CAUDA EQUINA SYNDROME

Cauda equina syndrome(CES) is an uncommon compression of the nerves at the end of the spinal cord within the spinal canal.
Cauda equina syndrome can be caused by any condition that results in direct irritation or pinching of the nerves which are located at the lower end of the spinal cord in lumbosacral spine.
These nerves provide motor and sensory function to the legs, feet, and pelvic organs.

It is a rare but serious disorder, and a medical emergency. Compression of these nerves can interrupt their function, and the effects can be severe. Cauda equina syndrome can lead to bladder and bowel dysfunction (loss of bladder/bowel control) and even permanent paralysis in the muscles of one or both legs.
The cauda equina gets its name from the Latin words meaning “horse’s tail.” The sac of nerve roots has an appearance similar to a horse’s tail.

ANATOMY:

The spinal cord tapers and ends at the level between the first and second lumbar vertebrae in an average adult. The most distal bulbous part of the spinal cord is called the conus medullaris, and its tapering end continues as the filum terminale. Distal to this end of the spinal cord is a collection of nerve roots, which are horsetail-like in appearance and hence called the cauda equina (Latin for horse’s tail).

CAUSES:

Lumbar Herniated Disc:
A lumbar disc can herniate in a single injury when excessive pressure is placed on the lower spine, or can occur when an already weakened disc is strained and ruptures. most lumbar disc hereniations occur either at the vertebral levels L4-L5 or L5-S1.

Inflammatory conditions:
It can contribute to cauda equina syndrome if bony overgrowth or inflamed tissues press on lumbar nerve roots. One example of an inflammatory condition that may possibly lead to cauda equina syndrome is ankylosing spondylitis.

Lumbar spinal stenosis:
If the lumbar stenosis put pressure on the spinal canal, cauda equina may result.

Infections:
Infections of the spinal canal (osteomyelitis) such as a spinal epidural abscess, which in turn may potentially press into the spinal canal, producing neurological symptoms.

Tumors/neoplasms:
It may put pressure on the spinal canal. Tumors may originate in the spine, but it is more common for cancer from another part of the body to spread toward the spine (malignancy).

Trauma:
Injury to the lumbar spine, such as a car accident, fall, or a penetrative injury such as gunshot or knife wound, can damage the cauda equina and produce neurological symptoms.

Postoperative complications:
complications from lumbar surgery. A small number of patients experience cauda equina syndrome following surgery to repair a lumbar herniated disc.

Iatrogenic:
Poorly positioned screws placed in the spine can compress and injure nerves and cause cauda equina syndrome.
Continuous spinal anesthesia has been linked to cases of cauda equina syndrome.
Lumbar puncture (spinal tap) can cause a collection of blood in the spinal canal (spontaneous spinal epidural hematoma) in patients receiving medication to thin the blood (anticoagulation therapy). This collection of blood can compress the nerves and cause cauda equina syndrome.

RISK FACTORS:

People most likely to develop CES include those who have a herniated disk, such as older adults or athletes in high-impact sports.

Other risk factors for a herniated disk include:  being overweight or obese
: having a job that requires a lot of heavy lifting, twisting, pushing, and bending sideways
: having a genetic predisposition for a herniated disk.

SYMPTOMS:

The severity of cauda equina syndrome symptoms varies depending on the degree of nerve compression. For some patients, cauda equina syndrome (CES) develops suddenly while other patients experience a gradual onset of symptoms.

LOWER BACK PAIN:

Low back pain can be divided into local and radicular pain.

Local pain is generally a deep, dull, steady, aching pain and may be felt across the lower back and/or pelvis resulting from soft tissue and vertebral body irritation.

Leg pain (radicular pain) is generally a sharp, stabbing pain resulting from compression of the nerve roots. Radicular pain projects along the specific areas controlled by the compressed nerve (known as a dermatomal distribution).

NEUROLOGICAL SYMPTOMS:

motor Weakness, tingling, or numbness in the legs, and/or feet on one or both sides of the body. Lower body weakness or numbness may make it difficult to walk or stand.

Altered sensation in the “saddle region,” or saddle anesthesia. The saddle region is the area of the body that would be in contact with a saddle when sitting on a horse. This region includes the groin, the buttocks and genitals, and the upper inner thighs. With cauda equina syndrome, all or parts of this region may have neurological symptoms of numbness, tingling, and/or weakness.

