Cauda Equina Syndrome

Aka: Cauda Equina Syndrome, Epidural Compression Syndrome

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II. Pathophysiology

  1. Massive Central DIsc protrusion
  2. Compression of lumbar spinal nerve roots

III. Precautions

  1. Maintain a high index of suspicion
  2. Delayed diagnosis or misdiagnosis is not uncommon (even by neurosurgical senior residents)
    1. Bell (2007) Br J Neurosurg 21(2): 201-3 [PubMed]

IV. Causes

  1. Large Central DIsc Herniation
  2. Lumbar Spinal Stenosis
  3. Lumbar Spine Trauma
  4. Spinal Neoplasm
  5. Lumbar Spondylosis with cauda equina compression
  6. Post-procedure (iatrogenic)
    1. Epidural Hematoma
    2. Epidural Abscess

V. Symptoms

  1. Bilateral Sciatica
    1. See also Lumbar Stenosis for extensive description
    2. Dull aching pain in perineum, Bladder or Sacrum
    3. Radiation to Buttock and leg
    4. Provoked by Exercise or prolonged standing
    5. Relieved with rest or forward bending
  2. Neurologic Changes
    1. Saddle Anesthesia
    2. Bowel Incontinence
    3. Bladder Incontinence or Acute Urinary Retention

VI. Signs

  1. Loss of perineal Sensation or perineal reflex
    1. May best correlate with cauda equina findings on MRI
  2. Loss of rectal tone
  3. Increased post-void residual Urine Volume
  4. Foot Drop
    1. Ankle dorsiflexion bilateral weakness
    2. Absent Ankle Jerk

VII. Imaging (See Lumbar Stenosis)

  1. L-Spine MRI (preferred)
  2. CT Myelography
    1. Indicated if MRI contraindicated

VIII. Lab (Indicated if Epidural Abscess or other infection suspected)

  1. Complete Blood Count
  2. Erythrocyte Sedimentation Rate (ESR)
  3. C-Reactive Protein (CRP)

IX. Diagnosis: High yield exam findings

  1. Altered perineal Sensation
  2. Abnormal rectal tone
  3. Increased post-void residual

X. Management

  1. Neurologic Deficits suggest Cauda Equina Syndrome
  2. Immediate Neurosurgery Consultation

XI. Prognosis

  1. Delay >72 hours risks permanent neurologic deficit

XII. References

  1. Cali and Bond (2022) Crit Dec Emerg Med 36(7): 4-11
  2. Balasubramanian (2010) Br J Neurosurg 24(4): 383-6 [PubMed]

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