Cauda Equina Syndrome: Symptoms and Recovery

Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine 

Fortunately, back pain is generally mild, and the prognosis for recovery is favorable. But there are certain situations where back pain can be extremely serious, and cause irreversible damage if it is not taken care of quickly. Cauda equina syndrome, although rare, can cause symptoms as severe as paralysis and incontinence.

This article covers everything you need to know about cauda equina syndrome, from diagnosis to various ways to optimize recovery from this condition.

Definition

Let's start with a little anatomy lesson to better understand cauda equina syndrome.

What is ponytail? Also called “Cauda Equina”, it is a bundle of nerves in the shape of a ponytail, which extends down the spinal cord. This amalgam of nerve roots then descends to the level of the lower limbs.

The role of these nerves is to provide sensation and strength in the legs. Likewise, they control the function of the genitals.

In cauda equina syndrome, the cauda equina is damaged for one reason or another. It affects approximately 1 in 100 people, and constitutes between 000-2% of disc surgeries¹. It mainly affects people between 31 and 50 years old. Its onset can be either acute (sometimes within a few hours!), or even gradual in people with chronic low back pain.

In acute onset, symptoms develop rapidly (within 24 hours). Often there is severe lower back pain, and changes in the genitals (such as rapid onset urinary incontinence). There are also sensory and/or motor changes in the legs (such as loss of sensation or paralysis).

In its progressive form, the symptoms appear after several weeks or months. They can be latent and intermittent. For example, low back pain associated with episodes of sciatica can be noted. Motor changes such as difficulty walking can be observed, as well as reduced sensation in the leg and more or less pronounced incontinence.

Cauda equina syndrome diagnosis

How to diagnose cauda equina syndrome? First of all, let's remember that cauda equina syndrome is a medical emergency, and that the time between the onset of symptoms and the diagnostic assessment should ideally be done on the same day.

On the one hand, the patient's medical history will provide valuable clues to the clinician. Then, a complete physical examination will direct towards a diagnosis of attack of the cauda equina. Among the clinical tests (including a neurological examination), there are sensitivity tests (dermatomas), myotomes, reflexes, etc.

Then themedical imaging will confirm the presence of cauda equina syndrome. MRI (magnetic resonance imaging) is the examination of choice to issue this diagnosis, and thus plan the consequent surgical treatment. A contrast medium may be used if a tumor or infection is suspected.

If no MRI is available in a timely manner, computed tomography can be used. Indeed, it is important to remember that the sooner the diagnosis is issued, the more favorable the recovery will be.

Finally, to quantify bladder dysfunction, an ultrasound or a urinary catheter could be used.

Link to herniated disc

What is the link between herniated disc and cauda equina syndrome? You should know that lumbar disc herniation is the most common cause of cauda equina syndrome. Often, it is at the height of L4-L5 or L5-S1.

For information, a herniated disc refers to refers to a displacement of the gelatinous nucleus inside a disc which pushes and pierces the periphery of the intervertebral disc.

In general, a herniated disc does not affect the ponytail. Indeed, it takes the presence of a relatively massive (and posterior) herniated disc to observe a compression of the cauda equina. This is called a sequestered hernia. This is not the case for the majority of herniated discs.

 To know everything about herniated disc and its treatment, see the following article.

Other causes of cauda equina syndrome

Although herniated disc is the main cause of cauda equina syndrome, this pathology can appear for various reasons. Here are other causes that can also cause a squeeze in the ponytail: 

• Tumors and bone metastases
• Infections (such asosteomyelitis or spondylodiscitis)
• Epidural abscess spinal
• Inflammatory condition (such as ankylosing spondylitis)
• Narrow lumbar canal
• Spondylolisthesis high grade
• Trauma (car accident, gunshot wound, fall, stab wound, vertebral fracture)
• Congenital deformities in children (such as a spina bifida)
• Arteriovenous malformation
• Post-operative complications
• Intra spinal hemorrhages
• Arachnoiditis
• Cysts
• Failed surgery of the spine

Symptoms of the disease

Symptoms of cauda equina syndrome will vary depending on the individual affected. They depend on the nerves affected, as well as the degree of nerve irritation or compression. Generally speaking, they appear bilaterally.

