Cauda Equina Syndrome

1. Cauda Equina Syndrome
Ade Wijaya, MD – September 2018

2. Outline:
• Introduction
• Etiology
• Symptoms
• Physical examination
• Diagnostic tools
• Differential diagnosis
• Treatment
• Referral
• Summary

3. Introduction
• Cauda equina: The peripheral bundle of
nerve roots originating from the lumbosacral
segments of the spinal cord
• Asymmetrical LMN
Kirshblum S, Gonzalez P, Nieves J, Cuccurullo S, Luciano L. Spinal cord injuries (SCI). In: Cuccurullo J, editor. Physical medicine and rehabilitation board review. 2nd ed.
New York: Demos Medical; 2010. p. 557–8.

4. Etiology
• Central disc herniations
• Spinal tumors
• Spinal abscesses
• Meningitis
• Spinal hematomas/hemorrhages
• Spinal arteriovenous
malformations
• Spinal trauma with a burst
fracture
• Spondylolisthesis
• Spinal stenosis
• Spinal anesthesia
• Postoperative spinal surgery
complications
• Ankylosing spondylitis
Cooper AB, Sharpe MD. Bacterial meningitis and cauda equina syndrome after epidural steroid injections. Can J Anaesth. 1996;43:471–4.
Cauda Equina Syndrome. American Association of Neurological Surgeons Web site. http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Cauda%20Equina%20
Syndrome.aspx. Published Nov 2005. Accessed Feb 2015.

7. Physical Examination
CAUDA EQUINA SYNDROME
• LMN signs
• Saddle anesthesia
• Gait ataxia
• Sexual, bowel, and/or bladder
dysfunction
CONUS MEDULLARY SYNDROME
• Same as cauda equine syndrome
• May develop UMN signs:
–– Spasticity
–– Clonus
–– Hyperreflexia
–– Babinski’s sign
Hatgis J, Hall AJ. Cauda Equina Syndrome. InMusculoskeletal Sports and Spine Disorders 2017 (pp. 447-449). Springer, Cham.

8. Diagnostic Tools
• MRI of the lumbosacral spine is essential in demonstrating
neurological compromise.
• CT scan, myelography, or a combination may be performed
if the patient has contraindications to MRI.
• AP, lateral, oblique, flexion, and extension view x-rays of
the lumbosacral spine should be obtained to rule out a
vertebral fracture or spondylolisthesis.
• Urodynamic studies may assess for bladder function subacutely
Hatgis J, Hall AJ. Cauda Equina Syndrome. InMusculoskeletal Sports and Spine Disorders 2017 (pp. 447-449). Springer, Cham.
Cauda Equina Syndrome. PatientPlus Web site. http://www.patient.co.uk/doctor/cauda-equina-syndrome#ref-4. Updated 8 Feb 2013.

9. Differential Diagnosis
• Conus medullaris syndrome
• Herniated nucleus pulposus
• Spinal stenosis
• Guillain-Barré syndrome
• Vertebral fracture
• Multiple sclerosis
• Peripheral neuropathy
• Lumbosacral plexopathy
• Polyradiculopathy
• Spinal tumor
Hatgis J, Hall AJ. Cauda Equina Syndrome. InMusculoskeletal Sports and Spine Disorders 2017 (pp. 447-449). Springer, Cham.

10. Treatment
• Immediate neurosurgical consultation. Surgical decompression may
be the only chance to reverse the deficits, which are not always
reversible.
• Malignant disease that is considered inoperable may be treated with
radiation therapy and chemotherapy
• Ideally the treatment should occur within the first 48 h after
symptom onset
• Spinal immobilization.
• Anti-inflammatories, steroids.
• Pain management.
• Antibiotic treatment if infection is suspected
Spengler D. Cauda Equina syndrome. In: Sarwark J, editor. Essentials of musculoskeletal care. 4th ed. Rosemont: American Academy of Orthopedic Surgeons; 2010. p. 919–21.
Cauda Equina Syndrome. PatientPlus Web site. http://www.patient.co.uk/doctor/cauda-equina-syndrome#ref-4. Updated 8 Feb 2013. Accessed Feb 2015.
Hatgis J, Hall AJ. Cauda Equina Syndrome. InMusculoskeletal Sports and Spine Disorders 2017 (pp. 447-449). Springer, Cham.

11. Referral
• Neurosurgery (emergent)
• Orthopedic spine surgery (emergent)
• Physiatry (subacute/chronic)
Hatgis J, Hall AJ. Cauda Equina Syndrome. InMusculoskeletal Sports and Spine Disorders 2017 (pp. 447-449). Springer, Cham.

12. Summary
• Asymmetrical LMN signs
• Various etiology
• VS conus medullary syndrome
• MRI
• Emergency (neurosurgical consultation)