[ RESIDENT’S CASE PROBLEM ]

MICHAEL S. CROWELL, PT, DPT¹šDEHC7DM$=?BB" PT, DSC, OCS, FAAOMPT²

Medical Screening and Evacuation:

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Cauda Equina Syndrome in a Combat Zone

ow back pain (LBP) is a prevalent condition, particularly in cific LBP, nerve root syndrome (radicu-

L primary care clinics, with billions of dollars spent each year

on treatment.33 It is the fifth most common reason for all
physician visits in the United States.11 Approximately 25% of
adults report LBP lasting at least 1 day within the past 3 months,11
lopathy or stenosis), and serious spinal
pathology.11,30
LBP secondary to nerve root syn-
drome, although less common, is a po-
tentially disabling condition.23 Nerve
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

with approximately 14% having an episode that lasts longer than 2 root syndrome may be related to radicu-
weeks.15 Prevalence ranges from 15% to 20% over a single year40 lopathy, spinal stenosis, or cauda equina
and approximately 70% over the course of a person’s lifetime.15,27,30,40 syndrome (CES).23 Due to the potential
for poor prognosis, timely recognition of
The majority of patients (85%) ease or spinal abnormality.11,15 Current neurologic involvement is essential for
with LBP have conditions that cannot recommendations suggest classifying optimal patient outcomes.23
be reliably attributed to a specific dis- patients into 3 broad categories: nonspe- Acute lumbar disc herniation is one
potential source of both radiculopathy
TIJK:O:;I?=D0 Resident’s case problem. weakness, absent right ankle reflex, and decreased and CES. Approximately 90% of cases of
Journal of Orthopaedic & Sports Physical Therapy®

T879A=HEKD:0 Cauda equina syndrome (CES)
is a rare, potentially devastating, disorder and is
considered a true neurologic emergency. CES often
has a rapid clinical progression, making timely rec-
ognition and immediate surgical referral essential.
T:?7=DEI?I0 A 32-year-old male presented to a
medical aid station in Iraq with a history of 4 weeks
of insidious onset and recent worsening of low back,
left buttock, and posterior left thigh pain. He denied
symptoms distal to the knee, paresthesias, saddle
anesthesia, or bowel and bladder function changes.
At the initial examination, the patient was neuro-
logically intact throughout all lumbosacral levels
with negative straight-leg raises. He also presented
with severely limited lumbar flexion active range of
motion, and reduction of symptoms occurred with
repeated lumbar extension. At the follow-up visit, 10
days later, he reported a new, sudden onset of saddle
anesthesia, constipation, and urinary hesitancy,
with physical exam findings of right plantar flexion
anal sphincter tone. No advanced medical imaging
capabilities were available locally. Due to suspected
CES, the patient was medically evacuated to a neuro-
surgeon and within 48 hours underwent an emergent
L4-5 laminectomy/decompression. He returned to full
military duty 18 weeks after surgery without back or
lower extremity symptoms or neurological deficit.
T:?I9KII?ED0 This case demonstrates the im-
portance of continual medical screening for physi-
cal therapists throughout the patient management
cycle. It further demonstrates the importance of
immediate referral to surgical specialists when
CES is suspected, as rapid intervention offers the
best prognosis for recovery.
TB;L;BE<;L?:;D9;0 Differential diagnosis,
level 4. J Orthop Sports Phys Ther 2009;39(7):541-
549. doi: 10.2519/jospt.2009.2999
TA;OMEH:I0 direct access, lumbar spine, low
back pain, red flags, spinal cord
sciatica are caused by a herniated disc.29
Overall incidence of symptomatic disc
herniation is 1% to 2%,29,39 for which
200 000 discectomies are performed an-
nually.39 Peak incidence of this disorder is
between the ages of 30 to 55 years.15
Characteristics of acute disc hernia-
tion include abrupt, intense onset of
pain that is increased by bending or lift-
ing.48 The most common levels of symp-
tomatic herniation are L5-S1 and L4-5,
which comprise approximately 90% to
98% of cases11,15 and correspond to the
spinal levels that receive the majority of
compressive forces in the lumbar spine.
Clinically, disc herniation at these levels
frequently manifests as L5 and S1 nerve
root compression disorders character-
ized by radiating pain below the knee,

