What is the appropriate course of action for a 57-year-old female patient experiencing numbness in her legs and buttocks, shooting pain, and bladder control problems, suspecting cauda equina syndrome?

From the Guidelines

The patient should seek immediate emergency medical attention at the nearest emergency department, as her symptoms strongly suggest cauda equina syndrome, a medical emergency requiring urgent surgical intervention, typically within 24-48 hours of symptom onset to prevent permanent neurological damage. The patient's symptoms, including numbness in her legs and buttocks, shooting pain, and bladder control problems, are consistent with cauda equina syndrome, a condition that occurs when the bundle of nerve roots at the end of the spinal cord (cauda equina) becomes compressed, often due to a herniated disc, tumor, infection, or spinal stenosis 1.

Upon arrival at the emergency department, the patient should clearly communicate all symptoms, especially the combination of leg numbness, buttock numbness, shooting pain, and bladder control problems. The emergency physician will likely order an immediate MRI of the lumbar spine to confirm the diagnosis, as MRI is the imaging study of choice in the evaluation of suspected cauda equina syndrome due to its ability to accurately depict soft-tissue pathology, assess vertebral marrow, and assess the spinal canal patency 1.

Key points to consider in the diagnosis and treatment of cauda equina syndrome include:

• The patient's symptoms have been present for 2 weeks but have worsened, indicating a potential progression of the condition
• The importance of urgent MRI assessment in all patients who present with new-onset urinary symptoms in the context of low back pain or sciatica 1
• The potential use of CT lumbar spine without IV contrast to answer the question of whether or not cauda equina compression is present, although MRI is superior in soft-tissue contrast and characterizing the etiology of cauda equina syndrome 1
• The need for emergency decompression surgery to relieve pressure on the compressed nerve roots if cauda equina syndrome is confirmed, to prevent permanent paralysis, bladder and bowel dysfunction, and sexual dysfunction.

From the Research

Symptoms and Diagnosis

• The patient is experiencing numbness in her legs and buttocks, shooting pain, and bladder control problems, which are consistent with the symptoms of cauda equina syndrome 2.
• Cauda equina syndrome is a potentially devastating spinal condition that results from conditions that compress the nerves in the lumbosacral spinal canal 2.
• A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment 2.

Appropriate Course of Action

• Given the patient's symptoms, an MRI scan is a suitable diagnostic tool to confirm the diagnosis of cauda equina syndrome 3, 4.
• If the diagnosis is confirmed, emergent spinal surgery referral is indicated, along with urgent decompression 2.
• Early intervention has been shown to portend a greater chance of neurologic recovery 2.
• The patient's symptoms have been worsening over the past 2 weeks, and prompt evaluation and treatment are essential to minimize the risk of permanent damage 3, 4.

Treatment and Management

• The treatment of cauda equina syndrome may involve medications such as pregabalin, tramadol, and dexamethasone to manage pain and inflammation 3.
• Surgical exploration is warranted if a mass lesion is demonstrated on imaging studies or if symptoms progress and the disease origin is not clear based on available information 5.
• Even with expeditious surgery, improvements remain inconsistent, but early intervention can optimize long-term patient outcomes and minimize the risk of litigation 2.