Cauda Equina Syndrome

Despite the awareness and familiarity of almost every medical professional with the cauda equine compression syndrome (CES), risk factors for a poor prognosis of the disease remain elusive. Even the relationship between subsequent outcome and the time elapsed from the time of appearance of symptoms to surgery taking place remain obscure. The aim of our study, therefore, was to analyze a relatively large population of our own patients studied consecutively, to identify outcome predictors for CES and to propose a clinical score for CES symptoms (Berlin CES score). We screened the hospital's electronic database retrospectively for patients admitted with CES between 2001 and 2010. Since our hospital is a superregional trauma center with standardized emergency room procedures, all patients included in the study underwent the same routine. Using baseline data, we analyzed the following parameters: duration of symptoms, period of time between diagnosis and imaging, respectively, surgery; pre- and postoperative pain, motor deficits, reflex changes, urinary and bowl dysfunctions, reduced anal wink, saddle anesthesia, genital or perianal sensations and residual urine. The semi-quantitative assessment of the neurological outcome was performed by application of the Berlin CES score. Surprisingly, we were not able to identify any single parameters that could reliably predict the outcome of the disease. We were able to show statistically significant correlations between a high preoperatively Berlin CES score (i.e., a weighted summation of bladder dysfunction, rectal dysfunction, genital sensation, perianal sensation, rectal tone and saddle anesthesia) and a poor outcome regarding the postoperative existence of perianal (p<0.001) and genital (p=0.001) hypoesthesia, as well as reduced rectal tone (p=0.0047). There was no significant interference of bladder or bowel function. Further analysis, in which we considered the time between diagnosis and surgery, revealed that both patients operated within 24h and after 48h could benefit from the intervention. Consequently, we were not able to show a correlation between speed of surgical treatment and outcome. Although we analyzed a relatively large cohort, we were not able to identify single parameters that were capable of reliably predicting the outcome of patients with CES. Nonetheless, we were able to show that consideration of multiple parameters of symptomatology would enable an improvement in making a prognosis. In conclusion, we propose establishing a simple semi-quantitative clinical score of the main symptoms of CES.

Cauda equina syndrome (CES) is a rare clinical entity with an incidence of two per million people annually [1]. Symptoms and signs are very variable. Amongst them are severe low back pain, bilateral or unilateral sciatica, saddle anaesthesia, motor weakness, sensory deficit, and bladder and bowel dysfunction [1, 2]. None of these features has a high predictive value for CES in its own right, and many are common complaints with a variety of possible causes [3]. A high level of suspicion for CES is needed in any clinician who may come across it. Unfortunately, CES is all too often mis-managed [4, 5], resulting in not only devastating consequences for the patient’s quality of life, but also a disproportionately high medico-legal profile and significant risk of litigation [3, 6]. CES is a true spinal surgical emergency which, if untreated, may progress to paraplegia and/or permanent incontinence [2]. Debate as to the optimum timing for decompressive surgery, where cauda equina compression is the cause, is ongoing [2, 7], but prompt diagnosis is mandatory. Although magnetic resonance imaging (MRI) scanning is the diagnostic tool of choice [3], the percentage of patients being scanned for a clinical diagnosis of CES and in whom a compressive lesion is found on imaging is only 22 % [8]. It is important, therefore, to keep an open mind as to the aetiology of the patient’s symptoms. A thorough history and examination should underpin the diagnostic process and should guide further investigation, particularly in those patients whose lumbar spine MRI scans are unremarkable. We present two cases of aortic occlusion mimicking compressive CES that presented to our unit.

