Cauda equina syndrome
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Cauda equina syndrome is considered an incomplete cord syndrome, even though it occurs below the conus, and refers to a collection of symptoms and signs that result from severe compression of the descending lumbar and sacral nerve roots. It is most commonly caused by an acutely extruded lumbar disc and is considered a diagnostic and surgical emergency.
Epidemiology
Cauda equina syndrome is rare with prevalence estimated at approximately 1 in 65,000 (range 33,000 to 100,000) 1. It has, however, been estimated to occur in ~1% (range 0.1-2%) of herniated lumbar discs 2,3.
Clinical presentation
Cauda equina syndrome can present either acutely or chronically and requires two sets of symptoms/signs 1-3:
- perianal and "saddle" paraesthesia
- bowel, bladder and/or sexual dysfunction
There is a host of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence 1-3,6,10:
- low back pain
- radiculopathy/sciatica (unilateral or bilateral)
-
paraesthesia of lower
limb paraesthesialimbs and/orperianal/saddle region (variable) -
weakness of lower limbs in a lower motor
weaknessneuron pattern (variable) - reduction/absence of lower limb reflexes
decreased rectal tone
Classification
Additionally, caudaCauda (CES) can be classified into two entitiesas incomplete or complete based on the presence of bowel and bladder symptoms 1,2,10:
-
incomplete
- may have loss of urgency or decreased urinary sensation
may be presentwithout, however, incontinence or retention -
cauda equina syndrome with retention(CES-R): perianal/saddle paraesthesia with urinary retention or incontinence
- may have loss of urgency or decreased urinary sensation
CES-R accounts for ~60% (range 50-70%) and CES-I accounts for ~40% (range 30-50%) of presentations 6.
- urinary and/or bowel retention or incontinence
- accounts for ~60% (range 50-70%) 6
Pathology
Aetiology
There is a long list of conditions that can cause cauda equina syndrome (some of these are very rare) 1-3:
- degenerative
- lumbar disc herniation (most common, especially at L4/5 and L5/S1)
- lumbar spinal canal stenosis
- spondylolisthesis
-
haemorrhage into a Tarlov
cystscyst11 - facet joint cysts
- inflammatory
- both acute and chronic form may be seen in long-standing ankylosing spondylitis (2nd-5th decades; average 35 years) 7-9
- traumatic
- spinal fracture or dislocation
- epidural haematoma (may also be spontaneous, post-operative, post-procedural or post-manipulation)
- infective
- arachnoiditis
- epidural abscess
- tuberculosis (Pott disease)
-
malignanttumours- primary
- tumours in vertebral bodies
-
leptomeningeal carcinomatosis
,schwannoma,neurofibroma)
- vascular
- numerous other rare space-occupying lesions (e.g. sarcoid)
Risk factors
- congenital or acquired spinal canal stenosis 3
- recent lumbar spinal surgery 2
Radiographic features
Plain radiograph
- limited value; may demonstrate gross degenerative or traumatic bony disease 2
CT myelogram
- useful in patients in whom MRI is contraindicated or not available
- partial or complete blockage of contrast
- may demonstrate an "hourglass" shape to the contrast-filled thecal sac in complete blockage 2
MRI
- imaging modality of choice 2,3
- sagittal and axial T1 and T2 sequences are usually sufficient 4
- post-contrast and STIR sequences may be required if infective causes are suspected 3,4
Treatment and prognosis
Cauda equina syndrome is considered a diagnostic and surgical emergency, although there is some debate about the timing of surgery (and depends on acute vs. chronic) but surgical decompression within 24 hours seems to have the best outcomes 1,3,6. Patients with CES-Rcomplete cauda equina syndrome have a poorer outcome 3. Approximately 20% of patients will have a poor outcome in terms of urological and/or sexual function as well as lower limb paraesthesia and weakness 6.
Differential diagnosis
Clinically the main differential is that of conus medullaris syndrome.
Practical points
It is worth remembering that cauda equina syndrome is a clinical diagnosis and thus the term should not be used in a radiology report unless there is known the presence of appropriate symptoms and sings. In the absence of corroborating history, a better phrasing is "compression of the cauda equina" which should then be correlated clinically. This is an important distinction as many elderly patients may have marked canal stenosis with compression of the cauda equina but not present acutely with cauda equina syndrome.
