Cauda Equina Syndrome (CES)

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Cauda Equina Syndrome (CES) is a serious neurological condition caused by the compression of the cauda equina, a bundle of spinal nerves located at the lower end of the spinal cord. It is a medical emergency that requires immediate diagnosis and treatment to prevent permanent neurological damage.

Aetiology

Cauda Equina Syndrome can result from various causes that lead to compression of the cauda equina nerves. Common causes include:

• Herniated lumbar disc, which is the most common cause
• Spinal stenosis, a narrowing of the spinal canal
• Spinal trauma, such as fractures or dislocations
• Spinal tumours, either primary or metastatic
• Epidural abscess or haematoma
• Inflammatory conditions, such as ankylosing spondylitis
• Complications following spinal surgery

Pathophysiology

The pathophysiology of CES involves:

• Compression of the cauda equina nerves, which supply motor and sensory innervation to the lower limbs, bladder, bowel, and perineum
• Ischaemia and inflammation of the affected nerves, leading to neurological deficits
• Potential irreversible damage to the nerves if the compression is not relieved promptly, resulting in permanent loss of function

Risk Factors

• Age, particularly middle-aged and older adults
• History of lumbar disc herniation or spinal stenosis
• History of spinal trauma or surgery
• Presence of spinal tumours or infections
• Chronic inflammatory conditions affecting the spine
• Occupational risks, such as jobs involving heavy lifting or repetitive spinal strain

Signs and Symptoms

Cauda Equina Syndrome presents with a combination of neurological symptoms that may include:

• Severe lower back pain, often radiating down the legs (sciatica)
• Saddle anaesthesia, or numbness in the groin, buttocks, and inner thighs
• Bladder dysfunction, including urinary retention or incontinence
• Bowel dysfunction, including faecal incontinence or constipation
• Lower limb weakness or paralysis, particularly affecting the legs and feet
• Sexual dysfunction, such as erectile dysfunction in men
• Loss of reflexes in the lower limbs

Investigations

Specific investigations to diagnose CES include:

• Magnetic Resonance Imaging (MRI): The gold standard for diagnosing CES, MRI provides detailed images of the spinal cord, nerve roots, and surrounding structures, allowing for the identification of nerve compression.
• CT myelography: May be used if MRI is contraindicated, to assess the spinal canal and nerve roots.
• Neurological examination: A thorough neurological assessment to evaluate motor, sensory, and reflex function in the lower limbs and perineum.
• Bladder scanning or post-void residual volume measurement: To assess bladder dysfunction, particularly urinary retention.
• Blood tests: To identify underlying infections or inflammatory conditions that may be contributing to CES.

Management

Primary Care Management

• Urgent referral: CES is a medical emergency; immediate referral to a hospital for emergency imaging and surgical evaluation is crucial. Delays can result in permanent neurological damage.
• Pain management: While awaiting transfer, pain relief with NSAIDs or opioids may be administered, but priority is on prompt referral rather than prolonged management in primary care.

Specialist Management

• Emergency surgery: Decompressive laminectomy or discectomy to relieve pressure on the cauda equina nerves is the definitive treatment. The timing of surgery is critical, ideally within 48 hours of symptom onset to optimise outcomes.
• Post-operative care: Includes rehabilitation with physiotherapy and occupational therapy to maximise recovery of function.
• Bladder and bowel management: Catheterisation may be required for urinary retention, and bowel care protocols may be implemented to manage constipation or incontinence.
• Long-term monitoring: Regular follow-up to assess neurological recovery and manage any residual deficits. This may involve urology, neurology, or pain management specialists.

References

1. NHS (2024) Cauda Equina Syndrome. Available at: https://www.nhs.uk/conditions/cauda-equina-syndrome/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Cauda Equina Syndrome. Available at: https://cks.nice.org.uk/topics/cauda-equina-syndrome/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Cauda Equina Syndrome: Clinical Features, Diagnosis, and Management. Available at: https://www.bmj.com/content/350/bmj.h3100 (Accessed: 24 June 2024).
4. American Academy of Orthopaedic Surgeons (2024) Cauda Equina Syndrome. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/cauda-equina-syndrome/ (Accessed: 24 June 2024).

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