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cauda equina syndrome
Etiology:
1) most common
- lumbar stenosis
- spinal trauma including vertebral fractures
- herniated nucleus pulposus
- massive, centrally herniated disc (most common)
- neoplasms
- metastases
- prostate cancer [2]
- multiple myeloma
- lymphoma [2]
- astrocytoma
- neurofibroma
- meningioma; 20% of all spinal tumors affect this area
- spinal infection or epidural abscess
- tuberculosis
- herpes simplex virus
- meningitis
- meningovascular syphilis
- cytomegalovirus
- schistosomiasis
- postoperative complications
- spinal anesthesia
- spina bifida & subsequent tethered cord syndrome
2) rare
- spinal hemorrhage compressing the spinal canal
- subdural hemorrhage
- epidural hemorrhage
- intravascular lymphomatosis
- congenital anomalies
- conus medullaris lipomas
- multiple sclerosis
- spinal arteriovenous malformations
- late-stage ankylosing spondylitis
- neurosarcoidosis
- deep venous thrombosis of the spinal veins (propagated)
- inferior vena cava thrombosis
Pathology:
- external compression on a sheath of nerve roots from the lower cord segments
- loss of sphinter control (bowel & bladder)
Clinical manifestations:
1) acute low back pain [2]
2) radicular pain [2]
3) saddle anesthesia (perianal or perineal sensory loss)
4) lower motor neuron signs
- bilateral motor weakness of the lower extremities
- knee extension
- ankle flexion, dorsiflexion or eversion
- decreased muscle tone, areflexia [2]
5) bowel & bladder dysfunction are usually late manifestations & do not occur in all patients [2]
a) urinary retention (most common presentation)*
b) urinary incontinence
c) fecal incontinence, lax anal sphincter
* clearly at odds with previous statement, but substantiated in ref [2]
Laboratory:
- see preoperative laboratory testing
- CSF analysis of no value
Radiology:
1) magnetic resonance imaging (MRI)
2) computed tomography (CT) if MRI unavailable
Management:
- immediate neurosurgical consultation
- glucocorticoids of no benefit if due to hematoma [2]
- may be of benefit if due to trauma
Related
cauda equina
General
spinal cord disease; myelopathy (disease/disorder primarily affecting spinal cord)
References
- Saunders Manual of Medical Practice, Rakel (ed),
WB Saunders, Philadelphia, 1996, pg 745
- Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 17, 18, 19.
American College of Physicians, Philadelphia 1998, 2009, 2015, 2018, 2021
- Dawodu ST and Lorenzo N
eMedicine: Cauda Equina and Conus Medullaris Syndromes
http://emedicine.medscape.com/article/1148690-overview#aw2aab6b2b4
- Gitelman A, Hishmeh S, Morelli BN et al
Cauda equina syndrome: a comprehensive review.
Am J Orthop (Belle Mead NJ). 2008 Nov;37(11):556-62. Review.
PMID: 19104682
- Long B, Koyfman A, Gottlieb M.
Evaluation and management of cauda equina syndrome in the emergency department.
Am J Emerg Med. 2020;38:143-148.
PMID: 31471075