Concept: Cauda equina syndrome
Cauda equina syndrome (CES) is a rare but important neurosurgical emergency. Despite being a recognised clinical entity since 1934, there remains significant uncertainty in the literature regarding the urgency for its surgical intervention. The past decade has seen the emergence of the much referred to 48-hour limit as a possible window of safety. The ramifications of this time-point are significant for early patients who may subsequently have urgent treatment delayed, and for litigation cases after which adverse decisions are more likely to occur.
A large number of patients do not have cauda equina syndrome (CES) on MRI to account for their clinical findings; consequently, the majority of urgent scans requested are normal. We aimed to determine whether any clinical manifestation of CES, as stated in Royal College of Radiology guidelines, could predict the presence of established CES on MRI. We also aimed to support a larger study to develop a more universal assessment tool for acute lower back pain.A retrospective analysis of consecutive patients who warranted urgent MRI was conducted. Seventy-nine patients were eligible for study. The Kendall’s tau test was used for statistical analysis of all data. A p value of less than 0.05 was considered to be significant. MRI was performed in 62 patients out of 79.A total of 32.9% of patients had scans within 24 hours of admission. Nine of these patients were referred to neurosurgery for urgent neurosurgical review. Of these, 6.3% of patients had an established CES on MRI scan. One patient who had an out-patient MRI spine (15 days from hospital presentation) was found to have an established CES, was urgently referred to spinal surgery and underwent primary fenestration excision of the lumbar vertebra. No clinical features that were able to predict the presence of an established CES on MRI were elucidated. Findings included decreased anal tone 7.6% (p = 0.282), faecal incontinence 3.8% (p = 0.648), urinary retention 7.6% (p = 0.510), bladder incontinence 8.9% (p = 0.474), constipation 2.5% (p = 0.011) and saddle anaesthesia 8.9% (p = 0.368). Patients who had an abnormal MRI spine for back pain prior to this presentation showed a correlation with a newly diagnosed CES on MRI (p = 0.016) with a correlation coefficient of 0.272.
Fifty-six human and animal studies of cauda equina syndrome (CES) were reviewed. The evidence from human studies was poor (level IV). Evidence from animal studies and limited evidence from human studies suggest that structural and functional neurological losses are a progressive, continuous process. The longer the cauda equina nerve roots are compressed the greater the harm and the poorer the extent of recovery. This should prompt diagnosis and surgery for all CES patients as soon as practicably possible.
The authors present a case of anterior sacral meningocoele demonstrating a clinical picture of cauda equina syndrome. To the best of our knowledge, such presentation has not yet been reported.
Study Design Case report. Objective Present a case of Foix-Alajouanine syndrome that presented as acute cauda equina syndrome and discuss the pathophysiology and management. Methods An adult male patient developed sudden onset of back pain and leg pain with weakness of the lower limbs and bladder/bowel dysfunction typical of cauda equina syndrome. Emergency magnetic resonance imaging revealed no compressive lesion in the spine but showed tortuous flow voids and end-on blood vessels in the peridural region suggesting spinal arteriovenous malformation resulting in Foix-Alajouanine syndrome. Results The case was managed by endovascular embolization with excellent results. The pathophysiology, imaging features, management, and literature review of the syndrome is discussed. Conclusion The authors conclude that this condition may be an important differential diagnosis for cauda equina syndrome.
Cauda equina syndrome typically requires emergent MR imaging to detect compressive lesions on the cauda equina, which may require surgical decompression. While CT is sometimes performed as a complementary imaging technique to evaluate osseous integrity in patients with cauda equina syndrome, the accuracy of CT in detecting significant spinal stenosis and cauda equina impingement is not well-defined in the literature. We hypothesized that percentage thecal sac effacement on CT of the lumbar spine would have high sensitivity and high negative predictive value in evaluating significant spinal stenosis and cauda equina impingement.
Cauda equina syndrome (CES) is a condition with significant implications and medico-legal profile. The literature still lacks large primary studies to provide strong evidence for a robust management pathway. Statements from Neurosurgical and Spinal societies support early diagnosis and imaging but this has not resulted in any noticeable shift in referral pattern. We strongly feel the need for a nationally agreed, evidence-based referral pathway in practice. We present our large series and in-depth analysis of the referral pathway to provide strong evidence for more robust referrals and management.
Conditions that affect the cauda equina are a diverse group of disorders that require timely recognition and management. This article reviews cauda equina anatomy, the diagnostic approach to disorders of the cauda equina, features of cauda equina syndrome, and diskogenic and nondiskogenic disorders of the cauda equina.
To quantify the clinical findings in patients with potential cauda equina syndrome (CES).
Concomitant mycotic abdominal aortic aneurysm and lumbar tuberculous spondylitis with psoas abscess and cauda equina syndrome is extremely rare. This condition can cause serious life-threatening problems if not diagnosed and treated properly.