The document provides a comprehensive overview of cauda equina syndrome, detailing its etiology, symptoms, diagnostic methods, and treatment options. Major causes include lumbar disc herniation and spinal stenosis, with key symptoms such as saddle anesthesia and bladder dysfunction. Emergency surgical decompression is crucial for effective treatment, aiming to prevent permanent nerve damage and restore function.

1. Cauda Equina Syndrome
By: Dr Gresh Kumar

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

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
 1. Lumbar Disc Herniation
• Most common cause of cauda equina syndrome,
particularly when a large disc herniates in the
lumbar spine (L4-L5, L5-S1), compressing the nerve
roots.
 2. Spinal Stenosis
• Narrowing of the spinal canal due to degenerative
changes, leading to compression of the cauda
equina nerves.
 3. Spinal Trauma
• Fractures, dislocations, or severe injury to the lumbar
spine can cause direct compression of the cauda
equina.

5.  4. Tumors
• Spinal tumors or metastatic cancer can cause direct
compression of the cauda equina.
 5. Infection or Inflammatory Conditions
• Spinal infections (e.g., abscess, osteomyelitis) or
inflammatory diseases (e.g., ankylosing spondylitis) can
compress the cauda equina.
 6. Epidural Hematoma
• Bleeding into the epidural space can compress the cauda
equina, sometimes following spinal surgery or trauma.
 7. Epidural Abscess
• A localized infection in the epidural space can compress
the cauda equina, causing CES.

6.  8. Iatrogenic Causes (Post-Surgical)
• Complications from spinal surgery or anesthesia
(e.g., lumbar puncture or epidural anesthesia)
can lead to hematoma or infection, compressing
the cauda equina.
 9. Vascular Causes
• Aortic dissection or vascular malformations can
lead to ischemia of the cauda equina nerves.
 10. Congenital Abnormalities
• Conditions such as spina bifida or tethered cord
syndrome may also cause cauda equina
syndrome.

8. Physical Examination
 Cauda equina Syndrome
Hatgis J, Hall AJ. Cauda Equina Syndrome. InMusculoskeletal Sports and Spine Disorders 2017 (pp. 447-449). Springer, Cham.
•Saddle anesthesia (loss of sensation in the perineum, buttocks,
inner thighs).
•Reduced anal sphincter tone.
•Lower limb motor weakness, particularly in muscles innervated by
the lower lumbar and sacral nerve roots.
•Absent or diminished reflexes in the lower limbs, such as the
Achilles reflex.
•Bladder and bowel dysfunction, with urinary retention being a key
feature.

9. Diagnostic Tools
 1. Magnetic Resonance Imaging (MRI)
• Gold standard for diagnosing cauda equina
syndrome.
• Provides detailed images of the spinal cord,
cauda equina nerves, and surrounding structures.
• Helps identify causes such as disc herniation,
spinal stenosis, tumors, or hematomas.

10.  2. Computed Tomography (CT) Myelogram
• Used when MRI is contraindicated (e.g., patients
with pacemakers or other MRI-incompatible
devices).
 3. Bladder Scan/Urodynamic Studies
• Used to assess bladder function, particularly in
patients with urinary retention or incontinence.
• Can identify incomplete bladder emptying,
suggesting nerve dysfunction in CES.

11. Differential Diagnosis
 1. Conus Medullaris Syndrome
• Location of compression: Conus medullaris, the
terminal end of the spinal cord.
• Symptoms:
• Sudden onset of bilateral symptoms.
• More severe motor weakness in the lower limbs.
• Early bladder and bowel dysfunction (retention,
incontinence).
• Saddle anesthesia is more symmetric.
• Distinction: Compared to CES, conus medullaris
syndrome has more prominent upper motor
neuron signs and less severe pain.

12. Differential Diagnosis
 2. Lumbar Radiculopathy (Sciatica)
• Location of compression: Individual lumbar nerve
roots, often due to disc herniation or spinal stenosis.
• Symptoms:
• Unilateral leg pain radiating down the affected
dermatome.
• Muscle weakness or sensory loss in the distribution of
the affected nerve root (e.g., L5, S1).
• Bladder or bowel dysfunction is absent.
• Distinction: Radiculopathy typically causes focal
symptoms without the systemic signs of CES, such as
bladder or bowel dysfunction.

13.  3. Spinal Cord Compression (Above the Lumbar
Region)
• Location of compression: Thoracic or cervical spinal
cord.
• Symptoms:
• Bilateral motor and sensory deficits in the lower limbs
(paraplegia).
• Upper motor neuron signs (e.g., hyperreflexia,
spasticity).
• Bladder and bowel dysfunction may occur.
• Distinction: Upper motor neuron signs (e.g.,
increased reflexes) are seen in spinal cord
compression, while CES presents with lower motor
neuron signs (e.g., hyporeflexia).

14.  4. Guillain-Barré Syndrome (GBS)
• Location of pathology: Autoimmune attack on
peripheral nerves.
• Symptoms:
• Progressive, ascending weakness starting in the lower
limbs and moving upward.
• Areflexia and sensory loss.
• Autonomic dysfunction, including bladder and bowel
issues, can occur.
• Distinction: GBS typically progresses over days to
weeks, with a symmetric pattern of weakness and
sensory loss, unlike the more rapid and localized
onset of CES.

