Cauda Equina Syndrome (CES) involves compression of the bundle of nerves at the end of the spinal cord, and can cause leg weakness, loss of sensation, and bladder/bowel issues. A herniated disc is a common cause of CES. Urgent surgical treatment is important to prevent permanent neurological damage. Early diagnosis and treatment leads to better outcomes, especially for bladder function.

1. CAUDA EQUINA
SYNDROME
(CES)
BY KAMAL
SUPERVISED BY DR KASHFULLAH

2. - Cauda equina (CE) is a bundle of intradural nerve roots at the
end of the spinal cord, in the subarachnoid space distal to the
conus medullaris.
- Cauda Equina (latin) = horse tail
- Sensory innervation to the saddle area, motor innervation to the
sphincters, and parasympathetic innervation to the bladder and
lower bowel (ie, from the left splenic flexure to the rectum).
- Nerves including L2-S5
ANATOMY

3. - A retrospective review in Slovenia found an annual incidence of
cauda equina syndrome resulting from intervertebral disc
herniation of 1.8 per million population. Using US data on annual
incidence of symptomatic disc herniation (1500 per million popula-
tion), the author estimates that each year 0.12% of herniated discs
are likely to cause cauda equina syndrome.
EPIDEMIOLOGY

4. - Cauda equina syndrome (CES) is a relatively uncommon
condition typically caused by a compression within the canal of the
lumbosacral spine. It is one of the few spinal surgical emergencies
and its prompt diagnosis and surgical treatment are of paramount
importance as, otherwise, patients could be left with permanent
and disabling neurological deficits involving lower limb
sensorimotor function, bladder, bowel and sexual function.
- Classic clinical presentation : bilateral leg weakness, decreased
reflexes, saddle anaesthesia and bowel/bladder disturbance.
DEFINITION

5. - the cause of CES is basically anything that causes
compression to the CE :
1. Degenerative - disc herniation (most common), spinal
stenosis, spondylolisthesis
2. Inflammatory - ankylosing spondylitis
3.Vascular - aortic dissection, arteriovenous malformation
4. Infective - epidural abcess, arachnoiditis, Pott’s
disease
5. Tumours - primary. Metastasis
6. Trauma
AETIOLOGY

6. - injury to the lumbosacral nerve causes
conduction block (discontinuity of electrical
impulses) hence causes loss of function
PATHOPHYSIOLOGY

7. -Three classic patterns of presentation have been
described:
Type 1: Presents acutely as the first symptom of
lumbar disc prolapse
Type 2: Presents as the endpoint of a long history
of chronic lower back pain with or without sciatica
Type 3: Presents insidiously with slow progression
to numbness and urinary symptoms
SYMPTOMS AND SIGNS

8. Red Flag symptoms
- Severe lower back pain
- Motor weakness, sensory loss or radicular pain
(usually bilateral)
- Loss of lower limb reflexes
- Saddle anaesthesia
- Recent onset of bladder dysfunction (i.e. urinary
retention or incontinence)
- Recent onset of faecal incontinence
- Recent onset of sexual dysfunction

9. 1. CESS (CES suspected) : Thecal sac compression with bilateral radiculopathy and/or
subjective sphincteric problems and/or subjective perineal sensory changes with no objective
evidence of CES
2. CESI (incomplete CES) : Thecal sac compression with subjective symptoms and objective
signs of CES
3. CESR (CES with retention) : Thecal sac compression with neurogenic urinary retention
CLASSIFICATION

10. - head to toe examination
- neurological examination :
Power, sensation, reflex, tone, clonus, anal tone,
bulbocavernosus reflex (BCR)
*LMN findings
- ASIA charting
PHYSICAL EXAMINATION

11. - Blood baseline investigation
- spine xray
- MRI/CT myelogram (if MRI contraindicated)
- further investigations depends on suspected
aetiology (blood C+S, tumour markers etc)
INVESTIGATION

13. Depends on aetiology :
1. Disc herniation (24-48hrs)
2. Infection/inflammation- treat underlying
infection/inflammation
3. Tumour - excision of tumour/chemotherapy
(metastasis)
4. Trauma - stabilisation
5. Vascular - graft, antihypertensive, resection,
embolisation
MANAGEMENT

14. Supportive :
- analgesia
- high dose steroids
- laxatives
- CBD insertion/pampers
- CRIB
- bone protection (malignancy)
- anticoagulants
- refer physio

15. - Early recognition and treatment of CES is associated
with improved outcome with respect to bladder
function.
- Outcomes in patients treated at the time of CESI are
generally favourable, whereas outcomes following
bladder paralysis (CESR) are less favourable. If male
patients present with erectile dysfunction, this usually
has a poor prognosis.
- For these reasons, failure to recognize and treat this
condition expediently may have outcome and
medicolegal implications.
PROGNOSIS

16. THANK YOU

17. 1. Junseok W Hur et al (2019) Guidelines for Cauda Equina Syndrome Management
2. Pararajasingham J. And Deniz K (2011), Cauda Equina Syndrome
3. Gardner A et al (2011), Cauda equina syndrome: a review of the current clinical and medico-legal position
4. Lady C et al (2009), Cauda Equina Syndrome
5. Ebnezar J (2010), Textbook of Orthopaedics
REFERENCES

18. Q&A
1. Cauda Equina nerves include ?
2. What is CES ?
3. Common cause of CES ?
4. What are the classic clinical presentation of CES ?
5. Gold standard investigation for CES ?
6. Management for CESI ?