Cauda Equina Syndrome

• Cauda Equina Syndrome

  A surgical emergency where the nerve roots of the cauda equina at the bottom of the spine are compressed, requiring emergency decompression surgery to prevent permanent neurological dysfunction
• Cauda Equina

  A collection of nerve roots that travel through the spinal canal after the spinal cord terminates around L2/L3
• Conus Medullaris

  The tapered end of the spinal cord
• Nerves of the cauda equina supply

  • Sensation to the lower limbs, perineum, bladder, and rectum
  • Motor innervation to the lower limbs and the anal and urethral sphincters
  • Parasympathetic innervation of the bladder and rectum
• Possible causes of compression in cauda equina syndrome

  • Herniated disc
  • Tumours, particularly metastasis
  • Spondylolisthesis
  • Abscess (infection)
  • Trauma
• Red Flags in cauda equina syndrome

  • Saddle anaesthesia (loss of sensation in the perineum)
  • Loss of sensation in the bladder and rectum
  • Urinary retention or incontinence
  • Faecal incontinence
• Key red flags for Cauda Equina Syndrome

  • Saddle anaesthesia (loss of sensation in the perineum)
  • Loss of sensation in the bladder and rectum
  • Urinary retention or incontinence
  • Faecal incontinence
  • Bilateral sciatica
  • Bilateral or severe motor weakness in the legs
  • Reduced anal tone on PR examination
• TOM TIP: 'A common way people ask about saddle anaesthesia when taking a history is to ask, “does it feel normal when you wipe after opening your bowels?”'
• Management of Cauda Equina Syndrome

  1. Immediate hospital admission

  2. Emergency MRI scan to confirm or exclude cauda equina syndrome

  3. Neurosurgical input to consider lumbar decompression surgery

  4. Surgery should be performed as soon as possible to increase the chances of regaining function. Even with early surgery, patients can be left with bladder, bowel or sexual dysfunction. Leg weakness and sensory impairment can also persist
• Treatments for Metastatic Spinal Cord Compression

  • High dose dexamethasone (to reduce swelling in the tumour and relieve compression)
  • Analgesia
  • Surgery
  • Radiotherapy
  • Chemotherapy
• Metastatic Spinal Cord Compression presents similarly to cauda equina with

  Back pain and motor and sensory signs and symptoms
• Key feature of Metastatic Spinal Cord Compression

  Back pain that is worse on coughing or straining
• Metastatic Spinal Cord Compression is an oncological emergency and requires rapid imaging and management. Specialist MSCC coordinators should be involved early to coordinate the imaging and treatment of patients with MSCC
• TOM TIP: 'Cauda equina presents with lower motor neuron signs (reduced tone and reduced reflexes). When the spinal cord is being compressed higher up by metastatic spinal cord compression, upper motor neuron signs (increased tone, brisk reflexes and upping plantar responses) will be seen'