Cauda equina syndrome: Difference between revisions
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==Background== | ==Background== | ||
* | *Compression of the cauda equina nerve roots (below the conus medullaris, typically L1-L2) | ||
*A '''surgical emergency''' — delayed treatment (>48 hours) associated with permanent neurologic deficit<ref name="ahn">Ahn UM, et al. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. ''Spine''. 2000;25(12):1515-1522. PMID 10851100.</ref> | |||
*Most common cause: large central [[Lumbar disc herniation|lumbar disc herniation]] (70%) | |||
*Other causes: spinal [[Epidural abscess|epidural abscess]], tumor, [[Epidural hematoma|spinal epidural hematoma]], spinal stenosis | |||
==Clinical Features== | ==Clinical Features== | ||
*'''Red flags''' (must screen for in any patient with [[Low back pain|back pain]]): | |||
**Urinary retention or incontinence (most consistent finding; post-void residual >200 mL) | |||
**Fecal incontinence or decreased rectal tone | |||
**Saddle anesthesia (perineal/perianal numbness) | |||
**Bilateral lower extremity weakness or radiculopathy | |||
**Progressive neurologic deficit | |||
**Sexual dysfunction | |||
*[[Low back pain]] is present in most cases but may be minimal | |||
*Bilateral [[Sciatica|sciatica]] is more concerning than unilateral | |||
*Decreased ankle reflexes bilaterally | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Conus medullaris syndrome]] (upper motor neuron signs, more symmetric) | |||
*[[Lumbar disc herniation]] without cauda equina involvement | |||
*[[Spinal cord compression (non-traumatic)]] | |||
*[[Epidural abscess]] | |||
*[[Transverse myelitis]] | |||
*[[Guillain-Barré syndrome]] | |||
==Evaluation== | |||
*MRI lumbar spine with and without contrast — imaging modality of choice<ref name="frost">Fairbank J, Mallen C. Cauda equina syndrome: implications for primary care. ''Br J Gen Pract''. 2014;64(619):67-68. PMID 24567577.</ref> | |||
**Emergent MRI — do not delay for other workup | |||
**CT myelography if MRI unavailable or contraindicated | |||
*Post-void residual (bladder scan) — >200 mL supports diagnosis | |||
*Rectal exam — assess sphincter tone (decreased in CES) | |||
*Labs: CBC, ESR/CRP (if infection suspected), coagulation studies | |||
== | ==Management== | ||
*Emergent neurosurgical or spine surgery consultation | |||
*Surgical decompression within 24-48 hours of symptom onset improves outcomes | |||
**Earlier decompression (<24h) associated with better recovery of bladder function | |||
*If [[Epidural abscess|epidural abscess]] suspected: blood cultures, IV antibiotics before imaging | |||
*Pain management: [[NSAIDs]], [[acetaminophen]], [[opioids]] as needed | |||
*Foley catheter if urinary retention present | |||
*[[Dexamethasone]] 10 mg IV if tumor-related compression suspected | |||
== | ==Disposition== | ||
*Admit for emergent surgical evaluation | |||
*Do NOT discharge patients with suspected CES — missed diagnosis carries significant medicolegal risk<ref name="todd">Todd NV. Cauda equina syndrome: the timing of surgery probably does matter. ''Br J Neurosurg''. 2005;19(4):301-306. PMID 16455534.</ref> | |||
==See Also== | ==See Also== | ||
*[[Epidural | *[[Low back pain]] | ||
*[[Spinal cord compression (non-traumatic)]] | |||
*[[Epidural abscess]] | |||
*[[Lumbar disc herniation]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Neurology]] | ||
[[Category: | [[Category:Orthopedics]] | ||
Latest revision as of 09:23, 22 March 2026
Background
- Compression of the cauda equina nerve roots (below the conus medullaris, typically L1-L2)
- A surgical emergency — delayed treatment (>48 hours) associated with permanent neurologic deficit[1]
- Most common cause: large central lumbar disc herniation (70%)
- Other causes: spinal epidural abscess, tumor, spinal epidural hematoma, spinal stenosis
Clinical Features
- Red flags (must screen for in any patient with back pain):
- Urinary retention or incontinence (most consistent finding; post-void residual >200 mL)
- Fecal incontinence or decreased rectal tone
- Saddle anesthesia (perineal/perianal numbness)
- Bilateral lower extremity weakness or radiculopathy
- Progressive neurologic deficit
- Sexual dysfunction
- Low back pain is present in most cases but may be minimal
- Bilateral sciatica is more concerning than unilateral
- Decreased ankle reflexes bilaterally
Differential Diagnosis
- Conus medullaris syndrome (upper motor neuron signs, more symmetric)
- Lumbar disc herniation without cauda equina involvement
- Spinal cord compression (non-traumatic)
- Epidural abscess
- Transverse myelitis
- Guillain-Barré syndrome
Evaluation
- MRI lumbar spine with and without contrast — imaging modality of choice[2]
- Emergent MRI — do not delay for other workup
- CT myelography if MRI unavailable or contraindicated
- Post-void residual (bladder scan) — >200 mL supports diagnosis
- Rectal exam — assess sphincter tone (decreased in CES)
- Labs: CBC, ESR/CRP (if infection suspected), coagulation studies
Management
- Emergent neurosurgical or spine surgery consultation
- Surgical decompression within 24-48 hours of symptom onset improves outcomes
- Earlier decompression (<24h) associated with better recovery of bladder function
- If epidural abscess suspected: blood cultures, IV antibiotics before imaging
- Pain management: NSAIDs, acetaminophen, opioids as needed
- Foley catheter if urinary retention present
- Dexamethasone 10 mg IV if tumor-related compression suspected
Disposition
- Admit for emergent surgical evaluation
- Do NOT discharge patients with suspected CES — missed diagnosis carries significant medicolegal risk[3]
See Also
References
- ↑ Ahn UM, et al. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine. 2000;25(12):1515-1522. PMID 10851100.
- ↑ Fairbank J, Mallen C. Cauda equina syndrome: implications for primary care. Br J Gen Pract. 2014;64(619):67-68. PMID 24567577.
- ↑ Todd NV. Cauda equina syndrome: the timing of surgery probably does matter. Br J Neurosurg. 2005;19(4):301-306. PMID 16455534.