II. Pathophysiology
- Massive Central DIsc protrusion
- Compression of lumbar spinal nerve roots
III. Precautions
- Maintain a high index of suspicion
- Delayed diagnosis or misdiagnosis is not uncommon (even by neurosurgical senior residents)
IV. Causes
- Large Central DIsc Herniation
- Lumbar Spinal Stenosis
- Lumbar Spine Trauma
- Spinal Neoplasm
- Lumbar Spondylosis with cauda equina compression
- Post-procedure (iatrogenic)
V. Symptoms
- Bilateral Sciatica
- See also Lumbar Stenosis for extensive description
- Dull aching pain in perineum, Bladder or Sacrum
- Radiation to Buttock and leg
- Provoked by Exercise or prolonged standing
- Relieved with rest or forward bending
- Neurologic Changes
- Saddle Anesthesia
- Bowel Incontinence
- Bladder Incontinence or Acute Urinary Retention
VI. Signs
- Loss of perineal Sensation or perineal reflex
- May best correlate with cauda equina findings on MRI
- Loss of rectal tone
- Increased post-void residual Urine Volume
-
Foot Drop
- Ankle dorsiflexion bilateral weakness
- Absent Ankle Jerk
VII. Imaging (See Lumbar Stenosis)
- L-Spine MRI (preferred)
- CT Myelography
- Indicated if MRI contraindicated
VIII. Lab (Indicated if Epidural Abscess or other infection suspected)
IX. Diagnosis: High yield exam findings
- Altered perineal Sensation
- Abnormal rectal tone
- Increased post-void residual
X. Management
- Neurologic Deficits suggest Cauda Equina Syndrome
- Immediate Neurosurgery Consultation
XI. Prognosis
- Delay >72 hours risks permanent neurologic deficit
XII. References
- Cali and Bond (2022) Crit Dec Emerg Med 36(7): 4-11
- Balasubramanian (2010) Br J Neurosurg 24(4): 383-6 [PubMed]