Cauda Equina Syndrome: Symptoms, Treatment, Surgery

Cauda equina syndrome (CES) occurs when the nerve roots of the cauda equina are compressed and disrupt motor and sensory function to the lower extremities and bladder

 

Cauda Equina Syndrome

 

Onsnet of Cauda Equina Syndrome

Acute onset is marked by a rapid development of symptoms thHuat often includes severe low back pain and significant loss of bladder and bowel function. In an acute onset, sensory and motor deficits in the lower body typically develop within 24 hours.

Gradual onset can develop over progressively, and symptoms may come and go over the course of several weeks or months. Gradual onset usually typically includes partial or intermittent loss of bowel and bladder function, as well as recurring low back pain in combination with muscle weakness and numbness and bladder and/or bowel incontinence or dysfunction. Sciatica may also occur in one or both legs.

Causes

Lumbar Herniated Disc Is Typical Cause of CES

• Nerve compression leading to cauda equina syndrome is most often caused a lumbar herniated disc. A lumbar disc can herniate in a single injury when excessive pressure is placed on the lower spine, or can occur when an already weakened disc is strained and ruptures.

• Typically, a herniated disc will not affect the cauda equina. Only between 2% and 6% of lumbar disc surgeries are performed to treat cauda equina syndrome

Other Causes of Cauda Equina Syndrome

In addition to lumbar herniated disc, it is possible for the following factors to impinge on the cauda equina and cause symptoms.

• Lumbar spinal stenosis. If the lumbar stenosis put pressure on the spinal canal, cauda equina may result
See Lumbar Spinal Stenosis

• Inflammatory conditions can contribute to cauda equina syndrome if bony overgrowth or inflamed tissues press on lumbar nerve roots. One example of an inflammatory condition that may possibly lead to cauda equina syndrome is ankylosing spondylitis.
Watch Ankylosing Spondylitis Video

• Infections of the spinal canal (osteomyelitis) such as a spinal epidural abscess, which in turn may potentially press into the spinal canal, producing neurological symptoms.
See Osteomyelitis, a Spinal Infection

• Tumors/neoplasms near the spine may put pressure on the spinal canal. Tumors may originate in the spine, but it is more common that cancer from another part of the body spreads toward the spine (malignancy).
See Symptoms of a Spinal Tumor

• Trauma to the lumbar spine, such as a car accident, fall, or a penetrative injury such as gunshot or knife wound, can damage the cauda equina and produce neurological symptoms.

• Postoperative complications from lumbar surgery. A small number of patients experience cauda equina syndrome following surgery to repair a lumbar herniated disc.
Risk factors for the condition are similar to risk factors for spinal stenosis and lumbar herniated disc, including overall health and lifestyle (such as nicotine use, obesity, and low activity level), being between 30 and 50 years old, and labor-intensive work.

Symptoms in Cauda Equina Syndrome

• Motor weakness, sensory loss, or pain in one, or more commonly both legs
• Saddle anesthesia (unable to feel anything in the body areas that sit on a saddle)
• Recent onset of bladder dysfunction (such as urinary retention or incontinence)
• Recent onset of bowel incontinence
• Sensory abnormalities in the bladder or rectum
• Recent onset of sexual dysfunction
• A loss of reflexes in the extremities

Diagnosis

• Medical history
• Physical examination

• Muscle strength of the following muscles should be tested to determine the level of lesion:
L2 • Hip flexors (iliopsoas)
L3 •  Knee extensors (quadriceps)
L4 •   Ankle dorsiflexors (tibialis anterior)
L5 • Big toe extensors (extensor hallucis longus)
S1 •   Ankle plantar flexors (gastrocnemius/soleus)

•  Magnetic resonance imaging (MRI) scan, which uses magnetic fields and computers to produce three-dimensional images of your spine.

•  Myelogram, an X-ray of the spinal canal after injection of contrast material – which can pinpoint pressure on the spinal cord or nerves.
•  Computed tomography (CT) scan.

Differential Diagnosis

•  Conus medullaris syndrome
•  Herniated Nucleus Pulposis
• Lumbar disc herniation
•  Lumbar Radiculopathy
•  Lumbar vertebrae fracture
•  Lumbar spinal stenosis
•  Mechanical back pain
•  Peripheral neuropathy
•  Spinal cord compression
•  Spinal tumor
•  Sacral fractures
•  Abscesses
•  Lymphoma

Management in Cauda Equina Syndrome

Medical treatment

• Depending on the cause of your CES, Treatment is Vary :
• NSAIDS, corticosteroids. These can reduce swelling.
• If you are diagnosed with an infection you may need antibiotics. If a tumor is responsible, radiation or chemotherapy may be needed after surgery.

Surgical Treatment

• Cauda equina syndrome of sudden onset is regarded as a medical/surgical emergency.
• Surgical decompression by means of laminectomy or other approaches may be undertaken within 6,24 or 48 hours of symptoms developing if a compressive lesion, e.g., ruptured disc, epidural abscess, tumor or hematoma is demonstrated. Early treatment may significantly improve the chance that long-term neurological damage will be avoided.

Physiotherapy Treatment

• Lower Limb Exercise
• Lower Limb Strengthening Exercise
• Physiotherapy Treatment is Variable According To Weakness In Lower Limb, Mostly Lower Limb Assessment Procedure Will Taken And Then Treatment Plan Will Be Decided.

Goals of Physiotherapy Treatment

• Maintain R.O.M (Range of Motion)

• Strengthening Exercise of Lower Limb.
• Gait Training.
• Improve standing Balance.
• Restoring Bladder-Bowl Control
• Avoid Bed-Sore
• MMT(Manual Muscle Testing) of Lower limb performed and according to which strengthening exercise of lower limb planned. Regular progression of muscle power will be tested in between.

Gain Bladder-Bowl control

• Pelvic Floor Exercise
• Pelvic Floor Muscle Strengthening Exercise

• Physiotherapy Treatment mainly for Bladder-Bowl Control is Pelvic floor exercises assist in controlling bowel movements. These exercises can be done standing, lying, or on all fours with the knees slightly separated. Full recovery of bowel and bladder control can take as long as two years. Electrical stimulation, IFT is also used to strengthening of Bladder-Bowl Muscle.