Cauda equina syndrome symptoms include:

• Severe lower back pain that sometimes radiates to the feet (of the sciatica or burn)
• Loss of sensation in the legs
• Loss of sensation in the area of ​​the genitals (glutes, adductors, upper thighs, perineum, anus)
• Numbness and/or tingling in the legs
• Loss of strength in one or both legs
• Loss of balance and difficulty walking
• Urinary and/or fecal disorders (incontinence, loss of sensation when urinating, urinary retention, constipation, difficulty holding a bowel movement, etc.)
• Sexual dysfunctions and erectile disorders

 

cauda equina syndrome surgery

Once cauda equina syndrome has been diagnosed, the surgery emergency is most often the treatment of choice. Corticosteroids are sometimes prescribed to reduce the swelling that would help compress the nerve roots.

The most commonly used surgical option is decompression surgery. A lumbar microdiscectomy can be considered, or a laminectomies. Either way, the goal will be to take pressure off the nerves responsible for the patient's symptoms.

Other operations may be indicated depending on the condition, and the preference of the surgeon. The possible options are: 

• Laminoplasty
• Discectomy
• Corpectomy
• Foraminotomy
• Arthrodesis
• Flavectomy

Regardless of the surgical technique, the main objective will be to correct the neurological disorders. To do this, it is suggested to operate within 24-48 hours of the symptoms appearing to optimize the prognosis.

Sequels

Surgery, although indicated for most cases of cauda equina syndrome, unfortunately does not guarantee complete recovery. Indeed, if the surgery is delayed too much, irreversible damage could be observed. For example, sequelae such as:

• Residual and persistent pain
• Residual weakness and paralysis of the lower limbs (paraplegia)
• Urinary and fecal incontinence
• etc.

The severity of the sequelae will depend on the pre-operative symptoms, as well as the time elapsed between the appearance of the symptoms and the medical treatment. In some rare cases, symptoms may worsen after failed spine surgery.

Post-operative rehabilitation

In general, rehabilitation after cauda equina syndrome is aimed at preserving function and maximizing healing potential.

After surgery, the surgeon will prescribe medication to control the pain. Of the catheters will also be used to control symptoms of incontinence.

In kinesitherapy (physiotherapy), strengthening and balance exercises will increase the strength of the lower limbs, thus reducing the risk of falling. Analgesic modalities will also help control pain in a natural way. Massages and gentle mobilizations performed by a physiotherapist or osteopath will also release tight muscles, increase mobility and improve function.

Note that neurological and reproductive system damage can continue to improve over the years, even after surgery.

If the cause of cauda equina syndrome is a tumor, chemotherapy or radiation treatments should be considered to treat the source of the problem.

Living with cauda equina syndrome

In addition to the physical symptoms, the psychological and social consequences of cauda equina syndrome should not be underestimated (especially when the symptoms are chronic, or if the surgery has left sequelae).

Admittedly, significant pain can prevent the person affected from exercising their profession. But urinary incontinence problems sometimes limit outings and other social activities, in addition to causing repeated urinary tract infections. As for sexual dysfunctions, these can affect the relationship with his/her partner.

For these reasons, it is not uncommon to observe isolation and depression in people with cauda equina syndrome. Emotional support is therefore essential in this population, whether by relatives or by a mental health professional (psychologist, sexologist, social worker, physiotherapist specialize in perineal rehabilitation, Etc.).

Conclusion

Fortunately, cauda equina syndrome is a very rare condition. But it must be remembered that this is a medical (and often neurosurgical) emergency!

If you ever experience any of the symptoms mentioned in the article, it is essential to consult a doctor as soon as possible. The speed at which surgical treatment has been established will greatly affect the prognosis for recovery. We must therefore not play down the situation, or wait for the symptoms to fade by themselves.

If not treated quickly, a cauda equina syndrome can leave sequelae as serious as paralysis of the legs, or even urinary and fecal incontinence.

Good recovery!

Resources

Testimonials from people living with cauda equina syndrome

Reference

• https://www.webmd.com/back-pain/guide/cauda-equina-syndrome-overview
• https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Cauda-Equina-Syndrome
• https://pubmed.ncbi.nlm.nih.gov/24453661/