This document discusses Cauda Equina Syndrome (CES) and other spinal disorders. It defines CES and describes its typical presentation, including severe lower back pain, sciatica, saddle numbness, and bladder/bowel dysfunction. CES requires urgent MRI and possible surgical decompression within 24 hours for best outcomes. Other topics covered include spinal anatomy, types of disc herniations, and patterns of spinal cord injury such as complete cord injury and Brown-Sequard syndrome.

1. Cauda Equina Syndrome
& Spinal disorders
Dafydd Loughran
F2 Wrexham Maelor
22nd July 2014

2.  Recap on spinal anatomy and radiographic description
 Disc herniation key facts
 Cauda Equina syndrome presentation & management
 Other spinal cord injury patterns
Learning objectives

3. Bony anatomy

4. Spinal tracts
Corticospinal = Motor control to
ipsilateral muscles
Dorsal colums = Fine touch,
vibration &
proprioception
Spinothalamic = Crude touch, pain &
temperature

5. Arterial supply
Anterior spinal artery
• Supplies 2/3
• Spinothalamic & corticospinal tracts
Posterior spinal artery
• Dorsal columns
Anterior cord syndrome, most commonly
due to insufficiencies in the aorta
(aneurysm/dissection/trauma), leads to
disturbance of spinothalamic & corticospinal
tracts.
Very poor prognosis

6. Cervical Spine – Radiograph lines
Important for describing alignments on
radiographs.
Anterior vertebral line
Posterior vertebral line
Spinolaminar line
Posterior spinous line

7. • Predominantly lower back / leg
pain
• Progression from disc protrusion –
annulus fibrosus intact
• Tear in annulus fibrosus (outer)
allows nucleus pulposus through
• Usually due to age related
degeneration
• More rarely due to trauma
• Usually resolve within a few weeks
without discectomy
Disc herniation

8. • Neurosurgical emergency
• Based on incidence &
catchment around 5 would be
expected yearly at WMH
• Most due to large central
lumbar disc herniation at L4/5
or L5/S1
• Three Classic patterns of
presentation
1. Acutely as first symptom of
disc herniation
2. Endpoint of long history of
back pain due to herniating
disc
3. Insidious progression to
numbness & symptoms
Cauda Equina Syndrome (CES)

9. • Red Flag symptoms:
• Severe lower back pain
• Sciatica type pain
• Saddle +/- genital sensory loss
• Bladder, bowel or sexual
dysfunction
• Defined as:
1. Incomplete Cauda Equina
syndrome
2. Cauda Equina syndrome with
urinary retention
• Patients with urinary retention
have worse prognosis
Cauda Equina Syndrome (CES)

10. • History including time frame &
bladder / bowel / sexual
dysfunction
• Examination:
• Full lower limb neuro including
reflexes
• Perianal sensation & anal tone
• Catheter tug sensation
• Clinical diagnosis even by
neurosurgeons has 43% false
positive rate so urgent MRI
recommended
• If clinical features & MRI
suggest reversible cause of
pressure then need transfer to
spinal centre for surgical
decompression
CES - Management

11. • Some debate regarding urgency of
surgery
• Most recent evidence shows that early
(<24hrs) decompression does lead to
better outcomes in incomplete CES
• Retrospective study noted that 87%
recovered normal bladder function if
<24hrs, compared to 43% if >24hrs.
• Inconclusive evidence regarding benefit
of surgery & its timing in CES with
retention
CES - Outcomes

12.  Other differentials to consider from history:
 Tumour – either primary bone or metastatic cord
compression
 Epidural / subdural haematoma
 Infective pathology

13.  Complete cord injury
 Due to major trauma
 Neither motor nor sensory below injury level
 Minimal chance of functional recovery
 Anterior cord syndrome
 Due to disruption / thrombosis of flow in
anterior spinal artery
 Motor, pain & temperature loss bilaterally
 Poor prognosis
Other spinal cord injury patterns

14.  Brown-Séquard syndrome
 Hemi-transection or unilateral compression
 Ipsilateral motor (corticospinal), proprioception &
vibration (dorsal columns) loss
 Contralateral pain & temperature (spinothalamic)
loss
 Central cord syndrome
 Commoner following hyperextension in patient with
cervical spondylosis
 Greater motor weakness in upper than lower limbs
 Burning sensation in upper extremities common
Other spinal cord injury patterns

15.  Recap on spinal anatomy and radiographic description
 Disc herniation key facts
 Cauda Equina syndrome presentation & management
 Other spinal cord injury patterns
Thank you,
Any questions?
Learning objectives