See also
-<p><strong>Cauda equina syndrome </strong>refers to a collection of symptoms and signs that result from severe compression of the descending lumbar and sacral nerve roots. It is considered a diagnostic and surgical emergency. </p><h4>Epidemiology</h4><p>Cauda equina syndrome is rare with prevalence estimated at approximately 1 in 65,000 (range 33,000 to 100,000) <sup>1</sup>. It has, however, been estimated to occur in ~1% (range 0.1-2%) of herniated lumbar discs <sup>2,3</sup>. </p><h4>Clinical presentation</h4><p>Cauda equina syndrome can present either acutely or chronically and requires two sets of symptoms/signs <sup>1-3</sup>:</p><ol>- +<p><strong>Cauda equina syndrome</strong> is considered an <a href="/articles/incomplete-cord-syndromes">incomplete cord syndrome</a>, even though it occurs below the conus, and refers to a collection of symptoms and signs that result from severe compression of the descending lumbar and sacral nerve roots. It is most commonly caused by an acutely <a href="/articles/disc-extrusion">extruded lumbar disc</a> and is considered a diagnostic and surgical emergency. </p><h4>Epidemiology</h4><p>Cauda equina syndrome is rare with prevalence estimated at approximately 1 in 65,000 (range 33,000 to 100,000) <sup>1</sup>. It has, however, been estimated to occur in ~1% (range 0.1-2%) of herniated lumbar discs <sup>2,3</sup>. </p><h4>Clinical presentation</h4><p>Cauda equina syndrome can present either acutely or chronically and requires two sets of symptoms/signs <sup>1-3</sup>:</p><ol>
-</ol><p>There is a host of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence <sup>1-3,6</sup>:</p><ul>- +</ol><p>There is a host of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence <sup>1-3,6,10</sup>:</p><ul>
-<li>radiculopathy/sciatica</li>-<li>lower limb paraesthesia and/or motor weakness</li>- +<li>radiculopathy/sciatica (unilateral or bilateral)</li>
- +<li>paraesthesia of lower limbs and perianal/saddle region (variable)</li>
- +<li>weakness of lower limbs in a lower motor neuron pattern (variable)</li>
-<li>decreased rectal tone</li>-</ul><h4>Classification</h4><p>Cauda equina syndrome (CES) can be classified into two entities <sup>1,2</sup>:</p><ol>- +</ul><p>Additionally, cauda equina syndrome can be classified as incomplete or complete based on the presence of bowel and bladder symptoms <sup>1,2,10</sup>:</p><ul>
-<strong>incomplete </strong>(<strong>CES-I</strong>): perianal/saddle paraesthesia but urinary retention/incontinence has not fully developed although the loss of urgency or decreased sensation may be present</li>- +<strong>incomplete</strong><ul>
- +<li>may have loss of urgency or decreased urinary sensation without, however, incontinence or retention</li>
- +<li>accounts for ~40% (range 30-50%) of presentations <sup>6</sup>
- +</li>
- +</ul>
- +</li>
-<strong>c</strong><strong>auda equina syndrome with retention</strong> (<strong>CES-R</strong>): perianal/saddle paraesthesia with urinary retention or incontinence</li>-</ol><p>CES-R accounts for ~60% (range 50-70%) and CES-I accounts for ~40% (range 30-50%) of presentations <sup>6</sup>. </p><h4>Pathology</h4><h5>Aetiology</h5><p>There is a long list of conditions that can cause cauda equina syndrome (some of these are very rare) <sup>1-3</sup>:</p><ul>- +<strong>complete</strong><ul>
- +<li>urinary and/or bowel retention or incontinence</li>
- +<li>accounts for ~60% (range 50-70%) <sup>6</sup>
- +</li>
- +</ul>
- +</li>
- +</ul><h4>Pathology</h4><h5>Aetiology</h5><p>There is a long list of conditions that can cause cauda equina syndrome (some of these are very rare) <sup>1-3</sup>:</p><ul>
-<li><a href="/articles/tarlov-cyst">Tarlov cysts</a></li>- +<li>haemorrhage into a <a href="/articles/tarlov-cyst">Tarlov cyst</a> <sup>11</sup>
