Epidural compression syndromes

Background

• The cauda equina (Latin for "horse's tail") begins at the 2nd Lumbar space extending down to the beginning of the sacral nerves. It is distal to the tapered end of the spinal cord, or conus medularis.

Epidural compression syndromes

Sensory dermatome by spinal level.

• Syndromes
  • Spinal cord injury
  • Spinal cord compression (non-traumatic)
  • Cauda equina syndrome
  • Conus medullaris syndrome
• Causes
  • Spinal cord injury
  • Epidural abscess (spinal)
  • Epidural hematoma (spinal)
  • Syringomyelia

Etiology

• Epidural abscess
• Malignancy
• Massive mid-line disk herniation
• Spinal canal hemorrhage

Clinical Features

• Back pain with neuro deficits
  • Weakness in lower extremities, paresthesias/sensory deficits, gait difficultly
  • Deficits usually affect both legs but are often asymmetric
  • Bladder and rectal sphincter paralysis usually reflect involvement of S3-S5 nerve roots

• Conus medullaris syndrome
  • Lesions at vertebral level L2
  • early and prominent sphincter dysfunction with flaccid paralysis of the bladder and rectum, impotence, and saddle (S3-S5) anesthesia

• Cauda equina syndrome
  • Low Back Pain
  • Urinary retention with or without overflow incontinence (Sn 90%, Sp 95%)
  • Rectal incontinence
  • Bilateral sciatica
  • Saddle anesthesia (75% pts)
  • Decreased anal sphincter tone (60-80% pts)
  • Difficulty ambulating and/or wew foot-drop
• Symptoms worsened by coughing (increases intraspinal pressure)

Differential Diagnosis

Lower Back Pain

• Spine related
  • Acute ligamentous injury
  • Acute muscle strain
  • Disk herniation (Sciatica)
  • Degenerative joint disease
  • Spondylolithesis
  • Epidural compression syndromes
    • Spinal cord compression (non-traumatic)
    • Cauda equina syndrome
    • Conus medullaris syndrome
    • Epidural abscess (spinal)
    • Epidural hematoma (spinal)
  • Thoracic and lumbar fractures and dislocations
  • Cancer metastasis
  • Spinal stenosis
  • Transverse myelitis
  • Vertebral osteomyelitis
  • Ankylosing spondylitis
  • Spondylolisthesis
  • Discitis
  • Spinal Infarct
• Renal disease
  • Kidney stone
  • Pyelonephritis
  • Nephrolithiasis
• Intra-abdominal
  • Abdominal aortic aneurysm
  • Ulcer perforation
  • Retrocecal appendicitis
  • Large bowel obstruction
  • Pancreatitis
• Pelvic disease
  • PID
• Other
  • Retroperitoneal hemorrhage/mass
  • Meningitis

Spinal Cord Syndromes

• Complete spinal cord transection syndrome
• Anterior cord syndrome
• Central cord syndrome
• Brown-Séquard syndrome
• Epidural compression syndromes
  • Spinal cord compression (non-traumatic)
  • Cauda equina syndrome
  • Conus medullaris syndrome
  • Epidural abscess (spinal)
  • Epidural hematoma (spinal)

• Emergent MRI
  • If considering compression due to neoplasm obtain scan of entire spine
• Consider Bladder scan/ultrasound for bladder volume (post-void residual)

Management

1. Dexamethasone: at least 16 mg IV as soon as possible after assessment
2. Consider foley for bladder decompression
3. Radiation therapy (if due to neoplasm)
4. Consult spine service (neurosurgery or ortho; institution dependent)

See Also

• Epidural Abscess (Spinal)