Cauda Equina Syndrome

Question 1

Define Spinal cord compression

Answer 1

Damage to or compression of the cauda equina with nerve fibers of L3–S5 (below L2)

Question 2

Explain the risk factors for SCC

Answer 2

• Young male (16-30)
• Older age (degenerative changes)
• Trauma (as well as damage to nerves, trauma can cause haematoma which is compressive)
  
  • Falls in the elderly
  • Motor vehicle accidents (young)
• Osteoporosis (cause compression fractures - compression in vertical plane)
• High-risk recreational activities (vehucle racing, gymnast, diving, vehicle racing)
• High-risk occupation (construction worker, vehicle drivers, military)
• Tumour (primary or metastatic)
  
  • Sarcoma (primary)
  • Metastases from:
    
    • Multiple Myeloma (cause bone resorption)
    • Renal
    • Lung
    • Breast
    • Prostate

Question 3

State reasons for SCC (trauma, infections, vertebral & Intervertebral disc disease, Tumours)

Answer 3

Trauma (causes acute SCC)

• Iatrogenic (post-surgical)
• Motor vehicle accident
• Fall
• Gun shot
• Sports injury (e.g. diving)

Infections

• Epidural abscess (Associated w/ IVDU)
• Pott’s disease/TB (can infect psoas - enalrged psoas seen on MRI)

Vertebral & Disc pathology:

• Spinal stenosis
• Lumbar disc hernation
• Spondylolisthesis (leaning forward of vertebra)
• Causes of compression fractures (you notice a loss of height)
  
  • Osteoporosis
  • Corticosteroid use
  • Osteomyelitis
  • Multiple Myeloma

Tumours:

• Primary sarcoma
• Metastatic lung cancer
• Metastatic breast cancer
• Metastatic prostate cancer

Question 4

Recognise the presenting symptoms of spinal cord compression (incl. cauda equina)

Answer 4

• Saddle anaesthesia (can you feel when you wipe)
• Reduced bladder (detrussor) tone (urinary retention - trouble starting/stopping a stream)
• Loss of peristaltic & anal sphincter tone (constipation)
• Paraesthesia (mainly asymmetrical but can be symmetrical)
• LMNL signs:
  
  • Flaccid paraparesis (hypotonic)
  • Hyopreflexic, Arreflexic
• BILATERAL SCIATICA
• Severe Low back pain (radiating to leg/thigh)

Question 5

Recognise the signs of spinal cord compression (incl. cauda equina) on physical examination

Answer 5

LMNL Signs:

• Absent/reduced knee and ankle reflexes
• Paraparesis (MRC < 5) - bilateral or unilateral
• Hypotonia

DRE:

• Saddle anaesthesia
• Lower anal sphincter tone

Abdominal exam:

• Will feel bladder in urinary retention

Question 6

Identify appropriate investigations for spinal cord compression (incl. cauda equina) and interpret the results

Answer 6

GOLD STANDARD: T2-weighted MRI (shows fluid as white) - suspected CES needs URGENT MRI

• Epidural mass
• Disc herniaton

FBC: If infection is suspected

• Leukocytosis
• ESR & CRP