1
Brigade Combat Team Physical Therapist, Iraq. 2 Program Director and Associate Professor, US Army-Baylor University Postprofessional Doctoral Program in Orthopedic Manual
Physical Therapy, Brooke Army Medical Center, Fort Sam Houston, TX. This case was seen at a Troop Medical Clinic in Iraq. The opinions or assertions contained herein are the
private views of the authors and are not to be construed as official or reflecting the views of the United States Army or Department of Defense. Address correspondence to CPT
Michael Crowell, 235 Lancaster Way, Richmond Hill, GA 31324. E-mail: michael.crowell2@us.army.mil

journal of orthopaedic & sports physical therapy | volume 39 | number 7 | july 2009 | 541
 [ RESIDENT’S CASE PROBLEM
TABLE 1
Unrelenting night pain
History of cancer or recent infection
Unexplained weight loss or gain
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Recent trauma
Difficulty with micturation*
Loss of anal sphincter tone or fecal incontinence*
Saddle anesthesia*
Gait disturbance*
* Indicates elements specific to cauda equina syndrome.
decreased sensation in a dermatomal
pattern, myotomal weakness, reflex
changes, and positive straight-leg raise
tests.11,15 However, examination of pa-
tients with acute disc herniation should
always include careful screening for se-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
rious pathology, both before initiation
of and during ongoing conservative
interventions. 3,11 Red flag differential
diagnoses may include CES, metastatic
spinal disease, spinal infection, epi-
dural hematoma, and spinal fracture
or dislocation. 3 Screening for red flag
conditions should include questions
regarding bowel and bladder function
Journal of Orthopaedic & Sports Physical Therapy®
changes, sensory function changes in
the perianal region and genitals, unex-
plained weight loss or gain, fever, night
pain, history of cancer or infection,
history of trauma, and any gait distur-
bances (TABLE 1). 3,22
In adults, the spinal cord is approxi-
mately 42 to 45 cm in length and ter-
minates at the lower border of the first
lumbar vertebra or upper border of the
second lumbar vertebra at the conus med-
ullaris.20 The spinal cord is ensheathed by
3 protective membranes from outward to
within: the dura mater, arachnoid, and
pia mater.20 These membranes extend
to the first segment of the coccyx as the
filum terminale.20 The outer layer of the
dura, arachnoid, and the subarachnoid
cavity is termed the thecal sac, which is
filled with cerebrospinal fluid.20
The term cauda equina describes the
lumbar and sacral spinal nerves descend-
ing from the conus medullaris. During
542 | july 2009 | volume 39 | number 7 | journal of orthopaedic & sports physical therapy
Red Flags
embryo development, the spinal cord and
vertebral column have relatively unequal
rates of growth.20 As a result, the lumbar
and sacral spinal nerves descend almost
vertically to reach their points of exit.20
This configuration resembles a “horse’s
tail,” from which the term cauda equina
is derived in Latin.
CES is a rare, potentially devastating
