Cauda Equina

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| |   THE TALE OF THE HORSE'S TAIL:CAUDA EQUINA SYNDROMEBy Dr. Sarah SmithINTRODUCTION:For those who suffer from Cauda Equina Syndrome (CES), there is usually a blank look from family, friends, acquaintances (and even doctors) when they mention their condition.CES is not a "back problem" in the way that people generally think of "backtrouble", although it may well have happened because of spinal problems such as a slipped disc.Both public and medical awareness of CES needs to be improved to avoid those cases that can be avoided by prompt treatment, as well as to help those who suffer from the chronic form by recognizing their condition and helping them with appropriate measures to cope with the numerous problems it causes.3IMPORTANT FACTS ABOUT CES: 1. CES is a neurological (nerve) condition. It may be regarded as a form of spinal cord injury (SCI). 2. CES is seen more commonly as a medical emergency and may also be a chronic condition. 3. CES is a descriptive diagnosis which pertains to a pattern of symptoms and signs, but can have various causes. WHAT IS THE HORSE'S TAIL? There are detailed anatomicaldescriptions available elsewhere, but in brief:The cauda equina (horse�s tail) is so-called because of its appearance.It is found at the lower end of the spinal cord. The spinal cord is shorter than the spinal (vertebral) canal in which it runs, ending at the approximate level of the first or second lumbar vertebra (this may vary in different people). The cauda equina contains the nerve roots from L1-5and S1-5. Note that nerve roots L4-S4 join in the sacral plexus which gives rise to the largest nerve in the body, the sciatic nerve. The sacral plexus is also involved in sensory and motor nerves to and from the anal and genital regions. The nerve roots emerge in pairs from the relevant vertebral foramen (hole) e.g. L3 spinal nerve exits at the L3/4 space (see Image 6). WHAT IS CES?The syndromearises through nerve damage to the cauda equina.There is a specific pattern: * Severe pain in radicular (nerve root) pattern: back, buttocks, perineum(saddle area), genitalia, thighs, legs. * Loss of sensation: often tingling or numbness in the saddle area. * Weakness: in legs, often asymmetric * Bladder/bowel/sexual dysfunction: incontinence / retention of urine; incontinence of feces;impotence/loss of ejaculation or orgasm * Loss of reflexes: knee/ankle reflexes may be diminished, as may anal and bulbocavernosus. (a muscle of the perineum, the area between the anus and the genitals) NOTE: This combination of symptoms arising suddenly is regarded as a medical emergency and requires immediate medical attention to avoid permanent nerve damage.However, CES may also be a chroniccondition as a result of belated treatment of the acute syndrome or as part of an ongoing illness such as Multiple Sclerosis. If it arises gradually, the major warning symptom may be urinary retention (inability to pass urine) which necessitates urgent medical attention.CAUSES:Damage to the nerve roots in the cauda equina may be due to: 1. Compression: by prolapsed disc most commonly; but alsoby any other lesion, including spinal injury (fracture) and chronic compression such as in arachnoiditis. 2. Stretching: e.g. by spondylolisthesis (slippage of one vertebra on another) 3. Inflammation: in conditions such as arachnoiditis. 4. Demyelination: loss of the myelin sheath, essential in nerve signal transmission, in conditions such as Multiple Sclerosis. 5. Toxic damage:(rare)due to spinal anaesthetics. CES due to compression/ distortion may respond well to speedy removal of the cause, but recovery will depend on the duration of the injury and the degree of damage sustained. However, in inflammatory or demyelinating conditions, CES may be chronic and progressive.HOW CES AFFECTS PEOPLE: CES is a devastating condition which can damage many aspects of life.Often, the...