Unfortunately in life, we can be met with a number of conditions that make us feel severely ill or debilitated. It is during these times that we realise how much we underestimate our body’s capability to perform the most simple without pain or discomfort!
We already know how much our nerves and the nervous system impact these basic functions, enabling the body to perform in an orderly and synchronized manner.
A signal from the brain gets swiftly sent to the relevant nerves and nerve roots in that particular region which ensures the function is performed effortlessly.
However, due to some conditions or problems in the nervous system, these functions can get compromised,. This can cause severe pain, disability, and general nuisance to the affected people.
One such condition is called the ‘Cauda Equina Syndrome’ and it affects the nerve roots in the lumbar and sacral (the lower back) region. It is a surgical emergency that warrants immediate treatment to save the life of the patient.
What Is The Cauda Equina Syndrome?
The term ‘Cauda Equina’ is given to the nerve roots of the spinal cord that are continued in the lumbar and sacral region from way upwards.
When these nerve roots called ‘cauda equina’ combine in this region, they start receiving and sending signals to the lower limb and the pelvic organs.
Thus, the cauda equina is involved in relaying and sending messages to and from the brain to regions that involve the lower limb and the pelvis.
Now, this also includes various functions such as bladder and bowel function, urinary and rectal function, and so on.
However, due to some form of compression or injury to the cauda equina, there might be an acute onset of Cauda Equina Syndrome.
This acute cauda equina syndrome presentation poses grave damage and discomfort to the patient as it could be greatly debilitating for them, affecting movement and function. The patient may not be about move around or perform basic tasks as efficiently as they once could.
The cauda equina syndrome is considered to be a medical emergency. It compromises the basic functions that the lower portion of the spinal cord manages and leads to sexual and bowel dysfunction, bladder impairment, and so on.
Suffering from cauda equina syndrome means an inability to perform the normal bladder and bowel function. This means that a person has no control over their bladder function and similarly, they lose bowel control as well.
What Are The Symptoms Of The Cauda Equina Syndrome?
There are a variety of symptoms that present in a patient suffering from cauda equina syndrome, and each symptom has its distinct intensity and nature with which it presents itself in an affected individual.
There are several sensory and motor deficits that can develop in a person suffering from cauda equina syndrome. The most common symptoms are:
The bladder normally stores urine until a point where the person feels the urge to urinate to expel it out from their body.
However, in the case of cauda equina, the person’s bladder will fill up with urine as it normally does but the person will not feel any urge to pass urine. This might lead to urinary retention in the long term.
This compromises a person’s normal bladder function. An impaired bladder could also lead to social embarrassment in many people.
The person might also develop either a localized or generalized weakness in one or more parts of their lower limb. This weakness varies from person to person and depends on the nerve root involved in the person. The patient may report a ‘paralysis-like’ feeling, which can very rarely turn into permanent paralysis as well.
Some people have also complained about experiencing severe backache, which could be attributed to the presence of a herniated disc in the lumbar spine (lumbar disc herniation).
Saddle anesthesia is the name given to a particular feeling of numbness around the back region, the inner thighs, or the genitals of an affected person. It commonly occurs in patients suffering from cauda equina syndrome and leads to weakness in the lower extremities.
In some people suffering from cauda equina syndrome, there is often the development of bowel incontinence due to the dysfunction of the anal sphincter and anal muscles.
A person loses control over their urge to defecate and it is seen that they often pass stool unnoticed, with no sense that they have indeed done the same.
This bowel dysfunction also often makes people socially embarrassed on certain occasions.
It was one thing to suffer from the loss of the urge to urinate, but another when it comes to losing the power to hold back your urine. When a person loses their bladder control, they do not realise when the bladder has filled up entirely and when they need to relieve pressure from it to empty the bladder completely.
This impaired bladder might either develop retention or incontinence, but in both situations, you might not feel when your bladder loses control on its own. Some people might also develop a recurrent urinary tract infection due to this problem.
With the development of lower limb dysfunction, it is expected that a person would ultimately develop dysfunction in all the related parts of this region as well. Sexual dysfunction is also seen to develop in cauda equina patients, which often warrants immediate medical attention.
These CES symptoms vary from person to person but are usually seen to develop one after the other in people suffering from this condition.
The earlier these red flag symptoms are recognised and brought to an orthopaedic spine surgeon’s attention, the earlier and more easier it is to gain remission from this condition.
How To Diagnose Cauda Equina Syndrome?
The sensory and motor deficits are not enough to confirm a diagnosis of cauda equina syndrome.
Therefore, it is important that a proper physical exam, either by orthopaedic surgeons or neurological surgeons is done to confirm whether or not the person is suffering from this condition or not.