- +</li>
- +<li><a href="/articles/arachnoiditis">arachnoiditis</a></li>
-<li>malignant<ul>- +<li>tumours<ul>
- +<li>primary<ul>
- +<li><a href="/articles/spinal-myxopapillary-ependymoma">myxopapillary ependymoma</a></li>
- +<li><a href="/articles/spinal-schwannoma">schwannoma</a></li>
- +<li><a href="/articles/spinal-meningioma">spinal meningioma</a></li>
- +<li>other <a href="/articles/neoplasms-of-the-cauda-equina-differential">tumours of the cauda equina</a>
- +</li>
- +</ul>
- +</li>
- +<li>tumours in vertebral bodies<ul>
-<li><a href="/articles/spinal-metastases">metastases</a></li>-<li>primary CNS malignancies (e.g. <a href="/articles/ependymoma">ependymoma</a>, <a href="/articles/spinal-schwannoma">schwannoma</a>, <a href="/articles/neurofibromatosis-type-1">neurofibroma</a>)</li>- +<li><a href="/articles/vertebral-metastases">vertebral metastases</a></li>
- +</ul>
- +</li>
- +<li><a href="/articles/leptomeningeal-metastases">leptomeningeal carcinomatosis</a></li>
-</ul><h4>Treatment and prognosis</h4><p>Cauda equina syndrome is considered a diagnostic and surgical emergency, although there is some debate about the timing of surgery (and depends on acute vs. chronic) but surgical decompression within 24 hours seems to have the best outcomes <sup>1,3,6</sup>. Patients with CES-R have a poorer outcome <sup>3</sup>. Approximately 20% of patients will have a poor outcome in terms of urological and/or sexual function as well as lower limb paraesthesia and weakness <sup>6</sup>. </p><h4>See also</h4><ul><li><a href="/articles/investigating-cauda-equina-syndrome-summary">investigating cauda equina syndrome (summary)</a></li></ul>- +</ul><h4>Treatment and prognosis</h4><p>Cauda equina syndrome is considered a diagnostic and surgical emergency, although there is some debate about the timing of surgery (and depends on acute vs. chronic) but surgical decompression within 24 hours seems to have the best outcomes <sup>1,3,6</sup>. Patients with complete cauda equina syndrome have a poorer outcome <sup>3</sup>. Approximately 20% of patients will have a poor outcome in terms of urological and/or sexual function as well as lower limb paraesthesia and weakness <sup>6</sup>. </p><h4>Differential diagnosis</h4><p>Clinically the main differential is that of <a href="/articles/conus-medullaris-syndrome">conus medullaris syndrome</a>. </p><h4>Practical points</h4><p>It is worth remembering that cauda equina syndrome is a clinical diagnosis and thus the term should not be used in a radiology report unless there is known the presence of appropriate symptoms and sings. In the absence of corroborating history, a better phrasing is "compression of the cauda equina" which should then be correlated clinically. This is an important distinction as many elderly patients may have marked canal stenosis with compression of the cauda equina but not present acutely with cauda equina syndrome. </p><h4>See also</h4><ul><li><a href="/articles/investigating-cauda-equina-syndrome-summary">investigating cauda equina syndrome (summary)</a></li></ul>
References changed:
- 10. Kunam V, Velayudhan V, Chaudhry Z, Bobinski M, Smoker W, Reede D. Incomplete Cord Syndromes: Clinical and Imaging Review. Radiographics. 2018;38(4):1201-22. <a href="https://doi.org/10.1148/rg.2018170178">doi:10.1148/rg.2018170178</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29995620">Pubmed</a>
- 11. Yates J, Jones C, Stokes O, Hutton M. Incomplete Cauda Equina Syndrome Secondary to Haemorrhage Within a Tarlov Cyst. BMJ Case Rep. 2017;2017:bcr-2017-219890. <a href="https://doi.org/10.1136/bcr-2017-219890">doi:10.1136/bcr-2017-219890</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28784878">Pubmed</a>
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