Cauda Equina (Latin for ‘horse’s tail’) describes the appearance of the nerve roots coming out at the bottom end of the spinal cord. Cauda Equina Syndrome (CES) relates to compression of nerves in the lumbar spine. These nerves if compressed affect the muscle power in the legs, control of bowel, bladder and sexual function.
Compression can occur from prolapsing of the vertebral disk space (when one of the discs becomes damaged and presses on the nerves), narrowing of the spinal column at that level, infections of the spinal canal, including abscesses, tumours, and other inflammatory causes such as sarcoidosis, Paget’s disease, and ankylosing spondylitis. Other causes include: trauma to the spine, spinal anaesthesia, and lumbar punctures (a test to tap spinal fluid).
Patients may present in a manner of different ways. There are no particular risk factors for developing the condition, other than lifting heavy objects. Patients, commonly men 40-50 years of age, may present either acutely or progressively with weakness of the legs, numbness in the area around the anus (so called ‘saddle distribution’), urinary retention of the bladder, loss of bowel control and/or loss of male sexual function.
Although the cause may relate to vertebral pathology, not all patients will necessarily have acute or progressive backache. Some patients may also describe stabbing pains shooting down the leg. In patients with abrupt onset of symptoms, the diagnosis may be more obvious. However, in cases where symptom progression is gradual, the diagnosis may be delayed. In cases with the above symptoms, a prompt diagnosis and treatment is essential to avoid or minimize permanent neurological damage.
Backache is a very common symptom, and only occasionally is associated with Cauda Equina Syndrome. The usual cause for a late diagnosis is where patients who may have initially presented with backache, were not warned that if they developed other symptoms, such as numbness, bladder, or bowel disturbances, should seek further attention. In addition, if the original backache is not resolving, Cauda Equine Syndrome should be considered.
The other scenario where the diagnosis may be late, is in the elderly, who may present with new onset of falling over or unsteadiness. There are numerous causes of this, and weakness in the legs may not have been documented. Ideally, all such patients who present ‘off their feet’ should have a neurological assessment, that should include testing sensation in the ‘saddle area,’ checking that there is no urinary retention, and whether there is loss of anal tone (by performing a rectal examination). The clinical examination findings need to be recorded in the notes.
The diagnosis needs to be made promptly, by either an MRI scan of the spine, CT scanning, or X-ray myelogram. Urgent discussion and referral to a neurosurgical centre needs to be made, and treatment should be within 48hours. There is a maximal chance of salvaging bladder and bowel function if surgery is in that time frame.
- Cauda Equine Syndrome is a rare condition, but prompt diagnosis and treatment needs to be expedited within 48 hours to minimize permanent neurological damage.
- Recurring or lingering backache should raise suspicions.
- The onset of loss of groin sensation, loss of bladder and bowel function should prompt urgent detailed clinical examination and investigation.
- If Cauda Equine is clinically suspected, urgent radiological investigation should not have been deferred.
- Scrupulous note keeping of clinical features in patients who have presented acutely ‘off their feet,’ or with features of leg weakness, should be evident.
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