Cauda Equina Syndrome: Causes, Symptoms and Treatment

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The 'cauda equine' is a bundle of nerve roots at the lower end of a person's spinal cord. The cauda equine, 'horse's tail,' is so-called because of how it looks. A person's spinal cord is shorter than the spinal canal in which it runs, ending at around the same level as the first or second lumbar vertebra; it varies among people.

What is Cauda Equina Syndrome (CES)?

Cauda equina syndrome is a serious neurologic condition in which damage to the cauda equina causes acute loss of function of the lumbar plexus (nerve roots) of the spinal canal below the termination (conus medullaris) of the spinal cord. CES is a lower motor neuron lesion. Early diagnosis can allow for preventive treatment. Signs that allow early diagnosis include bowel and bladder function changes and loss of feeling in the groin.

The cauda equina contains the nerve roots from L1 - S1-5. Nerve roots L4-S4 join in the sacral plexus, giving rise to the largest nerve in a person's body - the sciatic nerve. The sacral plexus is also involved in sensory and motor nerves to and from the genital and anal regions of a person's body. The nerve roots emerge in pairs from the relevant vertebral foramen. While leg pain; for example, is common and often goes away without surgery - cauda equina syndrome is a surgical emergency.

The nerve roots are an extension of a person's brain, sending and receiving messages to and from a person's pelvic organs and lower limbs. Cauda equina syndrome occurs when the nerve roots in a person's lumbar spine are compressed, cutting movement and sensation. Nerve roots that control the function of a person's bladder and bowel are particularly vulnerable to damage.

If people with cauda equina syndrome do not pursue immediate treatment to relieve the pressure, it may result in:

• Permanent paralysis
• Impaired bowel function
• Loss of sexual sensation
• Impaired bladder function

Even if a person with cauda equina receives immediate treatment, they might not recover complete function. For people who experience this syndrome, family members and friends usually present with a blank look when the person affected mentions their condition. Even some doctors draw a blank look.

Cauda Equina syndrome is not a 'back issue,' in the way people usually think of back trouble, although it may very well have occurred due to spinal issues such as a slipped disk. Medical and public awareness of cauda Equina syndrome needs to improve to circumvent instances that might be avoided through prompt treatment, as well as how to help those who experience the chronic form of the syndrome by recognizing their condition and helping them with measures that are appropriate to cope with the many issues the syndrome causes. Cauda Equina Syndrome is:

• A neurological condition that may be regarded as a form of spinal cord injury
• Seen more commonly as a medical emergency and might also be a chronic condition
• A descriptive diagnosis which pertains to a pattern of signs and symptoms yet may have various causes

Causes of Cauda Equina Syndrome

Cauda equina syndrome might be caused by a tumor, herniated disk, fracture, infection, or a narrowing of a person's spinal canal. Damage to the nerve roots in the cauda equina may also be caused by the following:

• Inflammation: Such as in conditions including arachnoiditis.
• Toxic Damage: Toxic damage is rare due to spinal anesthetics.
• Stretching: Stretching may occur by spondylolisthesis, or slippage of one vertebra on another.
• Demyelination: Demyelination involves loss of the myelin sheath, which is essential in nerve signal transmission, also experienced by those with Multiple Sclerosis, for example.
• Compression: Most commonly by prolapsed disk, although also by any other lesion - to include spinal injury or chronic compression such as that experienced by people with arachnoiditis.

Cauda Equina syndrome due to compression or distortion may respond to quick removal of the cause. Yet, recovery depends on the duration of the injury and the degree of damage sustained. However, cauda Equina syndrome might be both chronic and progressive in inflammatory or demyelinating conditions.

Symptoms of Cauda Equina Syndrome

Even though early treatment is required to prevent permanent issues, cauda Equina syndrome may be hard to diagnose. Symptoms vary in intensity and might evolve over some time. A specific pattern exists:

• Weakness in the Legs: The weakness is often asymmetric.
• Loss of Sensation: Those affected may experience numbness or tingling in their perineum.
• Severe Pain in Radicular Pattern: The pain can affect a person's buttocks, back, perineum, thighs, genitalia, and legs.
• Loss of Reflexes: A person's knee and ankle reflexes might be diminished, along with anal and bulbocavernosus abilities.
• Sensory Loss: Sensory loss may range from 'pins and needles' to complete numbness. It might affect the person's bowel, bladder and genitalia.
• Bladder, Bowel, and Sexual Dysfunction: The affected person may experience incontinence, retention of urine, impotence or loss of ability to ejaculate or orgasm, and fecal incontinence.
• Weakness: The weakness is usually in the person's legs and might make walking difficult. The person may experience 'foot drop,' where their foot drags and may cause trips and falls. In some instances, it may be necessary for the person to use walking aids or a wheelchair.
• Neurogenic Pain: Neurogenic pain tends to worsen at night, interfering with sleep and exacerbating the person's general debility. Another feature of this form of pain is pain the person may feel in otherwise numb areas. The pain is often burning and maybe both constant and unbearable.

