Cauda Equina Syndrome

Condition associated with compression of the nerve roots in the lumbosacral

spine characterized by progressive low back pain, sciatica, lower extremity
sensorimotor loss, and bowel and bladder dysfunction.

Overview

– Lesions involving the cauda equine are lower motor neuron lesions—patients
may demonstrate varying degrees of lower extremity muscle weakness and
sensory disturbance as well as decreased or absent reflexes.
– Can be caused by compression due to tumor, trauma, disc herniation, epidural
hematoma or abscess, spinal surgical implants, etc.
– Neurogenic bladder dysfunction is an essential element of cauda equine
syndrome. Dysfunction can be divided into two categories (retention and incon-
tinence). The injury to lower motor neurons causes disruptions to reflex arcs that
control bladder function. Loss of sensation of fullness and the inability to contract
lead to retention and overflow incontinence.

History

– Do you have a history of cancer or risk factors for cancer?

– Did you have any trauma?
– Have you had fevers, chills, or recent weight loss?
– Do you have bowel/bladder dysfunction?
– Do you have saddle anesthesia or any other motor/sensory deficits?
– When did the symptoms begin?

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Physical Exam

– Trauma evaluation (Appendix A)

– Complete neurologic evaluation (Appendix A)
– Rectal examination for decreased tone, perianal sensation
– Neurogenic bladder dysfunction
– Post-void residual - can indicate urinary retention
– Bulbocavernosus reflex

Diagnosis

Imaging

Diagnostic imaging should be obtained in an expedient manner; however, when the

diagnosis is strongly suspected and diagnostic tests are not available it may be
appropriate to recommend transfer of patient to a facility that can obtain advanced
imaging studies.
XR entire spine
MRI—allows for visualization of space-occupying lesions as well as other
potential causes of compression of neural structures.
CT myelography—for patient unable to undergo MRI.

Treatment

Non-operative treatment reserved for medically unstable

Otherwise, surgical decompression of offending lesion (tumor, disc, abscess, etc.)
Timing of surgery
Once a diagnosis is made and advanced imaging studies performed and reviewed,
should proceed to surgery
Discordance in literature for benefits of early versus delayed
Historical “48-h” window
RCT showing improved outcomes of surgery (<24 h) versus 48 h
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References

Daniels EW, Gordon Z, French K, Ahn UM, Ahn NU. Review of medicolegal cases for cauda
equina syndrome: what factors lead to an adverse outcome for the provider? Orthopedics.
2012;35(3):414–419.
Fehlings MG, Vaccaro A, Wilson JR, Singh A, W. Cadotte D, Harrop JS, et al. Early versus delayed
decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute
Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):1–8.
Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad
Orthop Surg. 2008;16:471–9.