Cauda equina syndrome (CES) is a rare neurological emergency that requires prompt diagnosis and immediate surgical intervention for the best potential patient outcome. CES results from the compression of spinal roots along the lower spine usually at the level of L2 or below. It typically presents with severe low back pain, pain radiating to lower extremities, motor weakness, sensory loss, saddle anesthesia, bladder and bowel dysfunction. It is most commonly caused by a large central intervertebral disc herniation or central canal spinal stenosis but can also occur on occasion from abscesses, neoplasms, and inflammatory conditions. If the patient's symptoms are overlooked and surgical intervention is delayed there is a risk for long-term damage to neurological function. Here, we will present a case of a 46-year-old female with a long-standing history of back pain that presented to her primary care office with worsening back pain symptoms as well as a new presentation of urinary incontinence. A prompt MRI confirmed CES and the patient was advised to report to the nearest ED. At the hospital, neurosurgeons performed a laminectomy and found a mass along L3 that was compressing the cauda equina and associated nerve roots. The pathology of the mass revealed an extramedullary plasmacytoma (EMP) that was later determined to originate from the right psoas muscle. The case provides insight into the patient's presentation of CES and the key differentiating factors that led the medical care team to order the appropriate work up and prevent the long-term complications associated with an untreated CES.

A prospective, observational cohort study. The aim of this study was to determine the role of pre and postvoid bladder scan in predicting cauda equina syndrome (CES). The thesis was that bladder scanning [specifically postvoid residual (PVR) volume] would have higher diagnostic accuracy than physical examination alone. CES is an ill-defined condition with a spectrum of presenting symptoms. There is neither a combination of clinical symptoms and/or signs that reliably predicts cauda equina compression nor single defining clinical criterion that has 100% predictive value to confirm or exclude CES. Patients with suspected CES admitted over a 6-month period at a single institution were prospectively assessed by physical examination (including digital rectal examination and pin prick perianal sensation) and bladder ultrasound scanning (recording pre- and PVR volume). These results were compared with the subsequent magnetic resonance imaging (MRI) scans and those patients who had emergent surgery for CES. Ninety-two patients were included in the study (52 women) with a mean age of 44.9 years.An MRI scan demonstrating causing compression of the cauda equina was present in only 18% (17/92).The sensitivity of anal tone to predict CES was 52.9%. Peri-anal numbness (either unilateral or bilateral) had sensitivity of 82.3% and negative predictive value of 92%.For nonoperated group (without CES), mean PVR was 199 mL (95% confidence interval ± 59 mL). On the basis of receiver operating curves, the optimal bladder volume cut-off for predicting CES was ≥200 mL for PVR volume. A PVR of <200 mL gave CES probability of 3.6%. If >200 mL, then the probability of having CES is 43% (P < 0.000003). A PVR <200 mL had a negative predictive value of 97%. Bladder scanning was a useful adjunct in the diagnosis of CES. It had a better negative predictive value than physical examination. 3.

Priapism, a symptoms of claudication of the cauda equina in spinal stenosis

Objective Cauda equina syndrome (CES) is a neurosurgical emergency, identified by a range of clinical symptoms including back pain coupled with saddle anaesthesia, bladder or bowel symptoms. A high index of suspicion for CES warrants an emergency lumbar MRI. However, up to 48% of patients undergoing such scans have no radiological correlate for their symptoms but are clinically indistinguishable from those with established CES (Rooney et al, 2009, J Neurol). Relatively little is known about this scan-negative patient group. We therefore examined a cohort of “CES” patients from a single regional centre and examined radiological and referral outcomes. Method 179 patients who had a lumbar MRI at Kings College Hospital, London, after attending A and E in a 12 month period ending December 2015 were retrospectively identified. 160 patients met the inclusion criteria: over 18; had lumbar MRI performed specifically to exclude suspected CES; and had an admission entry in the medical notes detailing their history. Electronic patient records were then assessed for age, gender, presenting symptoms and follow up. Results CES was confirmed in 16% of lumbar MRI scans (n=25), 84% (n=135) were ‘scan-negative’ with no structural correlate for CES although 44% showed some evidence of root involvement. Fisher’s exact test (two-sided) was used to compare the groups’ symptomology. No significant differences were found for back pain (p=0.59), urinary incontinence (p=0.98), urinary retention (p=0.16), altered urinary sensation (p=0.57), bowel incontinence (p=0.80), leg weakness (p=0.67), sciatica (p=0.57), leg paresthesia (p=0.37). There was an observed difference in the demographics: the scan-negative group was predominantly female [71% vs 48% (p=0.023)] and significantly younger [42.7 vs 54.7 years (p Conclusion These findings replicate established difficulties in identifying CES from clinical symptoms alone. Demographic differences between scan-positive and negative patients indicate heterogeneity requiring further investigation. It is likely that a proportion of the scan negative patients have a functional neurological disorder although the precise figure has yet to be determined. Routine follow up was inconsistent. More detailed neuropsychiatric evaluation and longer follow-up are required to characterise this patient group which would inform a range of clinical care pathways addressing their medical and psychiatric needs.

Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. The study confirms the low predictive value of 'red flag' symptoms and signs. Of note 'bilateral sciatica' had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed 'low-risk' of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677-682.

Cauda Equina Syndrome and Decreasing Opioid Requirements

Background:Cauda equina syndrome (CES) is an uncommon entity that presents acutely with all or some of the following symptoms; urinary incontinence from retention, fecal incontinence from loss of sphincter tone, saddle area hypoesthesia or anesthesia, and acute or progressive weakness in one or both lower extremities. The protean symptomatology is often mixed and is vulnerable to confounding comorbidities making the accurate and timely diagnosis of this syndrome uniquely challenging. Here, we present the case of a man who developed isolated sacral nerve dysfunction from CES in the midst of a diabetic crisis.Case Description:A 53-year-old male with a long history of uncontrolled Type 2 diabetes presented with acute-onset urinary and fecal incontinence, scrotal anesthesia, and a 3-day history of lower back pain with intermittent bilateral leg pain. This patient displayed no objective changes in leg strength, sensation, or reflexes. In addition, the patient tested positive for cocaine and had a blood glucose level of 800 mg/dL which confounded his clinical picture. The patient underwent bilateral laminectomies from L4–S1 with the removal of a large sequestered disc fragment from the S1–S2 disc space within 8 h of presentation with reasonable recovery.Conclusion:Highly variable presentations often confound the accurate and timely diagnosis of CES with severe implications on quality of life. Despite the limited functional recovery seen after surgical decompression, urgent or emergent intervention is paramount for treatment. Our patient’s presenting symptomatology and comorbidities highlight the need for practitioners to maintain a high index of suspicion in anyone with incontinence and back pain, regardless of distractors and even in the absence of other anticipated motor or sensory findings.

Spinal tumors and intervertebral disk prolapse are relatively uncommon causes of neurogenic bladder dysfunction. Cauda equina syndrome (CES) occurs when the nerve roots of the cauda equina are compromised, resulting in disruption of motor and sensory function to the pelvic floor, bladder, and lower extremities. Primary tumors of the spinal cord, spinal nerve roots, and dura are relatively rare, while the bony spinal column is a common site of metastases in patients with visceral cancers. Spinal tumors are anatomically characterized into extradural, intradural but extramedullary, and intradural intramedullary. The association of intervertebral disk prolapse with voiding dysfunction has long been recognized and typically results from the impact of spinal nerve root compression causing axonal dysfunction, ischemia, inflammation, and biochemical sensitization by the protruding disk. CES is characterized by a constellation of symptoms including low back pain, unilateral or bilateral lower extremity pain and weakness, bowel disturbance, bladder and sexual dysfunction, and saddle or perineal paresthesia.

A prospective patient's database operated on a cauda equina syndrome (CES). The aim of our study was to identify prognosis factors for favorable functional recovery after CES. CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery. One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted. The patients were young with a median age of 46.8 years (range 18-86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery. CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.Level of Evidence: 4.

Cauda equina syndrome is a rare, severe spinal condition requiring urgent evaluation and co-ordinated care. This article addresses educational priorities and care practices for nurses managing cauda equina syndrome, based on a survey of patients with the syndrome. The aim was to review literature, Getting It Right First Time guidelines, Freedom of Information surveys, and a patient survey conducted by support group Cauda Equina Spinal Cord Injury regarding bladder and bowel dysfunction following cauda equina syndrome diagnosis and surgery. Delays in diagnosis, variations in care and unmet patient needs were researched. An anonymous online survey, including multiple choice and open-ended questions, was developed and hosted on the Enalyzer platform from 11 August to 3 September 2023. The online survey collected data on diagnosis, management and quality of life for those living with cauda equina syndrome. Participants were recruited via a members-only Facebook page. Data from 137 responses was collected and analysed. This article integrates Getting It Right First Time national reports, Freedom Of Information responses from NHS trusts and published literature, highlighting roles for nurses and specialist services. Responses indicated diagnostic inconsistencies, low adoption of the cauda equina pathway, and suggested that there had been significant impact on patients' bladder, bowel and sexual function, as well as mental wellbeing. Nurse-led specialist services, improved training in neurogenic management, guideline adherence, clear referral pathways and patient information are recommended.

