Cauda equina syndrome

A 50-year-old woman presents 4 weeks after receiving an epidural

steroid injection for chronic back pain. She is now experiencing severe
back pain and perineal numbness.
What is the differential diagnosis?
Cauda equina syndrome
Chronic mechanical lower back pain
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http://dx.doi.org/10.1017/CBO9780511642142.004
Cambridge Books Online Cambridge University Press, 2012
68 Cauda equina syndrome C
Lumbar disc pathology
Spinal cord compression from infection, neoplasm or haematoma
GuillainBarr e syndrome
Peripheral nerve disorder
Conus medullaris syndrome
Lumbosacral plexopathy
What are the causes of cauda equina syndrome?
Vertebral disc herniation
_ Central disc prolapse incidence of 1%15%
Neoplasm
_ Metastatic prostate cancer, ependymomas, schwannomas
Inflammatory
_ Infective e.g. spinal abscess
_ Non-infective Diseases which predispose to developing
vertebral fractures or spinal stenosis, e.g.
Pagets disease
Lumbar spinal stenosis
Trauma
_ Violent Injuries to the lower back (gunshots, falls and road traffic
accidents)
Congenital
Vascular
_ Spinal haemorrhages (subarachnoid, subdural, epidural)
_ Spinal arteriovenous malformations (AVMs)
Iatrogenic
Post-operative lumbar spine surgery complications
Spinal and epidural anaesthesia resulting in an abscess or haematoma
Epidural steroid injection
What further history would you seek from her?
A history of severe low back pain
Weakness of her legs
Pain in one or, more commonly, both legs
Saddle anaesthesia Does wet toilet paper feel wet?
A recent onset of bladder dysfunction, which may manifest as an inability to
initiate or stop a stream of urine or as overflow incontinence
Recent onset of faecal incontinence
Sensory abnormalities in the bladder or rectum
Recent onset of sexual dysfunction
Severe recent trauma to her back
Recent lumbar spine surgery
A history of cancer
Recent severe infection
Spinal or epidural analgesia
CamDowbnrloidadgede f roBmo Coamkbsri dOgen Bloionkse O nlin eC bay mIP 2b02r.i5d9g.22e5 .9U0 noni vFrei Mrsari t0y9 0P3:1r7e:4s3s G,M 2T 0201120.
http://dx.doi.org/10.1017/CBO9780511642142.004
Cambridge Books Online Cambridge University Press, 2012
C Cauda equina syndrome 69
What are the signs of the cauda equina syndrome?
Saddle anaesthesia.
Residual urine on bladder catheterization indicative of a neurogenic
bladder.
Lower motor neuron weakness is found in the plantar flexors and evertors.
Lower limb reflexes are absent or impaired.
Loss of anal tone.
What are the markers of infection?
ESR and CRP
What further investigations would you carry out?
Haematology FBC, INR, APTT
Biochemistry Urea, electrolytes and LFTs
Radiology
_ Plain X-ray may reveal vertebral fractures, tumour or infection
_ CT scan
_ An urgent MRI scan is probably the gold standard investigation to
confirm and localise the lesion.
Anatomy relating to the cauda equina
The anatomy of the distal spinal cord and the cauda equina is responsible
for the inconsistency in presenting signs and symptoms.
The conus medullaris is narrower than the more cephalad spinal cord and
overlies the body of L1. It represents the termination of the spinal cord in
the proximal lumbar spine. The conus medullaris continues to taper to
form the filum terminale. The bridle of lumbar and sacral nerves descends
below the conus medullaris to form the cauda equina or horses tail.
The lumbar and sacral nerve roots contain:
Sensory and motor function for the lower limbs
Sensation to the perineum and genitals
Voluntary and involuntary functions: micturition, defaecation and
sexual function.
Compression of the cauda equina may involve all of the above
functions, sensory only, motor only, or only those roots responsible for
bowel and bladder function.