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
- Change in Sensation when wiping with toilet paper
- Bowel Incontinence or Constipation
- Urinary BladderIncontinence or acute Urinary Retention
- Acute Erectile Dysfunction
- Saddle Anesthesia
VI. Signs
- Loss of perineal Sensation or perineal reflex (or Anal Wink)
- May best correlate with cauda equina findings on MRI
- Loss of Rectal Tone
- Resting tone applies pressure to inserted finger without patient bearing down
- Patient tries to resist Defecation
- Puborectalis Muscle contracts and applies pressure to the anterior inserted finger
- External anal sphincter contracts and applies pressure circumferentially around the inserted finger
- Patient bears down
- Pressure on inserted finger increases
- Overall poor efficacy of Rectal Tone to diagnose S2-S4 neurologic deficit
- Loss of Bulbocavernosus Reflex
- 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
- Increased post-void residual
- Abnormal Rectal Tone
- More recent evidence (see above) suggests Rectal Tone is an unreliable test for cauda equina
X. Differential Diagnosis: Back Pain with Acute Neurologic Symptoms (e.g. Cord Syndrome, Peripheral Neuropathy)
- Central Spinal Stenosis (including cauda equina)
- Spinal Infection (e.g. Spinal Epidural Abscess, Discitis)
- Aortic emergencies (Aortic Dissection, Abdominal Aortic Aneurysm, Claudication)
- Neurologic Syndromes (Multiple Sclerosis, Guillain-Barre, Transverse Myelitis)
XI. Management
- Neurologic Deficits suggest Cauda Equina Syndrome
- Immediate Neurosurgery Consultation
XII. Prognosis
- Delay >72 hours risks permanent neurologic deficit
XIII. References
- Cali and Bond (2022) Crit Dec Emerg Med 36(7): 4-11
- Swaminathan, Shoenberger and Long in Swadron (2023) EM:Rap 23(3): 19-21
- Balasubramanian (2010) Br J Neurosurg 24(4): 383-6 [PubMed]
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| Definition (NCI) | A rare neurologic disorder caused by impingement of the nerve roots of the cauda equina secondary to disc herniation, spinal stenosis, vertebral fracture, neoplasm or infection. Clinical signs may include bladder or bowel dysfunction, paresthesia and weakness of the lower extremities. The clinical course rapidly deteriorates and necessitates emergent surgical decompression to minimize risk of incontinence, sexual dysfunction and permanent paralysis. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D011128 |
| ICD9 | 344.6 |
| ICD10 | G83.4 |
| SnomedCT | 192973005, 89356000, 192972000, 155032006, 192970008 |
| English | Cauda equina syndrome NOS, cauda equina syndrome, cauda equina syndrome (diagnosis), Cauda Equina Syndromes, Syndrome, Cauda Equina, Syndromes, Cauda Equina, lumbosacral syndrome, syndrome cauda equina, Cauda equina syndrome NOS (disorder), Lumbosacral syndrome, Polyneuritis equi, Cauda equina neuritis, Cauda equina syndrome, Cauda equina syndrome (disorder), cauda equina; syndrome, syndrome; cauda equina, Cauda equina syndrome, NOS, Cauda equina syndrome (disorder) [Ambiguous], Cauda Equina Syndrome |
| Italian | Cauda Equina, Sindrome lombo-sacrale |
| Dutch | lumbosacraal syndroom, cauda equina; syndroom, syndroom; cauda equina, cauda equina syndroom, Cauda-equinasyndroom |
| French | Syndrome lombosacré, Syndrome de la queue de cheval |
| German | Lumbosakralsyndrom, Cauda-equina-Syndrom, Cauda- (equina-) Syndrom, Cauda equina Syndrome |
| Portuguese | Síndrome lombossagrada, Síndrome da Cauda Equina, Síndrome da cauda equina |
| Spanish | Síndrome lumbosacro, Síndrome de Cauda Equina, síndrome de la cola de caballo, SAI (trastorno), síndrome de la cola de caballo, SAI, síndrome de la cauda equina, SAI, síndrome de la cauda equina, síndrome de la cola de caballo (concepto no activo), síndrome de la cola de caballo (trastorno), síndrome de la cola de caballo, Síndrome de cauda equina |
| Japanese | 馬尾症候群, 腰仙部症候群, ﾖｳｾﾝﾌﾞｼｮｳｺｳｸﾞﾝ, ﾊﾞﾋﾞｼｮｳｺｳｸﾞﾝ |
| Czech | Syndrom cauda equina, Lumbosakrální syndrom, syndroma caudae equinae, syndrom caudae equinae, syndrom kaudy |
| Korean | 말총증후군 |
| Hungarian | Cauda equina syndroma, Lumbosacralis syndroma |
| Norwegian | Cauda equina-syndrom |
