Cauda Equina Syndrome: Difference between revisions
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Cauda equina syndrome is a rare acute polyradiculoneuropathy of the conus medullaris and lumbosacral nerve roots. It can be caused by a lesion in the spinal canal at any level below T10.<ref name="patten">Patten, John. Neurological differential diagnosis. London New York: Springer, 1996.</ref> Cauda equina syndrome with bilateral lumbosacral radiculopathies, rapidly progressive weakness, saddle anaesthesia and urinary retention is a neurologic emergency that requires emergent MRI and surgical review. | Cauda equina syndrome is a rare acute polyradiculoneuropathy of the conus medullaris and lumbosacral nerve roots. It can be caused by a lesion in the spinal canal at any level below T10.<ref name="patten">Patten, John. Neurological differential diagnosis. London New York: Springer, 1996.</ref> Cauda equina syndrome with bilateral lumbosacral radiculopathies, rapidly progressive weakness, saddle anaesthesia and urinary retention is a neurologic emergency that requires emergent MRI and surgical review. If left untreated the patient can develop permanent neurological deficits. | ||
==Anatomy and Embryology== | ==Anatomy and Embryology== | ||
| Line 12: | Line 12: | ||
==Clinical Features== | ==Clinical Features== | ||
{{Red flags| | {{Red flags| | ||
*Bilateral radiculopathy | *Bilateral radiculopathy (sensory or motor disturbance) or radicular pain | ||
*Progressive neurological deficits in the legs | *Progressive neurological deficits in the legs | ||
* | *Difficulties in micturition (including impaired bladder or urethral sensation, hesitancy, poor stream) | ||
*Impaired anal tone | *Urgency of micturition with preserved control of micturition | ||
White flags | *Subjective and/or objective loss of perineal sensation | ||
*Possible red or white flags: Impaired perineal sensation, Impaired anal tone | |||
*White flags: Urinary retention or incontinence, faecal incontinence, perineal anaesthesia | |||
<small>White flags means surrender, the patient likely has irreversible cauda equina syndrome, and the diagnosis has been made too late{{#pmid:28637110|todd}}</small> | |||
}} | }} | ||
There are three main clinical pictures of Cauda Equina lesions in adults. In children, disc lesions are exceptionally rare below 15 years of age.<ref name="patten"/> Cauda equina syndrome generally presents as lower limb radicular pain, sensory deficit, bowel and bladder dysfunction, and asymmetric bilateral lower limb weakness. | There are three main clinical pictures of Cauda Equina lesions in adults. In children, disc lesions are exceptionally rare below 15 years of age.<ref name="patten"/> Cauda equina syndrome generally presents as lower limb radicular pain, sensory deficit, bowel and bladder dysfunction, and asymmetric bilateral lower limb weakness. | ||
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===Midline Cauda Equina Lesions From Outside=== | ===Midline Cauda Equina Lesions From Outside=== | ||
This is characterised by bilateral lumbar and sacral root lesions. If the patient has pain in unusual dermatomes such as L2, L3, S2, or S3, then the clinician should be suspicious. Pain in an L4, L5, or S1 region on the other hand is usually due to disc disease, but further imaging may still be required to exclude other pathology. Sinister causes include primary sacral bone tumours (chordomas), metastatic disease (especially prostate), reticulosis, leukaemia, direct seeding from malignant tumours in the CNS (medulloblastomas, ependymomas, pinealomas).<ref name="patten"/> | This is characterised by bilateral lumbar and sacral root lesions. If the patient has pain in unusual dermatomes such as L2, L3, S2, or S3, then the clinician should be suspicious. Pain in an L4, L5, or S1 region on the other hand is usually due to disc disease, but further imaging may still be required to exclude other pathology. Sinister causes include primary sacral bone tumours (chordomas), metastatic disease (especially prostate), reticulosis, leukaemia, direct seeding from malignant tumours in the CNS (medulloblastomas, ependymomas, pinealomas).<ref name="patten"/> | ||
==Definitions== | |||
*Cauda equina syndrome suspected (CESS) | |||
*Cauda equina syndrome incomplete (CESI) - there is objective evidence of cauda equina syndrome but the patient still has voluntary control of urination. There may be other urination problems such as urgency, poor stream, hesitancy, and/or reduced bladder or urethral sensation. | |||
*Cauda equina syndrome with painless retention of urine (CESR)<ref name="todd"/> | |||
==Diagnosis== | |||
Cauda Equina Syndrome is a clinical rather than radiological diagnosis, but MRI can inform which patients with the clinical syndrome have cauda equina compression. The symptoms and signs are non-specific. Clinical features with the highest predictive value, for example painless urinary retention, are features of late often irreversible disease. The emphasis is on symptoms that are severe and progressive. It is important that there is a high rate of negative MRIs in order to reduce the rate of missing cases, and so there should be a low threshold for urgent imaging. Cauda equina syndrome cannot be discounted without MRI imaging ruling out cauda equina compression.<ref name="todd"/> | |||