Background Cauda equina syndrome (CES) is a challenging condition and it can be caused by variable entities. Leptomeningeal carcinomatosis (LC) is a multifocal seeding of the leptomeninges by malignant cells and it is observed in 1–8% of patients with solid tumors. Diagnosis of intradural metastases of the cauda equina is often delayed due to the non-specific characteristics of this condition but also to the delay of presentation of many patients. Cauda equina metastases usually occur in advanced cancers, but rarely can be the first presentation of disease. Case description A 63-year-old man presented with 6 months history of low back pain and 20 d history of bilateral sciatica, hypoesthesia of the legs and the saddle, flaccid paraparesis and bowel incontinence determine by multiple nodular small lesions on the entire cauda equina with contrast-enhancement. Total-body CT showed a millimetric lesion at the lung. The patient underwent L2–L5 laminectomy and subtotal removal and histological examination showed a small cell lung carcinoma metastasis. Conclusions In the literature, 54 cases of CES from non-CNS tumor metastasis are described. The diagnosis is challenging, back pain, with or without irradiation to the lower limbs, is the most frequently reported disturbance. In about 30% of patients there is no known malignancy and CES is the first clinical presentation. Treatment of choice is surgery, followed by radiotherapy and less frequently adjuvant chemotherapy. The surgical removal is almost always incomplete and functional outcome is often not satisfactory. Prognosis is poor.

Compression of the cauda equina can lead to bladder, bowel and sexual dysfunction with lower limb pain, numbness and weakness. Urgent surgical decompression aims to prevent progressive neurological deficit. Symptoms of cauda equina syndrome (CES), such as back pain, sciatica and bladder dysfunction are common in the population, but the majority of those investigated do not have radiological cauda equina compression. However, a missed diagnosis can have significant medical, social and legal consequences. We investigated the effect of the COVID-19 pandemic on presentation and management of suspected CES. This retrospective cohort study analysed referral, investigation and treatment of CES in a regional neurosurgical centre during the initial COVID-19 surge between March and May 2020 compared with March to May 2019. Referrals for suspected CES were similar during the COVID-19 pandemic (n = 275) compared with 2019 (n = 261, p = 0.596) despite a significant (19%) decrease in total emergency neurosurgical referrals (1248 in 2020 vs 1544 in 2019, p < 0.001). Nineteen (7%) of the suspected CES referrals underwent decompression in 2020, similar to 16 (6%) in 2019 (p = 0.867). There were no differences in outcomes or complications and no evidence of delays in presentation or treatment. Unlike other emergency neurosurgical conditions, the number of referrals for suspected CES and the percentage of referrals with radiological cauda equina compression were unchanged during the COVID-19 pandemic. The persistence of CES referrals when many people stayed away from hospital highlights the distress and worry caused by suspected CES and its symptoms to both patients and healthcare providers.

Cauda equina syndrome (CES) is an orthopedic emergency. The common causes of CES are intervertebral disc prolapse and traumatic injuries of the spine. We report an unusual case of vertebral endplate erosion into the spinal canal leading to CES. We report a 37-year-old male patient who had a history of low back pain radiating to both the legs for 1 month. He was receiving treatment at a local hospital. He presented to our emergency department with the inability to stand, walk, or void for 1 day. Radiographs and magnetic resonance imaging confirmed CES due to intervertebral disc prolapse. Our patient's diagnosis of vertebral endplate extrusion was made intraoperatively when the extruded material was found to be hard in consistency, and histopathological analysis confirmed the diagnosis. A diagnosis of vertebral endplate causing CES has been reported only in adolescents but never in adults. Preoperative computed tomography scans can help in easy diagnosis.