Cauda equina syndrome (CES) is caused by compression of the lumbosacral nerve roots of the cauda equina.
CES is a neurosurgical emergency, and delays in diagnosis and treatment may lead to permanent disability.
Features of CES include: low back pain; bilateral or unilateral sciatica; progressive neurologic deficits; difficulty starting or stopping urination or impaired sensation of urinary flow; urgency; urinary retention with overflow urinary incontinence; loss of sensation of rectal fullness; fecal incontinence; laxity of the anal sphincter; saddle anesthesia or paraesthesia; and sexual dysfunction.
Not all patients show all of the above features, but bladder dysfunction is an essential component of CES.
Magnetic resonance imaging is carried out as soon as possible in patients with suspected CES.
Patients with CES require urgent surgical decompression of the spinal canal.
Cauda equina syndrome (CES) is caused by compression of the lumbosacral nerve roots that extend below the spinal cord. The most common cause is due to disk prolapse at the L4/5 or L5/S1 level and stenosis of the spinal canal. Less commonly, compression may be due to pathology in a higher disk, or to a tumor, infection, or trauma. Typical symptoms and signs of CES include bladder dysfunction, low back pain, bilateral or unilateral sciatica, lower limb weakness or numbness, bowel dysfunction, and sexual dysfunction. Although not all patients show all symptoms and signs, bladder dysfunction is always apparent at some stage in the progression of CES.
History and exam
Key diagnostic factors
- bladder dysfunction
- lower limb weakness
- saddle paresthesia/anesthesia
- bowel dysfunction
Other diagnostic factors
- low back pain
- sexual dysfunction
- lumbar disk herniation
- spinal trauma
- spinal surgery
- spinal epidural abscess
- anticoagulation therapy
- spinal stenosis
- spinal tumor
- ages under 50 years
1st investigations to order
- MRI lumbar spine without IV contrast
- CT lumbar spine without IV contrast
Investigations to consider
- CT myelography of the lumbar spine
- urodynamic testing
- digital rectal exam
- Spinal epidural abscess
- Osteoporotic spinal compression fracture
- Transverse myelitis
- Best practice guidelines: spine injury
- ACR appropriateness criteria: low back pain
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