Cauda Equina syndrome is a devastating condition that may damage many aspects of the affected person's life. Often, the person can no longer continue to work from severe pain, a loss of muscle power, or continence issues. A combination of these issues may also affect a person's ability to work.

The syndrome causes symptoms that might be invisible and also about which the person might feel unable to speak because they relate to very personal bodily functions. Loss of bladder and bowel control can be highly distressing and hurt a person's social life, relationships and work. The person may also experience frequent urinary infections. Losing sexual function can devastate the person and their partner and lead to relationship difficulties and depression.

Severe neurogenic pain may be resistant to treatment and require strong painkillers with side effects that might cause further issues for the person. If the pain is chronic, it might become 'centralized' and affect other parts of the person's body while involving unusual pains such as electric shock or pain from non-painful stimuli such as light touch. The person's pain may be viewed as neurotic or even worse if it is not recognized. The pain is also hard to treat and can be alarming for the person who may question their sanity or fear it indicates some underlying and undiagnosed disease such as cancer.

With these issues in mind, it is not surprising that people with cauda equina syndrome may become depressed. They endure several losses, such as the loss of

• Job
• Health
• Sexuality
• Self-esteem
• Relationships
• Social standing

A person with cauda Equina syndrome and their loved ones may grieve over these losses and need considerable support. A person needs to visit their doctor if they experience:

• Bladder and bowel dysfunction causing the person to retain urine or an inability to hold it.
• Severe or progressive issues in the lower extremities include loss of or altered sensation between the legs, over the buttocks, feet, and heels, or loss of sensation in the person's inner thighs and the backs of their legs.

Treatments

Cauda Equina Syndrome:

People with cauda equina syndrome may need urgent surgery to remove the material pressing on the nerves. The surgery might prevent pressure on the nerves from reaching the point where the damages are irreversible. There are two forms of cauda Equina syndrome; Acute and Severe.

Acute Cauda Equina Syndrome:

The acute form requires extremely prompt surgical treatment if there is a compressive injury. The person may experience residual issues following the surgery, which may take months to resolve. Extensive rehabilitation using physiotherapy and methods such as bladder re-training might be required.

Chronic Cauda Equina Syndrome:

Chronic cauda Equina syndrome is much more difficult to treat. The person affected deals with pain, bladder and bowel control, weakness, sexual dysfunction, and sensory loss. The person faces sore feet/ankles, poor circulation, and depression.

• Weakness:

  Physiotherapy may be helpful if there is no inflammatory component such as that found in arachnoiditis, where exercise might exacerbate the condition and cause flare-ups.

• Sensory Loss:

  Little conventional treatment exists for sensory loss in cauda Equina syndrome, although in conditions such as Multiple Sclerosis, the use of vitamin B complex is considered to have potentially beneficial effects.

• Sore Feet:

  Loss of muscle tone and control over the foot's movement may lead to foot pain. If foot drop is a significant issue, a brace to hold it in position may help. It is important, however, to attempt to maintain as much muscle tone as possible as a range of movement (ROM). Exercise might help.

• Sexual Dysfunction:

  Sexual dysfunction is sometimes hard for people to talk about. It might be best to pursue advice from specialists. Suppose no physical treatment is feasible for improving function. In that case, the person and their sexual partner might pursue counseling which might help to lessen the impact of this disability on not only the person affected but their partner.

• Depression:

  Depression is an understandable reaction to a debilitating illness. Antidepressant medication should be reserved for severe depression. Counseling and support are the preferred methods of managing depression. Sharing experiences may help people with cauda Equina syndrome to come to terms with the disabilities associated with cauda Equina syndrome.

• Pain:

  The pain usually requires strong painkillers such as narcotics. Adjuvant medications such as low-dose antidepressants, anticonvulsants, and Neurontin often help the person. The sedative effects of some medications may be helpful if taken at night because they may help the person to sleep. Antidepressants, however, might adversely affect the person's bladder and sexual function and contribute to the issues they experience.

• Poor Circulation:

  Poor circulation is a common issue in cauda Equina syndrome. The person's feet may be cold and turn white, then red when re-warmed (also known as, 'Raynaud's syndrome) and chilblains. Some medications can be taken, but it is most likely best to use general measures such as avoiding getting cold feet and foot massage with warm oil to help improve the person's circulation. Avoid hot baths after the feet have been cold because it will most likely cause chilblains.

