The terminology, "cauda equina," literally means tail of horse and refers to the normal anatomy of the end of the spinal cord in the low back where it divides into many bundles of nerve tracts resembling a horse's tail. *The credit card could be used by the patient particularly in an emergency setting to help express the change in embarrassing and sensitive symptoms. The survey identified that 70% of patients involved in claims were aged between 31-50. In: French, Sally, Sim, Julius (Eds. MedicineNet does not provide medical advice, diagnosis or treatment. Available from: Levack P, Graham J, Collie, D, et al. This can require pain medicine, physical therapy, supportive braces, urinary catheters, and other treatments etc. When the back and or leg pain started is significant but precisely when symptoms relating to parasympathetic supply began is vital; one hour, one day, one week, 15 years? The patient needs to recognise that the next questions are vital and accurate response of the utmost importance. Cauda equina syndrome can be caused by any condition that results in direct irritation or pinching of the nerves at the end of the spinal cord. Cauda equina. Patients with heart pacemakers, metal implants, or metal chips or clips in or around the eyes cannot be scanned with MRI because of the effect of the magnet. Sensory and motor fibres to the lower limbs. Sign up to receive the latest Physiopedia news, The content on or accessible through Physiopedia is for informational purposes only. Aggravating and easing factors should be explored. Partial cauda equina syndrome is the terminology that applies when there is incomplete compression of the nerves of the lower spinal cord. A similar study, relating to neurosurgical litigation in the UK [20], found that the highest number of claims related to spinal surgery (44%) and that 87.5% of claims relating to CES were successful. ©1996-2021 MedicineNet, Inc. All rights reserved. It is a group of 100 different diseases, and is not contagious. Cauda equina syndrome can be caused by any condition that results in direct irritation or pinching of the nerves at the end of the spinal cord. 2004. Taylor [19] analysed claims made to the MDU between 2005 and 2016 related to CES. In that period there were 150 claims made-92% against GPs. In general, the longer the duration of the compression of the spinal cord, the longer the recovery period and less likely complete recovery can occur. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Patients who present with painless urinary retention and overflow incontinence; the bladder is no longer under executive control. 2015; 29:2:169-177. Radiologic testing such as CT (computerized axial tomography) and MRI (magnetic resonance imaging) scanning can document the compressed spinal cord tissue. Journal of Orthopaedic Medicine. Where a patient reports sensory changes in the perineal area this should be tested to evaluate any sensory loss. Physical examination findings may help to confirm the diagnosis but should not be solely relied on. Relevant symptoms include unilateral or bilateral radicular pain and/or dermatomal reduced sensation and/or myotomal weakness with any suggestion of change in bladder or bowel function however minor should be investigated[3]. The terminology, "cauda equina," literally means tail of horse and refers to the normal anatomy of the end of the spinal cord in the low back where it divides into many bundles of nerve tracts resembling a horse's tail. Whilst it is difficult to accurately collate international statistics, there are robust data for the UK, which are presented below. Want More News? Cauda Equina Syndrome | Signs & Symptoms. CES UK. Is medication being used appropriately and titrated correctly? The use of a *credit card style patient information or a leaflet explaining what to look for and what to do should they develop symptoms is recommended. Medically reviewed by Joseph Carcione, DO; American board of Psychiatry and Neurology. At the base of the spinal column, near the first lumbar vertebra, is a collection of nerves called the cauda equina. Nothing is to be gained by delaying surgery and should be carried out as soon as is practically possible[2][3]. until optimal nerve and muscle recovery occurs. See a picture of Slipped Disc and learn more about the health topic. These patients could develop CESR and are a medical emergency and should have a surgical opinion urgently. The subjective history is the most important aspect of the examination early in the disease process as the subtle and vague symptoms related to early Cauda Equina Syndrome need to be identified using clear methods of communication. The important items to screen within the subjective history are Red Flags. Cervical spine – The neck region of the spine consisting of the first seven vertebrae. Disc herniation is usually the cause of sciatica. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. If CES/CES risk is suspected the subjective history must explore symptoms in even more detail. The proximal portion of the cauda equina is said to be hypovascular hence more vulnerable if compressed [6]. Fairbank J. That is usually the journal article where the information was first stated. Cauda equina syndrome is an uncommon compression of the nerves at the end of the spinal cord within the spinal canal. See additional information. ears, septum, bones, finger nails, toe nails, and intra-abdominal. conus medullaris. areas where hematomas occur including; inside the skull, on the scalp, UI occurs twice as often in women as in men. Often, the physical examination can reveal hyperactive reflexes of the lower extremities. Establish the pattern of pain through 24 hours. 