15.  5. Multiple Sclerosis (MS)
• Location of pathology: Central nervous system
demyelination.
• Symptoms:
• Vary widely but can include lower extremity
weakness, sensory changes, bladder dysfunction.
• Often episodic with remissions.
• Distinction: MS tends to have an episodic course,
with varied symptoms over time, whereas CES
presents acutely and involves more localized
compression signs.

16.  6. Epidural Abscess
• Location of infection: Epidural space of the spine.
• Symptoms:
• Severe back pain, fever, malaise.
• Neurological deficits including weakness and
sensory loss.
• Bladder or bowel dysfunction can occur if the
abscess compresses the cauda equina or spinal
cord.
• Distinction: Fever, elevated inflammatory markers
(CRP, ESR), and a history of infection are more
suggestive of an epidural abscess.

17.  7. Spinal Tumor
• Location of compression: Any part of the spine or
spinal cord.
• Symptoms:
• Gradual onset of back pain, motor and sensory
deficits.
• Bladder or bowel dysfunction may occur with
significant compression.
• Distinction: More gradual onset and often
associated with systemic symptoms of
malignancy, such as weight loss.

18.  8. Epidural Hematoma
• Location of compression: Epidural space of the
spine due to bleeding.
• Symptoms:
• Sudden onset of severe back pain, neurological
deficits (e.g., leg weakness, sensory loss).
• Bladder or bowel dysfunction can occur.
• Distinction: History of anticoagulation therapy,
trauma, or recent spinal procedure often
precedes the hematoma formation.

19.  9. Transverse Myelitis
• Location of inflammation: Across one segment of
the spinal cord.
• Symptoms:
• Sudden onset of back pain, weakness, and sensory
loss.
• Bowel and bladder dysfunction may occur.
• Frequently associated with viral infections or
autoimmune diseases.
• Distinction: Symptoms are more diffuse and affect
both sides of the body; MRI findings show
inflammation within the spinal cord itself.

20.  10. Peripheral Neuropathy
• Location of pathology: Peripheral nerves.
• Symptoms:
• Gradual onset of sensory loss and weakness in the
feet and legs.
• No bladder or bowel dysfunction unless severe
autonomic involvement.
• Distinction: Typically presents with a chronic
course of symmetric distal weakness and sensory
loss, unlike the acute and asymmetric symptoms
of CES.

21.  11. Vascular Causes (Spinal Cord Ischemia)
• Location of pathology: Blood supply to the spinal
cord.
• Symptoms:
• Sudden onset of severe back pain, motor and
sensory loss, often following a vascular event (e.g.,
aortic aneurysm, dissection).
• Bladder or bowel dysfunction can occur.
• Distinction: Rapid onset following a known
vascular event, and MRI may show ischemic
changes in the spinal cord.

22. Treatment
 The treatment of cauda equina syndrome (CES) is
a medical emergency aimed at relieving pressure
on the cauda equina nerves to prevent
permanent neurological damage, including
paralysis and loss of bladder and bowel control.
Prompt intervention is essential for a better
prognosis. Here is the approach to treating CES:

23.  1. Emergency Surgical Decompression
• Goal: Relieve pressure on the cauda equina nerves
as soon as possible, ideally within 24–48 hours of
symptom onset.
• Procedure:
• Laminectomy: Removal of part of the vertebral bone
(lamina) to decompress the spinal canal.
• Discectomy: Removal of a herniated disc if it's the
cause of nerve compression.
• Tumor Removal: If a tumor is compressing the cauda
equina, surgical resection may be performed.
• Outcome: Early surgery has the best chance of
preserving neurological function, particularly for
bladder and bowel control, as well as motor
function in the lower limbs.

24.  2. Medical Treatment (Adjunctive)
• Corticosteroids:
• High-dose steroids (e.g., dexamethasone) may be
administered in some cases to reduce inflammation and
spinal cord edema, especially if there’s suspicion of a tumor,
trauma, or infection.
• Antibiotics:
• In cases where CES is caused by infection (e.g., epidural
abscess), intravenous antibiotics are started immediately,
usually after cultures are taken.
• Broad-spectrum antibiotics are often given initially until
specific causative organisms are identified.
• Anticoagulation/Management of Hematomas:
• If CES is caused by an epidural hematoma, stopping
anticoagulants and reversing their effects is critical.
• Emergency decompression of the hematoma is required.

25.  3. Bladder and Bowel Management
• Bladder Catheterization:
• Urinary retention is common in CES, so bladder
catheterization may be necessary to relieve urinary
retention and prevent bladder damage.
• Bowel Management:
• Patients may need stool softeners or other
interventions to manage bowel dysfunction while
awaiting recovery of function after surgery.

26.  4. Rehabilitation and Physical Therapy
• After surgery, many patients require rehabilitation
to restore function and mobility.
• Physical therapy may be needed to strengthen
the muscles of the lower extremities, improve
walking, and regain balance.

27.  5. Pain Management
• Nonsteroidal anti-inflammatory drugs (NSAIDs),
opioids, or nerve pain medications (e.g.,
gabapentin, pregabalin) may be required to
manage post-surgical pain or neuropathic pain.
• Physical therapy may also help reduce pain by
improving mobility.

28. THANK YOU