==Treatment== | |||
Cauda equina syndrome is a neurological emergency. MR imaging should be organised emergently. It is imperative that the condition is recognised and decompressive surgery occurs before the onset of CESR if possible. | |||
Patients treated at the point of CESS with bilateral radicular pain or bilateral radiculopathy are at risk of cauda equina syndrome from a central disc prolapse but do not have the syndrome at that point in time. Good outcomes are achieved if decompressive surgery is performed. | |||
If treated at the stage of CESI with incomplete clinical features, there is a reduced chance of developing more severe disease with painless urinary retention. The longterm bladder function is good, but there may be some symptoms of urgency or other symptoms that don't require catheterisation. There may be longterm sexual dysfunction if there was genital sensory loss prior to treatment. However overall good outcomes are seen with decompressive surgery for most patients. | |||
If treated at the point of CESR with urinary retention, many patients have permanent severe impairment of cauda equina function with a paralysed insensate bladder and bowel that requires intermittent self-catheterisation, manual evacuation of faeces and/or bowel irrigation, and generally no sexual function. Only a small proportion of patients with severe deficits return to work. The timing of surgery after CESR develops is controversial, and recovery of function is more likely if there is some perineal sensation preoperatively. | |||
There is no single symptom or sign of combination thereof that has a strong positive predictive value for diagnosing cauda equina syndrome before it is irreversible. Many of the red flags are subjective. It can be difficult to detect subtle perianal sensory deficits. Anal tone can also be difficult to interpret, and there is poor interobserver reliability.<ref name="todd"/> | |||
[[Category:Lumbar Spine]] | [[Category:Lumbar Spine]] | ||
Revision as of 07:14, 16 May 2021
Cauda equina syndrome is a rare acute polyradiculoneuropathy of the conus medullaris and lumbosacral nerve roots. It can be caused by a lesion in the spinal canal at any level below T10.[1] Cauda equina syndrome with bilateral lumbosacral radiculopathies, rapidly progressive weakness, saddle anaesthesia and urinary retention is a neurologic emergency that requires emergent MRI and surgical review. If left untreated the patient can develop permanent neurological deficits.
Anatomy and Embryology
The spinal cord runs from the medulla oblongata to the level of T12-L1. The next caudal part of the spinal cord is the medullary cone. The cauda equina starts from the medullary cone and consists of the spinal nerves L2-L5, S1-S5, and the coccygeal nerve. These nerves are comprised of dorsal (sensory) and ventral (motor) nerve roots. The nerve root functions include sensory supply to the saddle region, voluntary control of the outer surface of the rectum, voluntary control of the urinary sphincters, and the sensory and motor innervation of the lower limbs. Dysfunction of the cauda equina can cause problems in the above functions. The cauda equina is situated in the thecal sac and is surrounded by cerebrospinal fluid in the subarachnoid space.[2]
The cauda equina starts forming in the third month of gestation, and the spinal cord extends the entire length of the body at this time. After this time, the verebtral column bones and cartilage grows faster than the spinal cord. This causes the nerves below the cervical spine to follow a slanted path. The lumbar and sacral nerves therefore move caudally and vertically inside the spinal canal, before exiting through the intervertebral foramina. The nerve roots below L1 form the cauda equina.[2]
Epidemiology
Lumbar disc herniation is the primary cause (45%) of cauda equina syndrome, and this occurs in 1-3% of all disc herniations. [2]
Clinical Features
- Bilateral radiculopathy (sensory or motor disturbance) or radicular pain
- Progressive neurological deficits in the legs
- Difficulties in micturition (including impaired bladder or urethral sensation, hesitancy, poor stream)
- Urgency of micturition with preserved control of micturition
- Subjective and/or objective loss of perineal sensation
- Possible red or white flags: Impaired perineal sensation, Impaired anal tone
- White flags: Urinary retention or incontinence, faecal incontinence, perineal anaesthesia
White flags means surrender, the patient likely has irreversible cauda equina syndrome, and the diagnosis has been made too late[3]
There are three main clinical pictures of Cauda Equina lesions in adults. In children, disc lesions are exceptionally rare below 15 years of age.[1] Cauda equina syndrome generally presents as lower limb radicular pain, sensory deficit, bowel and bladder dysfunction, and asymmetric bilateral lower limb weakness.
