Cauda Equina Syndrome

 

Cauda Equina Syndrome is a medical emergency. It is advised that surgery should occur within 48hrs of the onset of symptoms. Surgery at this point is not optional, it is critical.

From when we are born to when we are fully grown, the length of our spinal chord remains the same. As we grow, our spine grows with us, and out of the spinal chord grow the nerves of the Cauda Equina. The nerves delta out through either side of the individual levels of the lumbar spine and sacrum (the plate of bone that connects the spine and the pelvis). In most people, the spinal chord ends around the second lumbar vertebra.

Translated, Cauda Equina means horses tail – just as its appearance suggests.

When foreign matter obstructs the spinal canal through which the Cauda Equina passes, a compression can occur. Depending on the cause of the compression, symptoms start much like familiar lumbar back pain, but soon become more aggressive.

There are several possible causes of Cauda Equina Syndrome.

1) Disc Bulges or Herniated Discs – discs herniate, bulge, rupture and repair themselves fairly well on their own. This is why often, surgery is not necessary in relation to disc problems. Of Herniated Discs in the Lumbar Spine, only from 1 to 15% will potentially lead to compression of the Cauda Equina.

2) Spinal Stenosis – a narrowing of the spinal canal through which the Cauda Equina passes, can also lead to compression.

3) Spondylolisthesis – this is the sliding of one vertebra of the spine on top of or below another. This is generally more prominent in young people, with spines that are still developing and growing. This can also occur as a result of a severe impact incident.

4) Other pathologies, such as tumors, and even pregnancy, can also result in a compression.

It is said that the condition becomes critical at 48hrs, and if the effected nerves are not decompressed, nerve damage is increasingly likely to become irreversible. There is a debate as to whether it is the 48hr time frame that is of most importance, or the functionability of the bladder at the time of decompression, but the two seem to go hand in hand really, the longer the compression, the more likely the damage.

Below is a brief description of the symptoms of compression through the lumbar spine and sacrum.

L2 ~ Compression of the nerve roots at the second lumbar vertebra presents as pain in the upper thigh. The quad muscles may become weakened.

L3 ~ Compression at the third lumbar vertebra presents as pain in the lower thigh. Reflexes become restricted at the knee cap.

L4 ~ At the fourth vertebra of the lumbar spine compression presents as pain in the shin and knee.

L5 ~ Compression of the fifth lumbar vertebra presents as pain in the hamstrings and gluteal muscles, as well as limited dorsiflexion of the foot.

S1 – S5 ~ Compression in the sacrum presents as pain / numbness in the saddle area.

 

The Symptoms

If you have suffered from lower back pain for a long period of time (chronic pain), you will be familiar with how it feels. Tight, weak, tired, tense, burning. We all have different words for describing our pain. When lower back pain moves from chronic to acute words like stabbing, excruciating, immobilizing, debilitating come to mind. Often long term back pain sufferers will move between chronic and acute phases. Sometimes we can identify the causes of these acute flare ups –  long-haul flights, unsupportive beds, or beds that are too rigid, lengthy car journeys, other long periods of stillness like couch slouching, even just bending over to pick something up. Likewise, quick movements during sports and more vigorous actions can also lead to acute flare ups. And sometimes, there just seems to be no reason at all. Personally, I tend to think it is more a combination of all things that lead to such events. Even stress and emotions come into play here.

Low back pain and Sciatica are symptoms of Cauda Equina Syndrome. But, most people who have Low Back Pain or Sciatica will not end up with Cauda Equina Syndrome. If Back Pain and Sciatica are the start of the line,  Cauda Equina Syndrome is the end of that line. If sciatica is not a result of Piriformis Syndrome – a chronic tightness of the muscles around the hip and through which in most people the Sciatic nerve passes – it is most likely to be the result of an issue within the Lumbar Spine. The question is, how do you know when something more serious is at play? How do you know when it is time to get to the Emergency Room?

Real symptoms of Cauda Equina Syndrome start to display in the Perineal or Saddle regions. Known as Saddle Anesthesia, the feeling is at first of pins and needles, leading to a more intense but at the same time dull feeling, like when a local anesthetic is used. This can also spread out into the Gluteal muscles, and down the back of the legs into the Hamstrings. Other sensations could be of hot or cold temperature changes on the skin, a feeling like someone is pouring warm or cold water down the backs of the legs.

Bowel and bladder function are a definite red flag. Changes here should be monitored closely. Bowel function is potentially harder to recognise as movements might occur at a frequency of once a day or thereabouts. Unless you are regular as clockwork, this could prove hard to monitor. Bladder function is a much clearer indicator.  Urinary changes include retention, difficulty initiating flow, and decreased sensation of movement of urine through the urethra. Again, I recommend going immediately to hospital if any changes in bladder function are noticed.

Another symptom that I read of, but experienced 5 days previous to surgery, was dysfunction of the effected leg. My left leg would simply give out from underneath, and I would fall half way to the ground, as though I didn’t even have a left leg. Although this is noted as a symptom, I do not believe that I had a compression for 5 days.

Because of the fact that Cauda Equina Syndrome goes critical at 48 hrs, I can not emphasise enough the importance of going to Hospital at the onset of these symptoms. After this 48hr period, the consequences of the compression will most likely become permanent, and there will be no Bladder or Bowel function capabilities left, leading to permanent use of a catheter and colostomy, and for the guys, this could also mean permanent sexual dysfunction.

 

The Surgery

The surgery is comprised of a few parts. A Laminectomy must first be performed. The Lamina of the effected vertebral bone is removed, giving access to the spinal canal and the disc that has herniated and caused the compression.

A Discectomy is then performed. The bulging part of the disc is removed, and the gel from the disc is scraped out, so as to minimise chances of recurrence. This effectively decompresses the Cauda Equina.

Several stitches and a band aid to finish.

Back to Hospital