2004; 26: 102–105. Cauda equina syndrome is diagnosed based on the characteristic symptoms and confirmed by neurologic and radiology testing. Has there been any recent or past spinal surgery and any history of osteoporosis; a retropulsed vertebral insufficiency fracture could cause CES. Checking Red Flags and neurological status is important before this improved status can be assumed. The numbness of cauda equina syndrome typically is in the distribution of where the body would touch a saddle when sitting upon a horse, and is referred to as "saddle anesthesia.". 4 groups of patients have been classified according to their presentation :[3]. The most common cause of CES is a prolapse of a lumbar disc but other conditions such as metastatic spinal cord compression can also cause CES[1]. There are different A digital rectal examination should be performed to assess any loss of anal sphincter tone. The spinal cord ends around the first and second lumbar vertebrae in the lower back and continues as nerve roots. Available from: Standring, S (ED IN CHIEF) Grays Anatomy, the anatomical basis of clinical practice 40. Symptoms of cauda equina syndrome include low back pain, numbness and/or tingling in the buttocks and lower extremities (sciatica), weakness in the legs, and incontinence of bladder and/or bowels. It enables clinicians to frame the questions as important. It is often due to a failure of one or more of the components that allow the body to control the evacuation of feces, when it is socially appropriate. It is clear that litigation for CES is only likely to increase, and equally clear that as treating healthcare professionals, we need to ensure that we examine patients fully and appropriately, that we warn, or “safety net” them where we have concerns, and that we have robust pathways in place to ensure rapid access to MRI scanning and spinal surgical specialists. The cauda equina is formed by the roots arising from segments L2 to Co of the spinal cord. What is it? If CES is suspected the patient must undergo an MRI urgently to confirm the diagnosis. Symptoms of cauda equina syndrome include. Biopsychosocial assessment. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Establish the quality and intensity of pain e.g VAS. British Journal of Neurosurgery. What is the treatment for cauda equina syndrome? Presentation - A Neurological Perspective of Cauda Equina Syndrome . In human anatomy, the anterior spinal ... also sending off branches at its lower part to be distributed to the cauda equina. This should only be performed by an appropriately trained clinician. This bundle of nerve roots is called the cauda equina. The clinical cue card maps against a patient credit card using the same questions. Churchill Livingstone. Germon T, Ahuja,S, Casey A, Rai A. British Association of Spine Surgeons standards of care for cauda equina syndrome. Rare reported cases exist in which CES was associated with chiropractic manipulation, placement of interspinous devices, and thrombosis of the inferior vena cava. What Is Sciatica? These are taken from national agencies dealing with litigation against medical professionals (Medical Defence Union- MDU, and the National Health Service Litigation Authority-NHSLA) [18]. The Spine Journal 2015 15 (3), pS2-S4. There are numerous causes of chronic lower back pain and only one ailment gets more complaints. The ventral root provides motor fibres for the efferent pathway along with sympathetic fibres. What treatments have been tried including medication is helpful on a variety of levels. Terms of Use. The long-term management of cauda equina syndrome depends on whether or not there are persisting symptoms after surgical decompression of the irritated nerve tissue. Markham D E.2004. A CES cue card for clinicians to use in the clinical consultation to enable the patient to focus on important questions was developed. Swain J. Interpersonal communication. Coccyx – More commonly known as the tailbone, this is a bony structure in the region of the spine below the sacrum. The spinal cord ends around L1, consequently, the caudal nerve roots below the first lumbar root, form the cauda equina. They then leave these nerves as they exit the anterior sacral foramina and pass to the pre-sacral tissue. Topical Issues in Pain 2. Greenhalgh S, Truman C, Webster V , Selfe J. Basic Anatomy- BORING AND HARD TO UNDERSTAND. Neuromusculoskeletal examination and assessment a handbook for therapists. 