Cauda Equina syndrome (CES)

Cauda Equina syndrome (CES)

Description

Cauda Equina syndrome (CES) is an impaired condition of lumbar plexus, nerve roots, and spinal canal below the termination of the spinal cord. It is a serious, acute neurologic condition. The term cauda equina is referring to the lower end of the spinal cord where the nerve fibres appear like a horse’s tail (in a Latin word ‘Cauda equina’). These nerves leave out from the spinal canal through the tunnel in between each vertebrae. Cauda equina is located behind the lumbar discs of the spinal canal. If this disc is prolapsed or slipped away, the nerves of cauda equina become squashed and trapped. The effects may appear at getting old age. The other names that are called for CES are Compression of Spinal Nerve Roots Syndrome and Spinal Nerve Roots Compression Syndrome.

Pathophysiology

The pathophysiology remains unclear, but it is believed that the damage to the roots of spinal nerves causes cauda equina by direct mechanical compression and ischemia or venous congestion.

Classification

Patient under CES can be classified as follows

Suspected

An individual who doesn’t have any symptoms, but he or she may develop CES.

Incomplete

An individual who with incomplete CES, shows signs as urinary difficulties due to spinal nerve damage, which also includes loss of eagerness to void, unaware straining to empty their bladder, and loss in their urinary sensation. These patients might develop CES.

Retention

An individual shows painless urinary retention and overflow incontinence. The bladder losses it controls due to insensitive involuntary muscles like the sphincter.

Complete

An individual, who completely lost their function of cauda equine, vanished perineal sensation and paralyzed bladder and bowel with a loose anus.

Epidemiology

Cauda equina syndrome is a rare syndrome occurs with prevalence estimated at approximately 1 in 65,000 (range about 33,000 to 100,000). It is, however, been estimated to occur in ~1% (range 0.1-2%) of lumbar disc herniation. No gender, racial, or ethnic preference was observed

Causes

There are various conditions that can cause cauda equine syndrome

• Lumbar disc herniation (most commonly in L4/5 and L5/S1)
• Lumbar spinal canal stenosis
• Spondylolisthesis
• Tarlov cysts
• Facet joint cysts
• Spinal fracture or dislocation
• Epidural hematoma
• Epidural abscess
• Tuberculosis (Pott disease)
• Lymphoma
• Metastases
• Primary CNS malignancies
• Aortic dissection
• Arteriovenous malformation

Risk factors

• Individual with congenital or acquired spinal canal stenosis 3
• Earlier lumbar spinal surgery
• Penetrating trauma due to stabs and gunshots
• Paget disease
• Ankylosing spondylitis
• Spina bifida
• Hemorrhages affecting the spinal cord
• Coagulopathy

It does not mean that the risk factors definitely lead to CES, quite it increases the chances of getting this condition when compared to a person without these risk factors.

Symptoms

Symptoms of CES include:

• Low back pain
• Numbness
• Tingling in the buttocks and lower extremities
• Sensory loss in both the legs or muscle weakness
• Reduction of reflexes
• Bowel incontinence causing retain urine and unable to hold it
• Sexual dysfunction may suddenly occur

Complications

If the diagnosis and primary treatment are delayed, the following complications may arise such as follows:

• Paralysis
• Bladder, sexual and bowel dysfunction
• Abnormalities in sensory systems

Diagnosis and test

If a person feels the above symptoms, he or she should seek medical advice immediately or visit the emergency department of your nearest hospital. Your doctor may perform some of the diagnosis such as follows:

• Doctor may ask about your health history and other symptoms and activity
• Physical examination to access your sensations, reflexes, stability, strength, movement and alignment
• MRI scan, which uses magnetic fields and computers to produce three-dimensional images of your affected area in the spine
• A myelogram – an X-ray of the spinal canal after injection of contrast material – which can pinpoint pressure on the spinal cord or nerves
• CT scan

Treatment 

For the patients who with Cauda equina syndrome need surgery to prevent the permanent damage such as paralysis of the leg, loss of bowel and bladder control, sexual function or other problems. The main goal of the surgery is to restore the parts which are dysfunction. Based on the cause, the following surgery may be performed.

Discectomy

 Discectomy is the surgery in which the compressed nerves are removed from the portion of the disc. The window of bone is removed to expose the nerve root and disc by making an incision in the middle of the back by moving the spinal muscle aside. The portion of the ruptured disc compressing the spinal nerves is carefully removed.

Spinal decompression

Spinal decompression for stenosis removes the bone spurs and ligaments compressing the nerves. A small incision is made in the back. The surgeon removes the bone that forms the roof of the spinal canal. Next, soft tissue and bone spurs are removed to create more room for the nerves. Tumors and other lesions can also be removed.

Spinal cord disk compression

Medications

For long-term treatment, your doctor may prescribe drugs such as

• Pain relievers after surgery such as oxycodone (OxyContin)
• Over-the-counter pain relievers, such as ibuprofen (Advil) or acetaminophen (Tylenol), can be used for daily pain relief.
• Corticosteroids are prescribed to reduce the inflammation and swelling around the spine
• Hyoscyamine (Levsin), tolterodine (Detrol) and oxybutynin (Ditropan) for better bladder and bowel control

Prevention

• Prevention of cauda equina syndrome is focused on early diagnosis by identifying the symptoms described.
• While low back pain with leg pain and/or weakness is a common complaint that affects many people, cauda equina syndrome is a rare complication.
• Your doctors should be vigilant in identifying these cases. You should familiarise yourself with the signs and symptoms that could suggest possible cauda equina syndrome, including a change in bowel or bladder function and loss of sensation in the groin.
• Preventing infections and trauma is much essential to avoid these causes of cauda equina syndrome.