• Bladder Control:

  Depending on the exact nature of the issue, a neurogenic bladder requires treatment with drugs such as Oxybutynin if it is hyper-reflexive or intermittent self-catheterization if the person's bladder is unable to empty. Suppose the person's bladder is not able to empty. In that case, it might give rise to a residual volume of urine in their bladder after voiding - something that causes susceptibility to urinary infections that may require antibiotic treatment. An over-active bladder muscle may cause high bladder pressures and urine reflux up toward the person's kidneys; regular checks might be needed to exclude kidney damage. The person may wear pads in their underwear to protect against urine leaks.

• Bowel Control:

  Loss of control of feces may be an issue, but so are flatus, and the passage of gas at inconvenient times might be a source of considerable embarrassment for the person. Fecal incontinence of loose stools may be helped by using painkillers such as morphine or codeine, which tend to be constipating. Extreme constipation, however, which causes the impaction of feces, may lead to an overflow of diarrhea around the impacted fecal mass. Most commonly, in cauda Equina syndrome, it is hard for the person to empty their bowel. It is often necessary to assist the bowel in emptying; different methods are available. Consuming a high-fiber diet and maintaining good fluid intake are useful measures. The use of a laxative regularly may facilitate things.

General measures include reducing or stopping smoking, which might help improve local blood flow in the affected spinal region and the person's lower limbs. Exercise may be beneficial within the limits of pain as loss of mobility can lead to additional issues such as osteoporosis.

Interacting with a Doctor

To achieve a diagnosis of cauda equina syndrome, a doctor evaluates a person's medical history, pursues a physical examination, and may order multiple diagnostic imaging studies. Diagnostic imaging studies can include x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) to help assess. A person's medical history can help determine when the symptoms of cauda equina syndrome started.

During a physical examination of cauda equina syndrome, a doctor assesses strength, reflexes, sensation, alignment, and motion. The doctor may ask the person to sit, stand, walk on their heels and toes, bend backward, forward, and to the sides, and lift their legs while lying down. The doctor might check the tone and numbness of the anal muscles. The person may also require blood tests.

Managing Bladder and Bowel Function

Some bladder and bowel function is automatic, although the parts under voluntary control might be lost if you have cauda Equina syndrome. You may need to know when to urinate or move your bowels. A person with the syndrome may not be able to eliminate waste in the usual fashion.

Some general recommendations for managing bladder and bowel dysfunction include emptying your bladder with a catheter three to four times daily. Drink plenty of fluids and practice consistent personal hygiene to prevent urinary tract infections. Check for the presence of waste regularly and clear your bowels with gloved hands. It would be best to use glycerin suppositories or enemas to help empty your bowels. Use protective pads and pants to prevent leaks.

CES from Lumbar Herniated Discs

CES from lumbar herniated discs is considered the only absolute indication for surgery. It is considered a neurosurgical emergency with the outcome related to how quickly it is diagnosed and treated. The results of recovery of bladder function are felt by many authors to be related to early diagnosis and surgical intervention. Most authors recommend a wide decompressive laminectomy when surgery is performed.

Cauda Equina Syndrome (CES) Statistics

• Between 2001 and 2010, the incidence of CES in the military was 7 per 100,000 person-years.
• Female sex was found to have the highest incidence rate at 0.15 per 1000 person-years.
• Female sex, whites, individuals classified as other race, senior military rank, and age 30 and older were found to be significant risks for the development of CES.

Living With Cauda Equina Syndrome

The fact is - surgery might not repair permanent nerve damage. If this happens due to cauda equina syndrome, the person can learn how to improve their quality of life. Some suggestions include:

• Involve your family in your care
• Join a cauda equina syndrome support group
• Learn all you can about managing cauda Equina syndrome
• Along with medical personnel, you might want to seek assistance from a social worker, occupational therapist, sex therapist, or continence adviser

Author Credentials:

Thomas C. Weiss is a researcher and editor for Disabled World. Thomas attended college and university courses earning a Masters, Bachelors and two Associate degrees, as well as pursing Disability Studies. As a Nursing Assistant Thomas has assisted people from a variety of racial, religious, gender, class, and age groups by providing care for people with all forms of disabilities from Multiple Sclerosis to Parkinson's; para and quadriplegia to Spina Bifida. Explore Thomas' complete biography for comprehensive insights into his background, expertise, and accomplishments.

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Cite This Page (APA): Weiss, T. C. (2015, March 5). Cauda Equina Syndrome: Causes, Symptoms and Treatment. Disabled World. Retrieved April 18, 2024 from www.disabled-world.com/disability/types/spinal/backpain/ces.php

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