From the Guidelines
A primary care physician should immediately assess a patient with suspected cauda equina syndrome in the office by performing a thorough neurological examination, as this is a medical emergency requiring prompt evaluation and potential surgical intervention. The assessment should focus on lower extremity strength, sensation, reflexes, and perineal/saddle area sensation, as these are common symptoms of cauda equina syndrome, including back pain with or without radicular symptoms, weakness in the lower limbs, sensory changes or numbness in the lower limbs, or absent lower limb reflexes 1.
The step-by-step assessment should include:
- Testing for urinary retention with a post-void residual measurement using a bladder scanner or catheterization, as new-onset urinary symptoms in the context of low back pain or sciatica are a red flag for cauda equina syndrome 1
- Assessing for fecal incontinence, as this is another symptom of cauda equina syndrome
- Documenting rectal tone, as this can be affected in cauda equina syndrome
- Evaluating the patient's ability to walk and perform daily activities, as multifocal deficits and progressive neurologic deficits can be caused by cauda equina syndrome 1
The physician should clearly explain the serious consequences of delayed treatment, including permanent paralysis, bladder/bowel dysfunction, and sexual dysfunction, and document the patient's refusal to go to the emergency department, including that the patient was informed of the risks 1. The physician should arrange for immediate follow-up, potentially involving a same-day neurosurgical consultation if available, and consider using MRI lumbar spine without IV contrast as the preferred initial imaging study to evaluate suspected cauda equina syndrome 1. If the patient's condition deteriorates, the physician should again strongly recommend emergency evaluation.
From the Research
Assessment of Cauda Equina Syndrome in the Office
When a patient refuses to go to the emergency department (ED) and the primary care physician (PCP) suspects cauda equina syndrome, a thorough assessment is crucial. The following steps can be taken:
- History and Physical Exam: A thorough history and physical exam are essential to assess the patient's symptoms, including sensory loss, motor weakness, and bowel and bladder dysfunction 2.
- Neurological Examination: A neurological examination should be performed to assess the patient's neurological function, including perianal sensation and detrusor contraction 3, 4.
- Urodynamic Evaluation: If possible, a urodynamic evaluation can be performed to assess the patient's bladder function, including cystometry and pressure-flow electromyography study 3.
- Imaging Studies: Although not always possible in an office setting, magnetic resonance or computed tomography imaging myelogram can aid in diagnosis and treatment if available 2.
Key Findings to Look for
When assessing a patient with suspected cauda equina syndrome, the following key findings should be looked for:
- Bowel and Bladder Dysfunction: The presence of bowel and bladder dysfunction is required to definitively establish the diagnosis of cauda equina syndrome 2.
- Sensory Loss and Motor Weakness: Varying degrees of sensory loss and motor weakness can be present in patients with cauda equina syndrome 2.
- Perianal Sensation: Defective perianal sensation can be present in patients with cauda equina syndrome, even if detrusor contraction is preserved 3.
Management
If cauda equina syndrome is suspected, the patient should be referred for emergent spinal surgery and urgent decompression 5, 2. Even if the patient refuses to go to the ED, the PCP should emphasize the importance of timely diagnosis and treatment to avoid irreparable neurological damage.