Cauda equina syndrome
Updates to Article Attributes
Cauda equina syndrome (CES) 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
CES is rare with prevalence estimated at approximately 1 in 65,000 (range 33,000 to 100,000) 1.
CES has been estimated to occurs in ~1% (range 0.1-2%) of herniated lumbar discs 2, 3,3 and that 1 in 1.8 million suffers CES from a prolapsed intervertebral disc 3.
Clinical presentation
CES can present either acutely or chronically and requires two sets of symptoms/signs 1, 2, 3-3:
- Perianal and "saddle" paraesthesia.
- Bowel, bladder and/or sexual dysfunction.
There are a myriad of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence 1, 2, 3, 6-3,6:
- low back pain
- radiculopathy/sciatica
- lower limb paraesthesia and/or motor weakness
- reduction/absence of lower limb reflexes
- decreased rectal tone
Classification
CES can be classified into two entities 1-2,2:
- Incomplete CES (CES-I) - perianal/saddle paraesthesia but urinary retention/incontinence has not fully developed although loss of urgency or decreased sensation may be present.
- CES 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 CES (some of these are very rare) 1, 2, 3-3:
- 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
's diseasedisease)
- 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 film
- 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
"hour-glass"hourglass" shape to the contrast-filled thecal sac in in complete blockage 2
- may demonstrate an
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
CES is considered a diagnostic and surgical emergency although there is some debate about timing of surgery (and depends on acute vs. chronic CES) but surgical decompression within 24 hours seem to have the best outcomes 1,3, 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.
-<p><strong>Cauda equina syndrome</strong> (<strong>CES</strong>) 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. </p><h4>Epidemiology</h4><p>CES is rare with prevalence estimated at approximately 1 in 65,000 (range 33,000 to 100,000) <sup>1</sup>.</p><p>CES has been estimated to occurs in ~1% (range 0.1-2%) of herniated lumbar discs <sup>2, 3</sup> and that 1 in 1.8 million suffers CES from a prolapsed intervertebral disc <sup>3</sup>. </p><h4>Clinical presentation</h4><p>CES can present either acutely or chronically and requires two sets of symptoms/signs <sup>1, 2, 3</sup>:</p><ol>- +<p><strong>Cauda equina syndrome</strong> (<strong>CES</strong>) 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. </p><h4>Epidemiology</h4><p>CES is rare with prevalence estimated at approximately 1 in 65,000 (range 33,000 to 100,000) <sup>1</sup>.</p><p>CES has been estimated to occurs in ~1% (range 0.1-2%) of herniated lumbar discs <sup>2,3</sup> and that 1 in 1.8 million suffers CES from a prolapsed intervertebral disc <sup>3</sup>. </p><h4>Clinical presentation</h4><p>CES can present either acutely or chronically and requires two sets of symptoms/signs <sup>1-3</sup>:</p><ol>
-</ol><p>There are a myriad of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence <sup>1, 2, 3, 6</sup>:</p><ul>- +</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>
-</ul><h4>Classification</h4><p>CES can be classified into two entities <sup>1-2</sup>:</p><ol>- +</ul><h4>Classification</h4><p>CES can be classified into two entities <sup>1,2</sup>:</p><ol>
-</ol><p>CES-R accounts for ~60% (range 50-70%) and CES-I accounts for ~40% (range 30-50%) of presentations <sup>6</sup>. </p><h4>Pathology</h4><h5>Aetiology</h5><p>There is a long list of conditions that can cause CES (some of these are very rare) <sup>1, 2, 3</sup>:</p><ul>- +</ol><p>CES-R accounts for ~60% (range 50-70%) and CES-I accounts for ~40% (range 30-50%) of presentations <sup>6</sup>. </p><h4>Pathology</h4><h5>Aetiology</h5><p>There is a long list of conditions that can cause CES (some of these are very rare) <sup>1-3</sup>:</p><ul>
-<li>tuberculosis (<a href="/articles/pott-disease">Pott's disease</a>)</li>- +<li>tuberculosis (<a href="/articles/pott-disease">Pott disease</a>)</li>
-<li>partial or complete blockage of contrast<ul><li>may demonstrate an "hour-glass" shape to the contrast-filled thecal sac in in complete blockage <sup>2</sup>- +<li>partial or complete blockage of contrast<ul><li>may demonstrate an "hourglass" shape to the contrast-filled thecal sac in in complete blockage <sup>2</sup>
Image 8 MRI (T2) ( create )
Unable to process the form. Check for errors and try again.