Cauda Equina Syndrome

By Allan O. Fiesta, PT, DPT, OCS

What is Cauda Equina Syndrome?

Cauda equina syndrome (CES) is an uncommon, serious neurologic condition. It’s clinical presentation ranges from low back pain to loss of visceral function. It is a clinical diagnosis confirmed radiologically with evidence of compression of the cauda equina, or the collection of nerves at the end most part of the spinal cord. This collection of nerves resembles a horse’s tail, thus the name cauda equina. It is necessary to identify CES and determine what causes it as soon as possible in order to avoid lifetime and permanent neurologic impairments and to mitigate medico-legal issues.

Illustration of vertebral disc showingf the most common cause of Cauda Equina Syndrome CES. JOI Rehab

Most common cause of CES.

What is the prevalence and causes of Cauda Equina Syndrome?

CES has an estimated prevalence of 1 in 30,000 to 100,000 people per year and an annual incidence of 1.5 to 3.4 per million people in the United States. Other potential causes of CES are as follows:

Spinal infections or inflammation
Lumbar spinal stenosis
Spinal neoplasms or tumors
Traumatic injuries to the lower back (auto accidents, falls or gunshots)
Spinal hemorrhages (epidural, subdural or subarachnoid)
Spinal arteriovenous malformations
Birth abnormalities or defects
Complications from lumbar spine surgeries
Spinal anesthesia

A herniated intervertebral disc is the most common cause of CES in adults under the age of 50. A herniated disc occurs when the outer ring becomes weak or torn and allows the inner portion to slip out. A disc can slip out of place while you are twisting or turning to lift an object. Lifting a heavy object can place great strain on the lower back often resulting in a herniated disc.

Cauda equina syndrome is a medical emergency and is accompanied by some or all of the “red flag” symptoms. These symptoms include back pain that can radiate towards the lower extremities, loss of sensation in the genital area (saddle anesthesia), and inability to control your bladder. Since a patient is not able to tell when he needs to urinate due to the loss of this sensation or urge to urinate, the bladder becomes full and distended and will result in urinary incontinence. The nerves to the muscles of your anus could also be affected thereby losing control to hold your stool resulting in fecal incontinence. Symptoms can be severe and is dependent on the degree of compression as well as the exact nerve roots that are under compression. Other “red flag” symptoms include:

Inability to urinate. The patient will not have the urge to urinate or will not have the normal sensation to urinate
Weakness or paralysis of lower extremity muscles which can usually involve multiple nerve roots affecting multiple muscle groups of the leg leading to difficulty walking
Decreased or loss of lower extremity spinal reflexes
Sexual dysfunction

How do you test for Cauda Equina Syndrome?

A thorough medical history which include identifying the symptoms associated with CES and the following diagnostic procedures can be used to help with the diagnosis:

X-ray
Magnetic resonance imaging (MRI)
Myelogram
Computed tomography scans (CT)

X Ray illustration showing disc herniation for Cauda Equina Syndrome CES. JOI Rehab

Illustration of the human body showing disc herniation.

Treatment for Cauda Equina Syndrome

Cauda equina syndrome is often a potential surgical emergency requiring prompt surgical decompression to prevent long term or permanent neurological damage. The best chance for recovery depends on how soon you relieve pressure from the spinal nerve roots. The maximum potential for improvement of sensory or motor deficits results from surgery that is performed within 24-48 hours from the time of diagnosis. Surgical decompression is the best treatment option for cauda equina syndrome. This can be done by:

Lumbar laminectomy – involves removal of all or part of the lamina (posterior part of the vertebra) to provide relief of pressure for the compressed spinal nerve roots
Lumbar microdiscectomy – involves removal of all or part of a bulging or damaged (herniated) disc to provide relief of pressure for the compressed spinal nerve roots

After going through surgical treatment, you will also need physical therapy to improve your core, back and lower extremity muscle strength to restore your function.

While there is no immediate cure available, people who have been diagnosed with CES have been able to regain normal function through long term management utilizing a combination of surgical and conservative care.

Written By: Allan O. Fiesta, PT, DPT, OCS

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