Sharp or stabbing pain in the legs or lower extremities. Compression of the cauda equina may lead to sciatic nerve pain felt on both sides of the body and may be experienced as a sharp, hot pain felt down the backs of the thighs and possibly into the lower legs and feet.

BLADDER DISTURBANCES (URINARY MANIFESTATIONS):

Inability to urinate (urinary retention).

Difficulty initiating urination (urinary hesitancy)

Decreased sensation when urinating (decreased urethral sensation)

Inability to stop or control urination (incontinence)

BOWEL DISTURBANCES:

Inability to stop or feel a bowel movement (incontinence)
Constipation
Loss of anal tone and sensation

LOSS OF REFLEXES:
A person’s knee and ankle reflexes might be diminished, along with anal and bulbocavernosus abilities.

SEXUAL DYSFUNCTION:

The affected person may experience impotence or loss of ability to ejaculate or orgasm.

DIAGNOSIS:

A medical history, in which you answer questions about your health, symptoms, and activity.
A physical exam to assess your strength, reflexes, sensation, stability, alignment, and motion. You may also need blood tests.

The following tests may be helpful in diagnosing CES:-

Magnetic resonance imaging (MRI):

A diagnostic test that produces three-dimensional images of body structures using magnetic fields and computer technology. MRI produces images of the spinal cord, nerve roots and surrounding areas.

Myleogram:

A myleogram is an X-ray of the spinal canal following the injection of contrast material into the surrounding cerebrospinal fluid spaces; can show displacement on the spinal cord or spinal nerves due to herniated discs, bone spurs, tumors, etc.

A computed tomography (CT) scan

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 lower back.

PHYSICAL EXAMINATION:

Assessment of a patient suspected to have cauda equina syndrome aims at eliciting the following four cardinal features of the syndrome:
• Lower back pain with unilateral or bilateral sciatica
• Lower limb motor weakness
• Sensory abnormalities, particularly in the saddle area
• Visceral involvement, typically urinary bladder.

(i) Lower back pain and sciatica:

STRAIGHT LEG RAISING TEST:

lie the patient on their back, ensuring that knees are fully extended and leg relaxed.
Explain that you plan to raise your leg gently and that you will stop when it causes pain.
Watching the patient’s face, cup your hand under the heel and raise the leg slowly
stop at the onset of the pain and notice the degree of elevation.
lower the leg a few degrees and dorsiflex the foot fully with your free hand.
at this point ask the patient if the pain comes back and to point to where it is felt.
only reproduction of their radicular pain in correct dermatomes should count as a positive straight leg raising test particularly if it occurs at <60 degrees of hip flexion.

(ii) Lower limb motor weakness:

Asking patients to walk on tiptoes and then to walk on their heels is a commonly used screening test for obvious L5 and S1 weakness respectively.
A more sensitive examination of the L5 myotome involves the demonstration that the patient can both evert the foot and extend the big toe (not simultaneously) against resistance.

S1 can be tested by asking the patient to invert the foot or to curl the toes. Although radicular neuropathy results in lower motor nerve signs such as muscle wasting, fasciculations, reduced tone, and diminished reflexes, these are late signs.

(iii) Sensory abnormalities, particularly in the saddle area:

Ask the patient to close their eyes and by randomly touching the appropriate dermatomes with either a pin prick or a blunt end, ask them to say each time whether the stimulus felt sharp or blunt.

(iv) Visceral involvement:

Ask the patient to ‘bite down’ on your finger once inserted to check the power of the external anal sphincter, absent in up to 80%. Note whether there is faecal loading, which can indicate more advanced neuropathy.

TREATMENT:

NON SURGICAL TREATMENT:

Medical treatment options are useful in certain persons, depending on the underlying cause of the cauda equina syndrome. Anti-inflammatory agents, such as ibuprofen (Advil, Motrin), and corticosteroids, such as methylprednisolone (Solu-Medrol, Depo-Medrol).
People with cauda equina syndrome caused by an infection should receive appropriate antibiotic therapy. People with spinal tumors (neoplasms) should be evaluated for chemotherapy and radiation therapy.

SURGICAL TREATMENT:

LAMINECTOMY:

This procedure removes the back part (lamina) of the affected vertebra. A laminectomy is sometimes called decompression surgery because it eases the pressure on the nerves by creating more space around them.
In some cases, that vertebra may need to be linked to adjoining vertebrae with metal hardware and a bone graft (spinal fusion) to maintain the spine’s strength.

