Cauda Equina

• Cauda Equina clinical presentation:

  • Compression occurs below S2 and presents as urinary retention and bladder flaccidity, which presents as overflow incontinence (inadequate emptying, increased residual volume and decreased bladder sensitivity)
• Cauda Equina clinical presentation - Signs and symptoms:

  • Uni/bilateral neurogenic sciatica
  • Reduced perineal sensation
  • Altered bladder function leading to painless retention
  • Loss of anal sphincter tone
  • Loss of sexual function
• Cuada equina anatomy review:

  1. The bladder uses the S2 - S4 nerve roots to send I'm full messages to the brain and spinal cord
  2. The brain and spinal cord use S2 - S4 to send empty out messages
  3. Cuada equina syndrome causes these nerve roots to stop carrying these messages e.g. it can't say I'm full or empty out
  4. Essentially, it's cut off from the brain and spinal cord
  5. It fills up and up and doesn't empty - Bladder in Retention
  6. When it gets so full, it leaks out - Overflow Incontinence
• Cauda equina syndrome:

  • British Association of Spinal Surgeons:
  • A patient presenting with acute back pain and or leg pain with a suggestion of a disturbance of their bladder and bowel and or saddle sensory disturbance should be suspected as having Cauda equina syndrome
• Cauda Equina:

  • Caused by a space occupying lesion:
  • Disc herniation (most common – approx. 2 % of IVD’s)
  • Spinal stenosis
  • Tumours
  • Trauma
  • Spinal epidural haematoma
  • Epidural abscess
  • Developmental spondylolisthesis
  • Epidemiology: 0.002 % in UK
  • LBP = 0.04 % in primary care and 0.4 % in tertiary care
• How medications can confuse the picture - Opioid salts e.g. tramadol, codeine:

  • Possible CES symptoms: Constipation, reduced gastric motility, reduced bladder sensation
• How medications can confuse the picture - Anticonvulsants e.g. gabapentin, pregabalin

  • Possible CES symptoms: Urinary incontinence
• How medications can confuse the picture - Antidepressants e.g. amitriptyline, nortriptyline

  • Possible CES symptoms: Retention, sexual dysfunction, reduced awareness of need to pass urine
• How medications can confuse the picture - NSAIDs e.g. naproxen, ibuprofen

  • Possible CES symptoms: Retention twice as likely in men than women
• Management:

  • Surgical decompression should take place as soon as practically possible, and within a few hours of the onset of symptoms
• Consequences of a missed diagnosis:

  • Bladder and bowel dysfunction
  • Sexual dysfunction
  • Sciatic pain
  • Saddle and groin anaesthesia
  • Sensory abnormality in the lower body
  • Muscle weakness in the lower body
  • Paralysis