Cauda equina syndrome
Background
- The cauda equina (Latin for "horse's tail") begins at the 2nd Lumbar space extending down to the beginning of the sacral nerves. It is distal to the tapered end of the spinal cord, or conus medularis.[1]
Clinical Features
Epidural compression syndromes table[2]
| Syndrome | Spinal cord compression | Conus medullaris syndrome | Cauda equina syndrome |
| Location of lesion | Lesions at vertebral level L2 | ||
| Spontaneous pain | Unusual and not severe; bilateral and symmetrical in perineum or thighs | Often very prominent and severe, asymmetrical, radicular | |
| Motor findings | Deficits usually affect both legs but are often asymmetric | Not severe, symmetrical; rarely twitches | May be severe, asymmetrical, fibrillary twitches of paralyzed muscles are common |
| Sensory findings | Weakness in lower extremities, paresthesias/sensory deficits, gait difficulty | Saddle distribution, bilateral, symmetrical, disassociated sensory loss (impaired pain and temperature with sparing of tactile) | Saddle distribution (75% pts), may be asymmetrical, no dissociation of sensory loss |
| Reflex changes | Achilles reflex may be absent | Patellar and Achilles reflexes may be absent | |
| Sphincter disturbance | Bladder and rectal sphincter paralysis usually reflect involvement of S3-S5 nerve roots | Early and marked (both urinary and fecal) | Late and less severe (60-80% pts) |
| Male sexual function | Impaired early | Impairment less severe | |
| Onset | Sudden and bilateral | Gradual and unilateral | |
| Other | Urinary retention with or without overflow incontinence (Sn 90%, Sp 95%) |
The most common presenting symptom is urinary retention with or without resultant overflow urinary incontinence.
Differential Diagnosis
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Spinal fracture
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Renal disease
- Kidney stone
- Pyelonephritis
- Nephrolithiasis
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- PID
- Other
Spinal Cord Syndromes
Evaluation
- Emergent MRI
- If considering compression due to neoplasm obtain scan of entire spine
- Consider Bladder scan/ultrasound for bladder volume (post-void residual)
Management
General Epidural Compression Syndrome Management
- Dexamethasone: at least 16 mg IV as soon as possible after assessment[3]
- Note: dexamethasone can be used to reduce compressive edema from epidural metastases, but is more likely to worsen an infection from spinal epidural abscess.
- Consult spine service
- Consider foley for bladder decompression
- Consider dexamethasone 4 mg q4 hours after first dose
Disposition
- Admit
See Also
References
- Cohen MS, Wall EJ, Kerber CW, et al. The Anatomy of the Cauda Equina on CT Scans and MRI. J Bone Joint Surg Br 1991; 73 (3): 381-84.
- Bradley WG. Neurology in Clinical Practice: Principles of diagnosis and management. P363
- Metastatic spinal cord compression: Diagnosis and management of patients at risk of or with metastatic spinal cord compression. Full Guideline. November 2008. Developed for NICE by the National Collaborating Centre for Cancer. ©2008 National Collaborating Centre for Cancer
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