Cauda Equina Syndrome
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.
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:
- 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
- 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