Cauda equina syndrome
Updates to Article Attributes
Cauda equina syndrome refers to a collection of symptoms and signs that result from severe compression of the descending lumbar and sacral nerve roots. It is considered a diagnostic and surgical emergency.
Epidemiology
Cauda equina syndrome is rare with prevalence estimated at approximately 1 in 65,000 (range 33,000 to 100,000) 1. It has, however, been estimated to occur in ~1% (range 0.1-2%) of herniated lumbar discs 2,3.
Clinical presentation
Cauda equina syndrome can present either acutely or chronically and requires two sets of symptoms/signs 1-3:
- perianal and "saddle" paraesthesia
. - bowel, bladder and/or sexual dysfunction
.
There areis a myriadhost of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence 1-3,6:
- low back pain
- radiculopathy/sciatica
- lower limb paraesthesia and/or motor weakness
- reduction/absence of lower limb reflexes
- decreased rectal tone
Classification
Cauda equina syndrome (CES) can be classified into two entities 1,2:
- Incomplete (CES-I): perianal/saddle paraesthesia but urinary retention/incontinence has not fully developed although the loss of urgency or decreased sensation may be present.
- Cauda equina syndrome with retention (CES-R): perianal/saddle paraesthesia with urinary retention or incontinence.
CES-R accounts for ~60% (range 50-70%) and CES-I accounts for ~40% (range 30-50%) of presentations 6.
Pathology
Aetiology
There is a long list of conditions that can cause cauda equina syndrome (some of these are very rare) 1-3:
- degenerative
- lumbar disc herniation (most common, especially at L4/5 and L5/S1)
- lumbar spinal canal stenosis
- spondylolisthesis
- Tarlov cysts
- facet joint cysts
- inflammatory
- both acute and chronic form may be seen in long-standing ankylosing spondylitis (2nd-5th decades; average 35 years) 7-9
- traumatic
- spinal fracture or dislocation
- epidural haematoma (may also be spontaneous, post-operative, post-procedural or post-manipulation)
- infective
- epidural abscess
- tuberculosis (Pott disease)
- malignant
- lymphoma
- metastases
- primary CNS malignancies (e.g. ependymoma
;, schwannoma;, neurofibroma)
- vascular
- numerous other rare space-occupying lesions (e.g. sarcoid)
Risk factors
- congenital or acquired spinal canal stenosis 3
- recent lumbar spinal surgery 2
Radiographic appearance
Plain radiograph
- limited value; may demonstrate gross degenerative or traumatic bony disease 2
CT myelogram
- useful in patients in whom MRI is contraindicated or not available
- partial or complete blockage of contrast
- may demonstrate an "hourglass" shape to the contrast-filled thecal sac in complete blockage 2
MRI
- imaging modality of choice 2,3
- sagittal and axial T1 and T2 sequences are usually sufficient 4
- post-contrast and STIR sequences may be required if infective causes are suspected 3,4
Treatment and prognosis
Cauda equina syndrome is considered a diagnostic and surgical emergency, although there is some debate about the timing of surgery (and depends on acute vs. chronic) but surgical decompression within 24 hours seemseems to have the best outcomes 1,3, 6,6. Patients with CES-R have a poorer outcome 3. Approximately 20% of patients will have a poor outcome in terms of urological and/or sexual function as well as lower limb paraesthesia and weakness 6.
-<li>perianal and "saddle" paraesthesia.</li>-<li>bowel, bladder and/or sexual dysfunction.</li>-</ol><p>There are a myriad of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence <sup>1-3,6</sup>:</p><ul>- +<li>perianal and "saddle" paraesthesia</li>
- +<li>bowel, bladder and/or sexual dysfunction</li>
- +</ol><p>There is a host of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence <sup>1-3,6</sup>:</p><ul>
-<li>primary CNS malignancies (e.g. <a href="/articles/ependymoma">ependymoma</a>; <a href="/articles/spinal-schwannoma">schwannoma</a>; <a href="/articles/neurofibromatosis-type-1">neurofibroma</a>)</li>- +<li>primary CNS malignancies (e.g. <a href="/articles/ependymoma">ependymoma</a>, <a href="/articles/spinal-schwannoma">schwannoma</a>, <a href="/articles/neurofibromatosis-type-1">neurofibroma</a>)</li>
-</ul><h4>Treatment and prognosis</h4><p>Cauda equina syndrome is considered a diagnostic and surgical emergency although there is some debate about the timing of surgery (and depends on acute vs. chronic) but surgical decompression within 24 hours seem to have the best outcomes <sup>1,3, 6</sup>. Patients with CES-R have a poorer outcome <sup>3</sup>. Approximately 20% of patients will have a poor outcome in terms of urological and/or sexual function as well as lower limb paraesthesia and weakness <sup>6</sup>. </p>- +</ul><h4>Treatment and prognosis</h4><p>Cauda equina syndrome is considered a diagnostic and surgical emergency, although there is some debate about the timing of surgery (and depends on acute vs. chronic) but surgical decompression within 24 hours seems to have the best outcomes <sup>1,3,6</sup>. Patients with CES-R have a poorer outcome <sup>3</sup>. Approximately 20% of patients will have a poor outcome in terms of urological and/or sexual function as well as lower limb paraesthesia and weakness <sup>6</sup>. </p>
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