disorder that may arise from an acute
disc herniation and is considered a true
neurologic emergency.8,45,48 The estimated
prevalence of CES is 0.04% of all patients
presenting with a primary complaint of
LBP,11,15,45 and it is most prevalent in the
fourth or fifth decade of age.43,45 CES oc-
curs in 1% to 2% of all lumbar disc her-
niations that progress to surgery.1,8,15,43,44
CES is most frequently associated with
a nontraumatic massive midline posteri-
or disc herniation, commonly located at
L4-5, followed by L5-S1 and L3-4.43,44,45,48
The sacral nerves, which lie medially in
the cauda equina, are affected dispropor-
tionately in this disorder. A clear diagno-
sis or a high index of suspicion for CES
should prompt immediate referral to a
surgical specialist. Referral to an ortho-
paedic spine surgeon or neurosurgeon,
where available, is the most direct route
of referral; otherwise, the patient should
be sent to an emergency department.
The purpose of this resident’s case
problem is to describe the evaluation,
treatment, referral, and outcomes of a
patient exhibiting signs and symptoms
of CES evaluated by a physical therapist
in a direct-access environment.
]
:?7=DEI?I
History of Present Illness
T
he patient was a 32-year-old
Caucasian male (height, 1.83 m;
body mass, 77.1 kg; body mass in-
dex, 23.1 kg/m2) who initially presented
to a physical therapist in a combat zone
with a chief complaint of insidious onset
low back and left posterior thigh pain. He
was deployed for combat with a primary
responsibility of training foreign military
officers. During convoy operations, he was
a machine gunner, standing in the turret
at the top of an armored vehicle. This job
required prolonged periods of wearing
protective equipment weighing in ex-
cess of 36 kg, often for periods exceed-
ing 8 hours. His symptoms were located
in the lower lumbar spine (left greater
than right), left buttock, and left poste-
rior thigh, as shown in <?=KH;'. The total
duration of symptoms was approximately
4 weeks, but the patient reported a sig-
nificant increase in intensity of pain the
day prior to evaluation without any spe-
cific trauma. He described a dull, aching
pain, and a pain that was intermittently
sharp. The patient denied numbness or
tingling in any location or pain below the
level of the knee. Baseline numeric pain
rating scale (NPRS),25 where 0 is no pain
and 10 is the worst pain that the patient
could imagine, was 4/10 at rest and 7/10
at worst. The patient noted increased
pain with running and forward flexion of
the lumbar spine. Rest and lying supine
relieved his symptoms. His past medical
history was significant for 3 to 4 prior oc-
currences of LBP over the past 8 years,
with similar presentation that, he stated,
resolved without treatment. The patient
had no history of spine or extremity sur-
gery. No previous imaging studies had
been performed. His stated goal was to
decrease his overall pain level during per-
formance of his military duties.
Systems Review
The patient denied saddle anesthesia,
bowel or bladder function changes, unex-
plained weight loss or gain, night pain, or

