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Cauda equina syndrome

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Presented an in-service on the pathophysiology and differential diagnosis of cauda equina syndrome to Arcadia University's 2nd year Doctor of Physical Therapy students.

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Cauda equina syndrome

  1. 1. Jeffrey Turner SPT, CSCS Junsik Yoon SPT
  2. 2.  5th most common condition  ~25% adults report LBP w/in past 3 months  Prevalence of 70% over the course of one’s life  >85% cannot be reliably attributed to a specific disease or abnormality  Classified into 3 broad categories: 1. Nonspecific LBP 2. Nerve Root Syndrome (CES, etc.) 3. Serious Spinal Pathology Images Courtesy of www.ericcressey.com
  3. 3.  Less common than nonspecific  Potentially disabling condition  Most often caused by acute lumbar disc herniation  Commonly between ages of 30 – 55  Related to:  Radiculopathy  Spinal Stenosis  Cauda Equina Syndrome Images Courtesy of www.publichealthwatchdog.com
  4. 4.  Rare and devastating condition  Prevalence of ~0.04% of all patients presenting w/ LBP  “True neurologic emergency”  Rapid clinical progression  For optimal prognosis:  Early recognition/diagnosis  Immediate surgical referral  Recommended w/in 48 hours of Dx Images Courtesy of www.publichealthwatchdog.com
  5. 5. 32 year old male presented to a PT at a medical aid station in Iraq.  Convoy machine gunner  Prolonged periods of standing >8 hrs  Wearing equipment up to ~80 lbs  4 week history of insidious onset and recent worsening of:  Low back pain  Left buttock pain  Posterior left thigh pain  Goal: Decrease pain during work Images Courtesy of www.defense.gov
  6. 6.  Pain: 4/10 resting and 7/10 at worst  Hx: 3-4 prior occurrences of LBP  Physical Exam:  Neurologically intact, and negative SLR  Limited lumbar flexion AROM  Reduction of Sx w/ lumbar extensions  Findings consistent w/ nonspecific LBP  No red flag signs or symptoms  Treatment:  Prescribed extension-oriented exercises  Prescribed NSAIDs for pain  Patient education
  7. 7.  New Symptoms:  Saddle anesthesia, LE paresthesia constipation, and urinary hesitancy.  Physical Exam:  Right plantar flexor weakness, absent right ankle reflex, and decreased anal sphincter tone.  Findings consistent w/ CES  Referral:  Medically evacuated to neurosurgeon  L4-5 Laminectomy/decompression w/in 48 hours of CES diagnosis
  8. 8. Returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficits.  Demonstrates the importance of medical screening.  Demonstrates the importance of immediate referral to surgical specialties when CES is suspected.  Rapid intervention offers the best prognosis. Images Courtesy of www.englishrussia.com
  9. 9.  Spinal cord ends between vertebrae L1 & L2  Originates after Conus Medullaris  L2 to S5 nerve roots looks like horse’s tail  Includes motor nerves, sensory nerves and parasympathetic innervation of the bladder Images Courtesy of Clinically Oriented Anatomy
  10. 10.  Compressive causes  Herniated lumbosacral disc  Spinal stenosis  Spinal neoplasm  Fracture of vertebrae  Non-compressive causes  Ischemia  Infection  inflammation Image Courtesy of www.publichealthwatchdog.com
  11. 11. Images Courtesy of www.publichealthwatchdog.com
  12. 12.  Making a thorough evaluation  Continually monitoring patient’s status throughout the patient management  Acting appropriately when conditions emerge that requires immediate referral Image Courtesy of www.bu.edu
  13. 13.  Crowell MS, Gill NW. Medical Screening and Evacuation: Cauda Equina Syndrome in a Combat Zone. J Orthop Sports Phys Ther. 2009; 39(7):541-549.  Moore KL, Dalley AF, Agur AMR, et al. Clinically Oriented Anatomy 7th Edition. Lippincott Williams & Wilkins; 2013.

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