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Cauda Equina Syndrome (CES)

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Introduction

Cauda equina syndrome (CES) is a very rare condition associated with lower back pain. It often involves progressive pain and neurological symptoms in the leg(s) and changes to bladder, bowel and/or sexual function. How common it is isn’t fully understood, but the latest research suggests it affects approximately 1 person in 33,000-100,000 (NHSLA 2016). Although extremely rare, it is a very serious condition where fast action is required to avoid debilitating consequences. However, you can be reassured that our Physiotherapists at Pure are highly trained to identify this condition and maintain constant vigilance for the signs and symptoms. We believe it is our duty to stay alert and always carry out a series of checks in the small chance there is something more serious underlying. Although it can affect any age, some studies suggest it tends to affect those under 50 most, with literature supporting that 70% of those affected by CES are below 50 years old (Mercer, C 2019).

 

Definition

‘A patient presenting with acute back pain and/or leg pain with a suggestion of a disturbance of their bladder or bowel function and/or saddle sensory disturbance should be suspected of having a Cauda Equine syndrome (CES).’ (Germon et al., 2015). Saddle sensory disturbance is numbness or pins and needles on in the insides of the legs and genitals.

 

It is important that patients are able to comprehend the gravity of this problem and take responsibility for monitoring any development of symptoms. Below you will find information which details the symptoms of CES and your Physiotherapist will provide you with a card with this information for your reference.

Patient Information Cards

Relevant Anatomy

‘Cauda enquina’ can be translated from Latin origin as ‘horse’s tail’. This relates to the anatomy involved – the spinal cord descends and eventually flares out into many nerve branches, emulating a horse’s tail. This collection of nerves is known is the Cauda Equina. The spine is separated in different sections with 29 vertebrae (spinal bone) in total. It is comprised of the cervical (neck), thoracic (middle back), lumbar (lower back) and the sacrum (tail bone). At each vertebra, a nerve branches out from the spinal cord and supplies an area in the body with sensation and muscle power.

 

The spinal cord ends, and the caudal nerve roots start approximately between the 12th thoracic vertebrae and the 1st Lumbar vertebrae. This collection branches out more and more as it reaches the bottom of the spine and into the legs (Delong, Polissar & Neradilek, 2008). The cauda equina nerve roots are responsible for muscle power of the lower limbs and sensory innervation of the saddle area. They also responsible for voluntary control of the external anal and urinary sphincters.

Causes

Cauda equina syndrome occurs when there is compression of the spinal cord and/or the nerve/nerve roots in the lumbar spine. The most common cause is through disc herniation, accounting for approximately 45% of CES cases (Rider & Marra,2019).

 

Other reasons include traumatic injury or epidural haematoma (bleeding) sometimes leading to compression of the spinal cord and the development of CES. Space occupying legions (SOL) involved like spinal tumours or cancerous metastases. Spinal cysts would also fall into the group of SOL (Kostuik, 2004).

 

Although again rare, CES can develop congenitally but also with spinal conditions such as Spondylolisthesis, Spinal stenosis and Ankylosing Spondylitis and Arachnoiditis (Rubenstein et al., 1989), all of which our Physiotherapists at Pure are familiar with.

Symptoms

  • Numbness, pins & needles or tingling between your upper thighs, or around your genitals or bottom. You may notice this when wiping after going to the toilet (76% of CES patients in a scientific study were found to have ‘saddle anaesthesia’ (Gitelman et al., 2008).
  • New or increased difficulty in emptying a full bladder or in controlling your urine, such as leaking or incontinence or a need to use pads.
  • Loss of, or reduced feeling when urinating, or not being able to tell when your bladder is full.
  • Loss of bowel control or leaking, or loss of feeling in your back passage during bowel movements (75 patients of 173 tested had decreased anal tone) (Gooding, Higgins & Calthorpe, 2013).
  • New or increased difficulty with sexual functions, such as achieving/maintaining erection, reaching orgasm or loss of feeling in your genitals during sex.

