Cauda Equina Syndrome

Scenario

You are a SPR in Orthopaedics. A 52 year old lady with a 8 hour history of bilateral leg pain and urinary incontinence presents is referred to you by A+E. They have arranged for an MRI which is shown below.

Screenshot-2022-04-26-at-17.28.52

This is a single sagittal slice of a T2 weighted MRI scan taken on an unknown date from an unknown individual. The most obvious abnormality is a disc bulge at L4/5. There is also multi-level degenerative disc disease.

I would like to take a full history and examination. Salient questions would be:

  • Nature of pain
  • Duration of symptoms
  • Number of episodes of urinary incontinence
  • Any associated faecal incontinence
  • Any change in sensation on wiping back passage
  • Similar symptoms in the past
  • Any long-term history of back pain/interventions/surgery on the back

I would also perform a full examination including:

  • PR
  • Upper and lower limb neurological examination (power, sensation, reflexes, tone, clonus, plantars, PR.
  • Palpation of back
  • Pre and post void bladder scans

Following this with the history/radiological findings I am concerned of cauda equina syndrome and I would therefore keep the patient nil by mouth, inform the consultant on call and refer this patient to spinal surgery.

Most common level is L5/S1, followed by L4/5.

  • Disc herniation (most common)
  • Spinal cord tumour
  • Trauma
  • Developmental spondylolisthesis
  • Spinal epidural abscess
  • Spinal epidural haematoma

In adults the spinal cord ends at the L1-L2 level.

Sensory component: Skin over anterior aspect of thigh

Motor component: Hip flexion

Sensory component: Skin over anterior aspect of knee

Motor component: Knee extension

Sensory component: Skin over anterior medial aspect of leg

Motor component: dorsiflexion of ankle

Sensory component: Skin over anterior lateral aspect of leg

Motor component: Extension of great toe

Sensory component: Skin over lateral most surface of foot

Motor component: Plantar flexion of ankle