DISCETOMY:

For people with a herniated disk as the cause of cauda equina syndrome, the removal of a portion of the bone surrounding the nerves (laminectomy) is performed and the disk material compressing the nerves is removed (discectomy).

PHYSIOTHERAPY TREATMENT:

THERMOTHERAPY:

Applying heat to the lower back improves circulation, which reduces muscle spasms and tension and improves mobility.

CRYOTHERAPY:

Ice packs can reduce inflammation and numb mild pain.

It can be helpful to apply heat before physical activities to relax the muscles and to apply ice after activity to minimize

LUMBAR TRACTION:

By stretching the back, spinal traction works to alleviate pain caused by compressed nerves. The therapist can do that manually (by using his or her own body) or mechanically (with special machines).

ELECTRICAL STIMULATION:

A low-frequency electrical current is used to stimulate your muscles to reduce inflammation.

ULTRASOUND:

Ultrasound may help reduce muscle spasms, stiffness, and pain by sending sound waves deep into your muscle tissues. This creates a gentle heat that enhances circulation.

EXERCISES:

PELVIC TILT:

Lie on your back with your feet flat on the floor.
As you exhale, squeeze your abdominal muscles, push your belly button toward the floor, and flatten your low back.
Hold for 5 seconds. Relax.
Repeat 10 times, holding for 5 seconds each time.

LOWER TRUNK ROTATION:

Lie on your back in the hook-lying position (knees bent and feet flat on the floor).
Rotate your knees to 1 side, holding them for 3 to 5 seconds.
While contracting your abdominal muscles, slowly rotate your knees to the other side and hold for 3 to 5 seconds.
Repeat up to 10 times on both sides.

BRIDGING:-

• Lie on your back with your hands at your sides, knees bent, and feet flat on the floor under your knees.
• Tighten your abdominal and buttock muscles.
• Raise your hips to create a straight line from your knees to your shoulders.
• Squeeze your core and pull your belly button back toward your spine.
• Hold for 20 to 30 seconds, and then return to your starting position.
• Complete at least 10 reps.

HAMSTRING STRETCH:

• lying flat on your back with both legs flat on the floor.
  Next, bring your right knee towards your body and support your right thigh with your hands—or wrap a towel around your thigh and firmly hold each end of the towel.
  Raise your right foot towards the ceiling with the goal of placing your right leg in a perpendicular position. You can gently pull on the towel to bring your leg closer to your body.
  Hold this position for 30 seconds, and then repeat on your opposite leg.

KNEE TO CHEST ( unilateral and bilateral ):

• Lie on your back with feet flat on the floor.
  Bring your right knee toward your chest, using your hands to hold your leg in the stretched position. Hold for 10 seconds.
  Lower your right leg and repeat the exercise with the left knee. Hold for 10 seconds.
  Repeat with each leg 3 to 5 times.
  After stretching each leg individually, perform the exercise by holding both knees in the stretched position. Hold for 10 seconds and repeat 3 to 5 times.

FOREARM SUPPORT:

• Lie in prone position(face down)
  Put forearm at 90 degree with arm and stretch your body up without lifting elbow from floor.
  Hold this position for 10-15 sec and then relax.
  Repeat this for 10 times.

PRONE SLR:-

• Lie face down (prone) on the floor.
  Gently tighten your core muscles by keeping your abdominal muscles engaged. You should still be able to breathe while doing this.
  Keeping your abs engaged and your knees straight, slowly lift one leg up backward. You should keep your knee straight as your thigh lifts from the floor.
  Hold your straight leg up in the air for two seconds, and then slowly lower your leg back to the floor. Be sure you do not rotate your back or your pelvis while lifting your leg.
  Perform the exercise slowly for 10 to 15 repetitions, and then repeat the exercise for the opposite leg.

CAT AND CAMEL:

• Get onto your hands and knees, with your knees spaced hip-width apart and your hands directly beneath your shoulders.
  Tighten your abdominal muscles and arch your spine upward toward the ceiling.
  Hold the position for at least 10 seconds, then slowly relax your back.
  Allow your stomach to fall toward the floor, bring your shoulders together, and stretch your back downwards into a swayback position. Hold for 10 seconds, then return to the starting position.
  Repeat the entire sequence at least three more times.