Physiotherapy Assessment

Subjective Examination

The subjective element of the assessment involves obtaining a comprehensive history about your signs, symptoms and behaviour of your problem. It will include aggravating and easing factors, past medical history and medications. We are vigilant to back and/or leg pain that has any of the above ‘red flag’ symptoms. CES is often categorised as a progressive problem with worsening back pain and sometimes affecting one leg and then the other. There are various, less-alarming reasons for some of the above symptoms, so we would look to establish if they may be the cause also and this may be less worrying. Conditions that could cause some of the above symptoms are prostate problems, pelvic floor problems, stress incontinence or certain medications to name a few examples (Mtui, Gruener & Dockery, 2015).

 

‘Red flags’ are symptoms and certain questions asked which may be indicative of something more serious, one or more of these with or without physical signs after your objective exam would warrant a referral for an urgent medical assessment i.e. straight to Accident and Emergency (A&E) or less preferably, an urgent doctor appointment. A Physiotherapist may give you information that if there is worsening of the symptoms – or further symptoms develop, it is at this point you should seek urgent medical assessment rather than straight away. Finally, if there is no immediate threat, your Physiotherapist may refer you to your GP to seek another opinion and double-check for other medical causes.

 

Objective Assessment

The following is what constitutes an objective exam to assess for CES. Your Physiotherapist will relay the findings of this in written or verbal form to A&E if necessary.

  • Sensation.
  • Muscle power.
  • Reflexes.
  • Upper and lower motor neuron testing.

Medical Assessment

If you have been advised to go to A&E, it is helpful for medical staff to have an overview of your symptoms and the reason for your visit. Your Physiotherapist will provide you with an information card (located above) and ask you to explain which symptoms you have to the A&E department and that you require urgent assessment. Your Physiotherapist will likely call ahead to inform them you will soon be visiting or provide you with a letter. This letter/information will provide the hospital with an overview and direct their assessment to make sure you get processed appropriately and with urgency.

 

The assessment at A&E is what is best supported by research and helps to identify the problem most accurately and with speed. It is unfortunately thorough and personal, however necessary. It will help to identify whether there is a spinal cord compression by looking at whether its function is impaired. This includes the ability to provide normal sensation to the genitals, normal reflexes in the limbs, control and awareness of bladder and bowels, and, control of muscle power in the extremities. These functions are examined through digital rectal exam and anal tone testing, bladder ultrasound – to determine residual bladder volume, spinal MRI and neurological examination.

References

Delong, W. B., Polissar, N., & Neradilek, B. (2008). Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies. Journal of Neurosurgery: Spine8(4), 305-320.

 

Germon, T., Ahuja, S., Casey, A. T., Todd, N. V., & Rai, A. (2015). British Association of Spine Surgeons standards of care for cauda equina syndrome. The Spine Journal15(3), S2-S4.

 

Gitelman, A., Hishmeh, S., Morelli, B. N., Joseph Jr, S. A., Casden, A., Kuflik, P., … & Stephen, M. (2008). Cauda equina syndrome: a comprehensive review. Am J Orthop37(11), 556-62.

 

Gooding, B. W., Higgins, M. A., & Calthorpe, D. A. (2013). Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome?. British journal of neurosurgery27(2), 156-159.

 

Kostuik, J. P. (2004). Medicolegal consequences of cauda equina syndrome: an overview. Neurosurgical focus16(6), 39-41.

 

Mercer, C., 2019. Physio Matters [Podcast]. Available at: https://open.spotify.com/episode/5aBDuNVp7tWEzxQnVuy9ED?si-Vomm-SXaSQOa2QCxc4JTIw [Accessed: 26/4/2020].

 

Mtui, E., Gruener, G., & Dockery, P. (2015). Fitzgerald’s Clinical Neuroanatomy and Neuroscience E-Book. Elsevier Health Sciences.

 

Rider, I. S., & Marra, E. M. (2019). Cauda Equina And Conus Medullaris Syndromes.

 

Rubenstein, D. J., Alvarez, O., Ghelman, B., & Marchisello, P. (1989). Cauda equina syndrome complicating ankylosing spondylitis: MR features. Journal of computer assisted tomography13(3), 511-513.

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