The spinal cord ends at the level of L1-L2.
The distal part of the cord it the conus medullaris and its distal end continues as the filum terminalae. Distal to the conus, there are nerve roots and endings that look like a horse’s tail (thus the term canda equina).
Cauda Equina Syndrome occurs when there is compression of the lumbosacral nerve roots.
Second what causes compression?
-Central lumbar disc protrusion of L4/5 or L5S1
- Lumbar canal stenosis
- Trauma
- Tumours – metastases – lung, breast, renal
- Infection – abscess
- Haematoma
Clinical Picture:
Patients can present with a pure canda equina or conus medalluris syndrome, or a mixture of both. Canda equina syndrome is really a peripheral nerve lesion.
Conus medullaris Syndrome may have some upper motor neurone(UMN) signs and present with increased tone and reflexes (UMN) and bilateral signs. I
In terms of the diagnosis, differentiating between the two syndromes doesn’t matter, as the management is the same. What’s needed is an MRI and urgent referral.
What you see in your patients?
- Lower back pain- sciatica
- Power – decreased power in lower limbs – symmetrical or asymetrical
- Sensory – decreased sensation in lower limbs and saddle area to light touch / pin prick
- Reflexes – knee (spaned in conus) Ankle and Plantar reflexes affected.
- Erectile dysfunction
- Sphincter dysfunction -Urinary retention/Decrease urethral sensation/Loss of anal tone.
Those with shorter time to treatment do better . Those patients with unilateral deficits do better (J. Bone Joint Surgery 1965). Recovery is proportional to the extent of saddle sensory deficit (Ann R. Coll Surg Engl 2008)
Conclusion
Cauda Equina is a medical emergency.
If the patient presents with back pain and leg and perianal numbness, leg weakness as well as impotency and any urinary symptoms, get an MRI and refer to the spinal surgeons urgently
Prognosis vs. actual outcome varies individually. I'm currently 8 months since my injury. Due to a central L4/L5 massive herniation, I had full sensory loss below the waist, lower back pain, severe pain down both legs, bilateral weakness, bladder & bowel retention, and erectile dysfunction. Emergency Room doctor misdiagnosed me and it was 2 weeks before I had decompressive surgery. Neurosurgeon said it was the worst he'd ever seen. Fast forward to today - I have normal feeling restored to both thighs except a narrow strip on the back of the right one. I have touch sensation in both shins and some feeling in both calves. Both feet have tingly pins & needles feeling - left foot not painful, right foot painful but the pain is decreasing every month. Strength has come back to about 60-70% of pre-injury level. I can walk unassisted for about 150 feet before needing a short break. After about 3 of those, I need a long break. Using a cane or walking stick, I can cover over 500 feet before needing a rest. I do both of these multiple times each day. I work a full day and commute an hour each way to get there. From worst case prognosis to a really good case recovery thus far. I'm blessed and want others to know that there is hope once stricken with Cauda Equina Syndrome. Follow my journey at my blog - http://davidunthank.com
ReplyDeleteBravo David - when the going gets tough...tough get going!
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