From the Guidelines
Cauda equina syndrome is a medical emergency that requires immediate surgical intervention, ideally within 24-48 hours of symptom onset, to prevent permanent neurological damage. Patients typically present with severe low back pain, bilateral sciatica, saddle anesthesia (numbness in the perineal region), bowel and bladder dysfunction (including urinary retention or incontinence), and lower extremity weakness or sensory changes. Sexual dysfunction may also occur. The most frequent finding in cauda equina syndrome is urinary retention, with a sensitivity of 90% 1.
Clinical Presentation
The clinical presentation of cauda equina syndrome can vary, but common symptoms include:
- Severe low back pain
- Bilateral sciatica
- Saddle anesthesia (numbness in the perineal region)
- Bowel and bladder dysfunction (including urinary retention or incontinence)
- Lower extremity weakness or sensory changes
- Sexual dysfunction
Diagnostic Approach
The diagnostic approach for cauda equina syndrome involves a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement 1. Imaging studies, such as MRI or CT, may be used to confirm the diagnosis and identify the underlying cause of the compression.
Treatment Options
The definitive treatment for cauda equina syndrome is emergency surgical decompression, which typically involves a laminectomy to remove the compressive lesion. Post-operatively, patients require comprehensive rehabilitation, including physical therapy, occupational therapy, and potentially bladder and bowel retraining. Pain management often includes NSAIDs, muscle relaxants, and sometimes gabapentinoids for neuropathic pain.
Recent Guidelines
According to recent guidelines, MRI lumbar spine without IV contrast is the preferred initial imaging study for suspected cauda equina syndrome, due to its ability to accurately depict soft-tissue pathology and assess spinal canal patency 1. CT lumbar spine without IV contrast may also be useful in certain situations, such as when MRI is not available or when significant spinal stenosis is suspected.
Prognosis
Recovery from cauda equina syndrome depends on the severity and duration of compression before treatment, with some patients experiencing residual neurological deficits despite prompt intervention. The urgency of treatment stems from the fact that prolonged compression of these nerve roots can lead to permanent loss of bowel, bladder, and sexual function, as well as lower extremity paralysis.
From the Research
Clinical Presentation of Cauda Equina Syndrome
- Cauda equina syndrome is characterized by varying patterns of low back pain, sciatica, lower extremity sensorimotor loss, and bowel and bladder dysfunction 2
- The syndrome may present with urinary retention, saddle anesthesia of the perineum, bilateral lower extremity pain, numbness, and weakness 2
- Decreased rectal tone may be a relatively late finding 2
- Early signs and symptoms of a developing postoperative cauda equina syndrome are often attributed to common postoperative findings, making early diagnosis challenging 2
- The condition can result in bowel, bladder, and sexual dysfunction, plus lower limb weakness, numbness, and pain 3
Treatment Options for Cauda Equina Syndrome
- Urgent surgical decompression of the spinal canal is the treatment for cauda equina syndrome, regardless of the setting 2
- Early diagnosis and treatment are imperative for optimal outcomes and for avoiding medicolegal ramifications 4
- A thorough history and physical exam, followed by magnetic resonance or computed tomography imaging myelogram, can aid in diagnosis and treatment 4
- Emergent spinal surgery referral is indicated, along with urgent decompression, once cauda equina syndrome is suspected 4
- Even with expeditious surgery, improvements remain inconsistent, but early intervention has been shown to portend a greater chance of neurologic recovery 4
Causes and Management of Cauda Equina Syndrome
- Cauda equina syndrome can be caused by trauma, central disc protrusion, hemorrhage, and neoplastic invasion 5
- The syndrome can present as a herniated lumbar disk, with low back pain and unilateral sciatica, but may progress to bilateral sciatica, saddle anesthesia, and bowel and bladder dysfunction 6
- Both surgical and nonsurgical management options have been studied in the setting of primary and secondary neoplasms 5
- Accurate and up-to-date information about the presentation, management, and outcome of patients with cauda equina syndrome can inform standards of service design and delivery for this condition 3