Cauda Equina Syndrome

Posted bythespinebookadminPosted inTopics, Trauma

Background 

  • Severe compression of nerve roots in thecal sac of L spine 
  • Usually due to acute lumbar disc herniation 
  • M > F 
  • Age 30s 
  • L45 
  • Conus Medullaris Syndrome 
    • L12 
    • More sudden and bilateral 
    • Mixed UMN LMN 
      • Hyperreflexic, fasciculations 
    • Less severe weakness 
    • More back pain 
    • More symmetric 
    • Earlier urinary/ bowel incontinence 
    • Impotence/ sexual dysfunction more common 

Causes 

  • Disc herniation 
  • Spinal stenosis 
  • Tumour 
  • Trauma 
  • Epidural hematoma 
  • Abscess 
  • Iatrogenic 

Stages 

  • Early 
    • Suspected 
    • Bil radic +/- weakness 
  • Incomplete 
    • Perianal sens changes, bladder disruption 
  • Retention 
    • Completely parralyzed, insensate bladder 

Bladder Changes 

  • Internal Sphincter – para relaxes, sym contracts 
  • External Sphincter – baseline contracted, voluntary relax 
  • Detrusor – para contracst, sym relaxes 
  • Bladder wall feedback (via para) 
  • In CES 
    • Symp – comes from symp chain 
    • Para – blocked because it is with PNS 
    • Voluntary – blocked 
  • So OVERFLOW incontinence 

Investigations 

  • PVR 
    • Adults <50 normal, >200 abnormal 
    • Children <20 normal 
    • >300cc is 90% sensitive for CES in patient with clinical exam consistent with CES 

Management 

  • Decomperssion and Discectomy 
    • “wide pedlcle to pedicle decompression taking 1/3 of the medical facet, followed by lateral annulottomy and discecetomy” 
  • Timing <48H yes, <24H no difference 
    • CESE or CESI – earlier surgery ycan save bladder function 
    • CESR – timing no longer matters 

Outcomes 

  • Recovery up to 4 years 
  • Backpain – persists 
  • Incontinence – 10% decrease 
  • Perianal sensation – minimal recovery 
  • Bladder (least likely to improve Orrthobullets) 
  • Sexual dysfunction 30% 

1959 – Shepherd et al; “Early surgery is mandatory” 

2000 – Ahn et al via meta-analysis: decompression <48 is better than >48, and <24 makes no difference 

2004 – Kohles et al – <24h is better 

2007 – McCarthy et al – <48h makes difference, <24 makes no difference 

2012 Daniels et al – if surgery time >48h, 83% lawsuits favour plaintiff 

2015 Fehlings et al – recommends <24h, but notes weak evidence in literature, cites STASCIS rationale