer 3

Recent PMH of disc prolapse. Age 40-50yrs. LMN signs and symptoms,

Red flags: (from Z2F)
Saddle anaesthesia
Loss of sensation in rectum and bladder (unsure how full they are)
Urinary incontinence or retention
Fecal incontinence
Bilateral sciatica
Bilateral weakness in LL (including ED)
Reduced anal tone in PR exam

Question 4

What is the investigation for suspected CES?

Answer 4

Emergency lumbar-sacral MRI

Question 5

What does MRI of CES show?

Answer 5

Cauda equina nerves being compressed. Shows cause of compression

Question 6

How do you manage CES?

Answer 6

Surgical decompression within 48hrs of onset of sphincter symptoms

Question 7

Name 2 risk factors for CES?

Answer 7

Disc herniation L5/S1 or L4/L5. Trauma.
Neoplasm - tumour affecting vert column or meninges.
Spinal stenosis - usually 2y to arthritis
Spinal infection or abscess.
Chronic spinal inflammation - ankylosing spondylitis (late stage). Iatrogenic - haematoma secondary to spinal anaesthesia.

Question 8

Name a complication of CES

Answer 8

• Chronic neuropathic pain.
• Impotence.
• Need to do self catheterisation.
• Fecal incontinence.
• Impaction of faeces.
• Loss of sensation and motor weakness of LL.
• Requirement of lifelong wheelchair.

Question 9

Define spinal stenosis

Answer 9

Degenerative in nature. Narrowing of the spinal canal or other nerve pathways in the spinal column. This puts pressure on nerves travelling through the spine. (Can affect spinal cord, or N roots).

Question 10

How may spinal stenosis present?

Answer 10

Gradual onset. Over 60 years old (as it is due to degenerative changes in spine).
Intermittent neurogenic claudication below level: usually bilateral
- lower back pain
- buttock and leg pain
- leg weakness.

Absent at rest or sitting.
Present when walking/standing.

Bend = Better
Straight = Symptoms

Note: ^ for central spinal stenosis - most common. Lateral stenosis and foramina stenosis = present w Sciatica

Question 11

What investigation would you order for suspected spinal stenosis?

Answer 11

MRI of the whole spine

Question 12

How is spinal stenosis managed?

Answer 12

Analgesia, exercise, weight loss. If a malignancy is present, high dose corticosteroids, chemo and radiotherapy. Spinal cord decompression.

Question 13

What are risk factors for spinal stenosis?

Answer 13

• Malignancy,
• trauma,
• infection,
• disc prolapse.

Question 14

What complications can arise from spinal stenosis?

Answer 14

CES

Question 15

What are the causes of cauda equina?

Answer 15

• Lumbar disc herniation at L4/5 and L5/S1 level,
• neoplasms,
• abscesses,
• iatrogenic causes

Question 16

How does cauda equina present?

Answer 16

Lower back pain with alternating or bilateral radicular pain, saddle parasthesia, urinary retention, urinary incontinence, bowel incontinence or retention

Question 17

How do you manage cauda equina?

Answer 17

Suspicion of cauda equina should have whole spine MRI and surgical decompression within 48 hours

If malignancy is suspected or shown then administer dexamethasone 16mg daily in divided doses with PPI cover

Question 18

What does common peroneal nerve injury cause?

Answer 18

Foot drop, due to paralysis of foot extensor.

Foot eversion may also occur.

Question 19

How is common peroneal nerve injury treated?

Answer 19

Conservatively.

Surgical intervention is indicated in those who do not have improved neurological function within 2-3 months

Question 20

What scoring tool could you use for back pain?

Answer 20

Keele STarT Back scoring tool

Evaluates the risk of acute back pain becoming chronic and intital interventions - CBT, group therapy, physio, exercises.
Qus focus on pts function and psychological response to pain. There are 9 questions in total. 4/ 9 are psychological questions
You get 2 scores - a total score (out of 9) and subscore (out of 4) for the psychological score

TOTAL SCORE = 3 or less - LOW risk
SUBSCORE = 3 or less - LOW risk

TOTAL SCORE = more than 3 - MEDIUM RISK
SUBSCORE = 3 or less - MEDIUM RISK

TOTAL SCORE =more than 3 - HIGH RISK
SUBSCORE = more than 3 - HIGH RISK

Question 21

How would you treat a patient who received a LOW RISK score on the Keele STarT Back scoring tool?

Answer 21

Self-management / Education
Reasurrance
Stay as active as possible
Analgesia

Question 22

How would you treat a patient who received a MEDIUM / HIGH RISK score on the Keele STarT Back scoring tool?

Answer 22

LOW RISK : Self-management / Education / Reasurrance / Stay as active as possible /Analgesia

PLUS ADD in :
Non drug:
CBT
Physiotherpay
Group exercise

Drug:
NSAID
Codeine (NSAID alternative)
Benzos - diazepam for muscle spasm (short term e.g. 5 days)

tell to look for red flag symptoms e.g. saddle parathesia
DO NOT use opiods / gabapentin / amytriptyline / pregabalin for lower back pain

Question 23

NICE 2020 guidance for drug medication for sciatica:

1. What drugs should you NOT USE?
2. Which neuropathic can use if worsening / persisting symptoms ?

Answer 23

p. 263 of Z2F

1. No opiates, gabapenitn, pregabalin, oral corticosteroids, diazepam.
2. Amitriptyline or Duloextine

(Specialist management can include : Epidural corticosteroid injections / local anaesthetic injections / spinal decompression )