2002;14: 472–480. Rupturing of the tissue that separates the vertebral bones of the spinal column. Establish if these symptoms have been experienced before or are they different? The 4th and 5th sacral nerves, S4 and 5, along with posterior primary ramus of the coccygeal nerve supply the skin and fascia around the coccyx. Through this study it emerged that in order to identify CES patients early in the disease process to facilitate a timely surgical opinion one of the key problems was the use of language that reflected the patient’s own voice. The physical examination should include a full neurological assessment to determine dermatomal sensory loss, myotomal weakness and reflex change. The facial nerve has three components, motor, parasympathetic (efferent) and visceral (afferent) fibres. Most of these patients will not have critical compression of the cauda equina. Compression of the spinal cord at this level can lead to a number of typical symptoms of the syndrome (low back For a comprehensive overview of neurological integrity testing the reader is referred to the following book 'Neuromusculoskeletal examination and assessment' [16]. How do doctors diagnose cauda equina syndrome? Relationships and pain. What is cauda equina syndrome? Facts you should know about cauda equina syndrome. Over the same time period, £8 million ($10.4m) was paid out on settled claims, most of which were under £100 000 ($130 000). Specialized neurologic nerve testing of the lower extremities, such as nerve conduction velocity (NCV) and electromyography (EMG) tests can indicate nerve irritation effects in the low back. Previous history of serious conditions such as cancer must be noted and may be important. The scale and impact of claims for negligence against clinicians treating people with CES is significant, and rising. Other causes include epidural abscess, spinal epidural hematoma, diskitis, tumor (either metastatic or a primary CNS cancer), trauma (particularly when there is retropulsion of bone fracture fragments), spinal stenosis and aortic obstruction. Around 12% of claims were for more than 500 000 pounds ($650 000). Of the 293 cases identified, 232 were still under investigation and unsettled; 20 had settled with agreed damages; 41 had concluded with no damages awarded. Millions of women suffer from urinary incontinence (UI). Diseases of muscle and/or nerves can produce abnormal electromyogram patterns. However it can have life changing consequences and it is important to act quickly if it is suspected. Cauda equina syndrome results from compression of the spinal cord and nerves/nerve roots arising from L1-L5 levels. J Bone Joint Surg Am 1981; 63: 53–62. Oncol. The pelvic splenic nerves to the pelvic viscera composed of parasympathetic fibres, travel in the ventral rami of S2,3 and 4. Patients who present with urinary difficulties with a neurogenic origin, including loss of desire to void, poor stream, needing  to strain to empty their bladder, and loss of urinary sensation. Cauda equina syndrome is an uncommon compression of the nerves at the end of the spinal cord within the spinal canal. A CT scan is a low-risk procedure. Does patient history and physical examination predict MRI proven cauda equina syndrome? Voluntary control of the external anal and urinary sphincters. Cauda equina syndrome (CES) is a rare but serious neurological condition affecting the bundle of nerve roots at the lower end of the spinal cord. MRI (or magnetic resonance imaging) scan is a radiology technique which uses magnetism, radio waves, and a computer to produce images of body structures. However, in the absence of reliably predictive symptoms and signs, there should be a low threshold for investigation with an emergency scan'[2]. Cauda equina syndrome is a grey area and there is no consensus on which signs and symptoms should be acted on. The patient participants emphasised the need for clinicians to use language that they could understand during a clinical consultation, especially in the context of severe pain. It is important to understand your locally agreed pathway to make sure there is no delay to diagnosis and where CES is confirmed, there is no delay to surgical intervention. [Level Of Evidence: 1]. ), Physiotherapy a Psychosocial Approach, 3rd ed. Reference of pain and precise area of pins and needles and numbness must be identified and clearly documented. Archives of Physical Medicine and Rehabilitation 2009 90(11), pp.1964–1968. Disorders. While the lumbar spine is sturdy and resilient, it is subject to a high degree of stress and loads, which may cause various problems, resulting in pain. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Et al. This highlights symptoms to look out for and crucially timely action to take should symptoms develop. There is no agreed definition of CES but the British Association of Spinal Surgeons (BASS) present a definition that is useful in clinical practice; '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 CES. Electromyogram or EMG is defined as a test that records the electrical activity of muscles. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). The majority of these were successfully defended (70%) though the MDU paid out 350 000 pounds ($456,340) in legal costs. The spinal cord ends at the top of the lumbar spine, and the remaining nerve roots, called the cauda equina, descend down the remainder of the spinal canal. Physiotutors. 1173185. Although not specifically focused on CES, a study by Taylor in 2014 of litigation cases in the USA against neurosurgeons, found that they were more likely to be sued following spinal surgery than cranial surgery, with the average claim being around $278 362. Causes of cauda equina syndrome include herniation of lumbar intervertebral discs, abnormal growths (tumor or cancer) adjacent to the lower spinal cord, localized infection near the spinal cord (epidural abscess, and localized bleeding (epidural hematoma) causing pressure on the spinal cord in the low back. They exit the spinal canal through openings in the vertebrae (foramen), just like other nerve roots. Pain in the low back can relate to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area. Where a patient reports bilateral leg pain, signs of upper motor neuron involvement should be examined (babinski and clonus). With complete cauda equina syndrome, the array of symptoms listed above is commonplace. 