The spinal nerve roots and the sacral nerve roots need to be assessed to make a clinical diagnosis regarding cauda equina syndrome.
Early diagnosis leads to early treatment and early surgery in many cases, recovery to some extent.
Enlisted below are some of the most common ways that are used to diagnose cauda equina syndrome
Emergency Magnetic Resonance Imaging (MRI):
In more than half of the cases, the acute onset of severe back pain warrants emergency surgery. This example of a case requires emergency MRI for the condition to be diagnosed and treated accordingly.
Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of cauda equina syndrome as it helps visualize the spinal canal, spinal cord, spinal nerve roots, and other related structures.
CT scan is also helpful in diagnosing the condition as it can easily help the doctors visualise whether there has been any transient or permanent damage to the spinal column, any displacements, or the presence of a herniated disk in the lumbar spine.
How To Treat Cauda Equina Syndrome (CES)?
Once the diagnosis of cauda equina syndrome (CES) has been established, it becomes easier to plan the treatment and management plan accordingly.
The primary goal is pain management, and for that, it is essential that surgical intervention is done on an emergency level.
The urgent surgery that is done to treat CES is called spinal decompression surgery. This surgical decompression of the spine has the best surgical outcomes and the highest recovery rates in treating patients suffering from this syndrome.
However, it is best if the people undergo surgery within 24 hours of the onset of the syndrome. It helps restore the sensory function of the lower limbs that might have otherwise been compromised due to the onset of cauda equina syndrome.
Once the surgical treatment has been completed, it is often recommended by orthopedic spine surgeon and neurological surgeons to seek physical therapy from a physical therapist or an occupational therapist.
The reason for this is to restore the power again in the lower limbs, to make sure that the bladder and bowel function are taking place normally, and that there are no other focal deficits left untreated in the person suffering from this condition.
In summary, cauda equina syndrome is a medical emergency that compromises the lower limbs, pelvic organs, and the lower portion of the spinal canal and the spinal cord all at the same time.
Although it may affect people differently, there is always a need to rule our permanent paralysis in patients suffering from cauda equina syndrome secondary to spinal stenosis, spinal infections, and herniated disk of the lumbar spine as all of them are highly compromising conditions involving the spinal cord.
If cauda equina syndrome diagnosis takes place early and immediately, it is possible for the condition to be taken care of effectively. It is also possible for the bowel control, bowel function, bladder function, and sexual function of the person to return back to normal.
- Gardner, A., Gardner, E., & Morley, T. (2011). Cauda equina syndrome: a review of the current clinical and medico-legal position. European Spine Journal, 20(5), 690-697.
- Kumar, V., Baburaj, V., Rajnish, R. K., & Dhatt, S. S. (2021). Outcomes of cauda equina syndrome due to lumbar disc herniation after surgical management and the factors affecting it: A systematic review and meta-analysis of 22 studies with 852 cases. European Spine Journal, 1-11.
- Rider LS, Marra EM. Cauda Equina And Conus Medullaris Syndromes. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537200/
- Lavy, C., Marks, P., Dangas, K., & Todd, N. (2022). Cauda equina syndrome-a practical guide to definition and classification. International orthopaedics, 46(2), 165–169. https://doi.org/10.1007/s00264-021-05273-1
- Berg EJ, Ashurst JV. Anatomy, Back, Cauda Equina. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513251/
- Spector, L. R., Madigan, L., Rhyne, A., Darden, B., 2nd, & Kim, D. (2008). Cauda equina syndrome. The Journal of the American Academy of Orthopaedic Surgeons, 16(8), 471–479. https://doi.org/10.5435/00124635-200808000-00006
- Fairbank, J., & Mallen, C. (2014). Cauda equina syndrome: implications for primary care. The British journal of general practice : the journal of the Royal College of General Practitioners, 64(619), 67–68. https://doi.org/10.3399/bjgp14X676988
- Bulloch, L., Thompson, K., & Spector, L. (2022). Cauda Equina Syndrome. The Orthopedic clinics of North America, 53(2), 247–254. https://doi.org/10.1016/j.ocl.2021.11.010
- Dias, A., Araújo, F. F., Cristante, A. F., Marcon, R. M., Barros Filho, T., & Letaif, O. B. (2017). Epidemiology of cauda equina syndrome. What changed until 2015. Revista brasileira de ortopedia, 53(1), 107–112. https://doi.org/10.1016/j.rboe.2017.11.006
- Kuris, E. O., McDonald, C. L., Palumbo, M. A., & Daniels, A. H. (2021). Evaluation and Management of Cauda Equina Syndrome. The American journal of medicine, 134(12), 1483–1489. https://doi.org/10.1016/j.amjmed.2021.07.021