Lateral Cauda Equina Syndrome
Neurofibroma is the most frequent cause, and high disc lesions are a rarer cause. The clinical features include anterior thigh pain, quadriceps wasting, weakness of foot inversion (L4 root lesion), and an absent knee jerk. With very high lesions that lie lateral to the terminal spinal cord, there may be pyramidal signs below the lesion. In this case there may be very brisk ankle jerks, ankle clonus, and an extensor plantar response. In this context, any sphincter compromise is likely a result of the cord compression.[1]
Midline Cauda Equina Lesions from Within
This is also called a conus lesion. The most common causes are ependymomas, dermoid tumours, and lipomas of the terminal cord. The roots are damaged from the inside, that is from S5 to S4 to S3 etc. In the early stages clinical features include rectal and genital pain, urination problems, and erectile dysfunction, but with no clear physical signs except if the perianal sensation (saddle anaesthesia) and anal reflex are tested carefully. Later clinical features include reduced ankle jerks and weakness of L5 and S1 myotomes. For ependymomas, the patient may have a 5 year history of a dull backache.[1]
Midline Cauda Equina Lesions From Outside
This is characterised by bilateral lumbar and sacral root lesions. If the patient has pain in unusual dermatomes such as L2, L3, S2, or S3, then the clinician should be suspicious. Pain in an L4, L5, or S1 region on the other hand is usually due to disc disease, but further imaging may still be required to exclude other pathology. Sinister causes include primary sacral bone tumours (chordomas), metastatic disease (especially prostate), reticulosis, leukaemia, direct seeding from malignant tumours in the CNS (medulloblastomas, ependymomas, pinealomas).[1]
Definitions
- Cauda equina syndrome suspected (CESS)
- Cauda equina syndrome incomplete (CESI) - there is objective evidence of cauda equina syndrome but the patient still has voluntary control of urination. There may be other urination problems such as urgency, poor stream, hesitancy, and/or reduced bladder or urethral sensation.
- Cauda equina syndrome with painless retention of urine (CESR)[3]
Diagnosis
Cauda Equina Syndrome is a clinical rather than radiological diagnosis, but MRI can inform which patients with the clinical syndrome have cauda equina compression. The symptoms and signs are non-specific. Clinical features with the highest predictive value, for example painless urinary retention, are features of late often irreversible disease. The emphasis is on symptoms that are severe and progressive. It is important that there is a high rate of negative MRIs in order to reduce the rate of missing cases, and so there should be a low threshold for urgent imaging. Cauda equina syndrome cannot be discounted without MRI imaging ruling out cauda equina compression.[3]
Treatment
Cauda equina syndrome is a neurological emergency. MR imaging should be organised emergently. It is imperative that the condition is recognised and decompressive surgery occurs before the onset of CESR if possible.
Patients treated at the point of CESS with bilateral radicular pain or bilateral radiculopathy are at risk of cauda equina syndrome from a central disc prolapse but do not have the syndrome at that point in time. Good outcomes are achieved if decompressive surgery is performed.
If treated at the stage of CESI with incomplete clinical features, there is a reduced chance of developing more severe disease with painless urinary retention. The longterm bladder function is good, but there may be some symptoms of urgency or other symptoms that don't require catheterisation. There may be longterm sexual dysfunction if there was genital sensory loss prior to treatment. However overall good outcomes are seen with decompressive surgery for most patients.
If treated at the point of CESR with urinary retention, many patients have permanent severe impairment of cauda equina function with a paralysed insensate bladder and bowel that requires intermittent self-catheterisation, manual evacuation of faeces and/or bowel irrigation, and generally no sexual function. Only a small proportion of patients with severe deficits return to work. The timing of surgery after CESR develops is controversial, and recovery of function is more likely if there is some perineal sensation preoperatively.
There is no single symptom or sign of combination thereof that has a strong positive predictive value for diagnosing cauda equina syndrome before it is irreversible. Many of the red flags are subjective. It can be difficult to detect subtle perianal sensory deficits. Anal tone can also be difficult to interpret, and there is poor interobserver reliability.[3]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Patten, John. Neurological differential diagnosis. London New York: Springer, 1996.
- ↑ 2.0 2.1 2.2 Kapetanakis et al.. Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature. Folia medica 2017. 59:377-386. PMID: 29341941. DOI.
- ↑ 3.0 3.1 3.2 3.3 Todd. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. British journal of neurosurgery 2017. 31:336-339. PMID: 28637110. DOI.
Literature Review
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,