205–219. What are the symptoms of cauda equina syndrome? This can give an indication of the severity of pain and its control. pain, sciatica, saddle sensory changes, bladder and bowel incontinence, and lower extremity motor and sensory loss). Fourth edition. The roots descend at an almost vertical angle to reach their corresponding foramina, gathered around the filum terminale within the spinal theca[5]. Cauda equina syndrome can be confirmed with neurologic and radiology testing but such testing should not be delayed. Cauda equina syndrome: diagnosis, delay and litigation risk. Medically reviewed by the Healthline Medical Network. There is no way of predicting who will progress from CESS to CESR and how quickly this may happen and so precise recording of the timing of chronology cannot be underestimated. Primary Health Care Research & Development. From the skull the tube adheres to bone at the foramen magnum and extends down to the second sacral vertebra where it tapers to cover over the filum … Special Contribution - Laura Finucane, Sue Greenhalgh, Chris Mercer, Original Editor - Laurie Fiegle and Tabitha Korona, Top Contributors - Laura Finucane, Tabitha Korona, Scott Buxton, Laura Ritchie and Thibaut Seys. In most cases Physiopedia articles are a secondary source and so should not be used as references. There are many causes of back pain. Clin. Patients need to understand the relevance of the questions you ask as they may not fully appreciate the importance and subsequent consequences if not explained properly. Many medications cause symptoms that masquerade as CES. The most common cause of compression in 45% of CES is a herniated lumbar intervertebral disc. Medication to alleviate pain, physical therapy, and bed rest are treatments for sciatica. Ultimately, the outlook for patients affected by cauda equina syndrome is determined by the extent of damage to involved nerve tissue. The thecal sac or dural sac is the membranous sheath (theca) or tube of dura mater that surrounds the spinal cord and the cauda equina.The thecal sac contains the cerebrospinal fluid which provides nutrients and buoyancy to the spinal cord. The cauda equina roots have both a dorsal and ventral root. In order to answer these questions, by understanding the anatomy you can score full-marks because this is a very easy exam question! How Climate Change Can Put MS Patients in Danger, Sports Position Doesn't Affect Risk of Concussion, Implant Improve Lives With Balance Disorders, Pigs Show Their Smarts in Complex Experiments. It is important that these questions are framed to highlight their gravity. Other data suggests that average payouts for CES claims in the UK are around £336 000 ($436 800), with around £133 000 of that going to the patient and the remainder on legal costs. Don’t wait for a sensory level-listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. It is well recognized that the presence of Red and Yellow Flags are not mutually exclusive [13]. Symptoms, Causes, Treatments. Diabetes, Multiple Sclerosis, Benign prostatic hyperplasia, pregnancy. A Qualitative research study has identified that clear communication plays a pivotal role in identifying Cauda Equina Syndrome patient’s early to facilitate bringing these patients to the surgical team in a timely manner [15]. Overall £25 million had been paid out. Others pass immediately into retroperitoneal tissue and into the mesentry of the sigmoid and descending colon [5]. Patients who do not have CES symptoms but who may go on to develop CES. 2011. This can elicit various degrees and combinations of the symptoms listed above. Edinburgh, pp. Todd, N V; Dickson, R A . Explore the patient’s medication regime and escalation up the analgesic ladder? 2015;36:81-86. 2016, 30 (5), p518-522. Fecal incontinence can be defined as the unintentional loss of stool (feces) or gas (flatus). If surgical intervention is delayed irreversible damage can occur to the bladder, bowel and sexual function. The pudendal nerve supplies the perineum and arises from S2,3 and 4 with its terminal branches including the dorsal nerve of the penis or clitoris[7]. A hematoma is a collection of blood that is outside a blood vessel. Sign Up for MedicineNet Newsletters! There are many types of urinary incontinence: stress incontinence, urge incontinence, overactive bladder, functional incontinence, overflow incontinence, transient incontinence, and mixed incontinence. MRI scanning is painless and does not involve X-ray radiation. Some pass to the pelvic viscera alongside the pelvic sympathetic supply and supply the urogenital organs and distal aspect of the large intestine. 2016 Development of a toolkit for early identificationof cauda equina syndrome. Establishing the history of the present condition in detail is key as timing is of paramount importance in this condition. A nerve conduction velocity test is an electrical test that detects nerve injury in conditions such as: Sciatica pain, caused by irritation of the sciatic nerve, typically radiates from the low back to behind the thigh to below the knee. The CE provides innervation to the lower limbs, and sphincter,controls the function of the bladder and distal bowel and sensation to the skin around the bottom and back passage [1] . Brash J Jamieson E,(ed) Cunninghams Text book of Anatomy 7. Can Playing Golf Help Parkinson's Patients?