What is the diagnosis and treatment for Cauda Equina Syndrome (CES)?

From the Guidelines

Cauda equina syndrome (CES) is a medical emergency that requires immediate diagnosis and treatment, typically involving urgent MRI imaging followed by surgical decompression within 24-48 hours of symptom onset to prevent permanent neurological damage. The diagnosis of CES is based on a combination of clinical symptoms, including severe low back pain, saddle anesthesia, bladder or bowel dysfunction, weakness or numbness in the legs, and sexual dysfunction, as well as imaging studies such as MRI or CT scans [1].

Clinical Presentation

The clinical presentation of CES can vary, but common symptoms include:

• Severe low back pain
• Saddle anesthesia (numbness in the groin and buttocks)
• Bladder or bowel dysfunction
• Weakness or numbness in the legs
• Sexual dysfunction These symptoms can be caused by a variety of etiologies, including lumbar disc herniation, neoplasm, infection/inflammation, spinal stenosis, and hemorrhage [1].

Imaging Studies

The imaging study of choice for evaluating suspected CES is MRI, specifically MRI lumbar spine without IV contrast, due to its ability to accurately depict soft-tissue pathology, assess vertebral marrow, and assess the spinal canal patency [1]. However, CT lumbar spine without IV contrast can also be useful in determining whether cauda equina compression is present [1].

Treatment

The standard treatment for CES involves emergency surgical decompression to relieve pressure on the nerves, typically within 24-48 hours of symptom onset [1]. Post-surgery, patients may need physical therapy, pain management with medications, and possibly bladder or bowel retraining. The urgency of treatment stems from the fact that prolonged compression can lead to permanent nerve damage, resulting in chronic pain, incontinence, and paralysis. A recent study by Bell et al [1] recommends urgent MRI assessment in all patients who present with new-onset urinary symptoms in the context of low back pain or sciatica.

Prognosis

The prognosis for CES varies depending on the severity and duration of compression before treatment, with better outcomes associated with earlier intervention [1]. Therefore, it is essential to prioritize prompt diagnosis and treatment to minimize the risk of permanent neurological damage and optimize patient outcomes.

From the Research

Diagnosis of Cauda Equina Syndrome (CES)

• Cauda equina syndrome is diagnosed based on a combination of clinical presentation, medical history, and imaging studies 2, 3, 4
• Red flag symptoms that should lead to a high clinical suspicion of CES include:
  • Bladder dysfunction
  • Saddle anesthesia
  • Sciatica
  • Bilateral neurogenic sciatica
  • Reduced perineal sensation
  • Altered bladder function leading to painless urinary retention
  • Loss of anal tone
  • Loss of sexual function 2, 3, 4
• Imaging studies, such as magnetic resonance imaging (MRI) or computed tomography myelography, are crucial in confirming the diagnosis of CES 2, 5, 4

Treatment of Cauda Equina Syndrome (CES)

• Urgent decompressive surgery is usually recommended for the best outcomes, to reduce morbidity and complication rates 2, 6, 4
• Early diagnosis and treatment are essential to prevent permanent neurological dysfunction and improve patient outcomes 3, 5, 4
• A clinical pathway that empowers emergency department senior decision makers to order MRIs prior to neurosurgical review can help reduce the time to diagnosis or exclusion of CES 5
• Treatment relies upon surgical consultation and operative intervention for decompression, and should be done as soon as possible after diagnosis 2, 6, 4