Cauda Equina Syndrome: Causes, Symptoms and Treatment
- Publish Date: 2015/03/05 - (Rev. 2018/09/04)
- Author: Thomas C. Weiss
- Contact : Disabled World
Outline: Information regarding Cauda Equina Syndrome including causes, symptoms and treatment options.
The, 'cauda equine,' is a bundle of nerve roots at the lower end of a person's spinal cord. The cauda equine or, 'horse's tail,' is so-called because of the way 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 changes in bowel and bladder function and loss of feeling in groin.
The cauda equina contains the nerve roots from L1 - S1-5. Nerve roots L4-S4 join in the sacral plexus which gives 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 their lower limbs. Cauda equina syndrome occurs when the nerve roots in a person's lumbar spine are compressed, cutting of 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 in order 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 coping 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 and 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. In inflammatory or demyelinating conditions; however, cauda Equina syndrome might be both chronic and progressive.
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 a period of time. A specific pattern exists:
- Weakness in the Legs: The weakness is often times 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/or 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 be worse at night, something that can interfere with sleep and exacerbate 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 of a burning nature and may be both constant and unbearable.
Cauda Equina syndrome is a devastating condition, one that may damage many aspects of the affected person's life. Often, the person can longer continue to work - either from severe pain, or because of a loss of muscle power, or because of 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 have a negative impact on a person's social life, relationships and work. The person may also experience frequent urinary infections. A loss of sexual function can be devastating to the person and their partner and might 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 type of pain, or pain from non-painful stimuli such as light touch. The person's pain may lead to their pain being 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 being to question their own sanity or fears the pain 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 a number of losses such as loss of:
- Social standing
It is very possible that a person with cauda Equina syndrome and their loved ones may grieve over these losses and might need a considerable amount of support. It is important for a person to visit their doctor if they experience:
- Bladder and/or bowel dysfunction causing the person to retain urine or an inability to hold it.
- Severe or progressive issues in the lower extremities, to include loss of or altered sensation between the legs, over the buttocks, feet and/or heels, or loss of sensation in the person's inner thighs and the backs of their legs.
Cauda Equina Syndrome:
People with cauda equina syndrome may need urgent surgery in order to remove the material that is 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 and these 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.
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 use of vitamin B complex is considered to have potential beneficial effects.
- Sore Feet:
Loss of muscle tone and control over movement of the foot may lead to foot pain. If foot drop is a notable 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 well as range of movement (ROM). Exercises might help.
- Sexual Dysfunction:
Sexual dysfunction is very hard for people to talk about at times. It might be best to pursue advice from specialists. If no physical treatment is feasible for improving function, 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 is an understandable reaction to a form of debilitating illness. Antidepressant medication should be reserved for severe depression. Counseling and support are the preferred method of managing depression. Sharing experiences may help people with cauda Equina syndrome to come to terms with the disabilities associated with cauda Equina syndrome.
The pain usually requires strong painkillers such as narcotics. Adjuvant medication such as low dose antidepressants, anticonvulsants, and neurontin often help the person. The sedative effects of some medication 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,) as well as chilblains. Some medications exist that can be taken, yet 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 extremely 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. If the person's bladder is not able to empty, 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 a reflux of urine up towards the person's kidneys; regular checks might be needed to exclude any 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 use of painkillers such as morphine or codeine which tend to be constipating. Extreme constipation; however, which causes impaction of feces may lead to 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 to empty and there are some different methods available. Consuming a high fiber diet and maintaining good fluid intake are useful measures. Use of a laxative on a regular basis may facilitate matters.
General measures include reducing or stopping smoking, something that might help to improve local blood flow in the affected spinal region as well as in 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. The diagnostic imaging studies can include x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) to help with assessment. A person's medical history can help to find out when the symptoms of cauda equina syndrome started.
During a physical examination related to 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, as well as to lift their legs while lying down. The doctor might check the tone and numbness of 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. What this means is you may not know when you need to urinate or move your bowels. A person with the syndrome may not have the ability 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 each day. Drink plenty of fluids and practice consistent personal hygiene in order to prevent urinary tract infections. Check for the presence of waste regularly and clear your bowels with gloved hands. You might want 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 as a result of 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
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- 4 - Surgical or Non-surgical Treatment for Spinal Stenosis | Wolters Kluwer Health (2015/01/11)
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