Cauda Equina Syndrome is a condition involving the bundle of nerves originating from the lower end of the spinal cord. It can result from central disc herniations, spinal tumors, trauma, or other causes. Patients may experience LMN signs, saddle anesthesia, gait ataxia, and sexual/bladder/bowel dysfunction. MRI is used for diagnosis. Treatment requires immediate neurosurgical consultation and decompression, as delays can lead to permanent deficits.

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)