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Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
<?=KH;'$Body chart of symptoms at initial presentation through day 9.
recent trauma, and had no history of cancer
or infection. In screening for nonmusculo-
skeletal pathology, the patient reported no
history of cancer, cardiovascular, or pul-
monary disease, and no recent occurrence
of nausea, vomiting, fever, changes in ap-
Journal of Orthopaedic & Sports Physical Therapy®
petite, difficulty swallowing, shortness of
breath, dizziness, or changes in balance.
Test and Measures
The patient was neurologically intact
bilaterally with 5/5 strength as assessed
with manual muscle testing26 through-
out the L2 to S1 myotomes, sensation
was intact to light touch throughout the
L2 to S1 dermatomes, and knee jerk and
ankle jerk muscle stretch reflexes were
2+ (normal). Babinski reflex testing was
negative. He presented with decreased
lumbar lordosis and a guarded, obviously
painful, movement of the spine. The pa-
tient displayed a left-sided antalgic gait,
with decreased left hip extension and
early termination of the stance phase of
the gait cycle. Active range of motion was
severely limited in lumbosacral flexion,
with the ability to reach only the mid-
anterior thigh region with the fingertips,
and moderate to severe pain in the low
journal of orthopaedic & sports physical therapy | volume 39 | number 7 | july 2009 | 543
back, left buttock, and left posterior thigh
at the end range of motion. Lumbosacral
extension and side bending were within
normal limits, without an increase in
pain from his baseline NPRS. Repeated-
motion testing was performed as de-
scribed by McKenzie.35 Ten repetitions
of flexion in standing increased his back,
buttock, and posterior thigh pain, while
10 repetitions of extension in standing
reduced those symptoms. Straight-leg
raise tests did not produce radicular pain
but caused a severe increase in LBP at 15°
of hip flexion on the right and 45° of hip
flexion on the left. Hip flexion range of
motion during single knee to chest was
within normal limits bilaterally, with in-
creased LBP that was approximately 50%
less than with straight-leg raise testing.
A lumbar quadrant test was negative bi-
laterally. Passive vertebral motion testing,
as described by Maitland,34 produced lo-
cal pain at L3, L4, and L5 with central
passive posterior-anterior accessory in-
tervertebral motion (PAIVM). Unilateral
PAIVM testing produced local pain at
L3-4, L4-5, and L5-S1, equal bilaterally.
No referral of pain was noted with pas-
sive accessory movement assessment.
Assessment, Intervention,
and Re-evaluation
Using a treatment-based classification
approach,6,7,18 the patient was classified
into the specific exercise classification
and prescribed extension-oriented exer-
cises. Either standing or prone repeated
extension exercises were to be performed
every 2 waking hours, with 10 repetitions,
holding each repetition 2 to 3 seconds at
end range. Education consisted of avoid-
ance of sitting for greater than 20 to 30
minutes, avoidance of full end-range
flexion positions, and the use of a lumbar
roll while sitting and wearing protective
equipment. The treating physical thera-
pist, who had privileges for prescribing
nonnarcotic medication,5 prescribed 7.5
mg Meloxicam (Mobic, 2 tablets once
daily) and 500 mg acetaminophen (Tyle-
nol, 2 tablets every 4-6 hours, as needed)
for pain relief during performance of his
military duties. Because this patient was
essential to the success of his unit’s mis-
sion, only a home exercise program was
prescribed, and a follow-up was sched-
uled for 2 weeks later. He was instructed
to return to the clinic at an earlier time
for re-evaluation if symptoms worsened.
The patient presented for follow-up on
day 4 (3 days after the initial evaluation)
with a complaint of increased pain unre-
lieved by positioning and only short-term
relief with the home exercise program.
His baseline NPRS at rest had increased
to 6/10. He reported a decreased NPRS
to 4/10 after performing home exercises,
but he would return to baseline after ap-
proximately 30 to 60 minutes. Since the
initial evaluation, he had continued to
perform all of his duties, including ex-
tended wear of protective equipment.
The physical examination, including the
neurological examination, did not differ
from the initial evaluation, with the ex-
ception of increased pain with all testing.
His case was discussed with a physician
and he was prescribed a narcotic pain
medication for use as needed, re-educat-
ed in the home exercises to ensure proper
performance, and instructed to continue
the home exercises as tolerated. The pa-
 [ RESIDENT’S CASE PROBLEM ]
tient was to follow-up within 1 week to
monitor the stability of his symptoms and
assess his response to the modified treat-
ment plan.
At a second follow-up 3 days later (day
7 after initial exam), the patient contin-
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ued to have significant pain. He was able

to perform his duties, but the sharp pain
was becoming more frequent and in-
tense. He also reported a recent onset
of numbness in his left posterior thigh.
He continued to deny any radiating pain
below the knee or right-sided symptoms.
The physical exam was unchanged from
initial evaluation and a neurological as-
sessment continued to reveal no mo-
tor, sensory, or reflex deficits bilaterally.
Although strength of left ankle plantar
flexion was 3+/5, he was limited by pain
secondary to a recent ankle inversion
<?=KH;($Body chart of symptoms at 10-day follow-up.
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

sprain on rocky, uneven terrain, which

he described as unrelated to his low back
symptoms and had occurred between the
first and second re-evaluation.
Due to increasing pain despite conser-
vative therapy and medications, he was
restricted from missions that required the
wear of his protective gear and from any
lifting, bending, or twisting. Daily physi-
Journal of Orthopaedic & Sports Physical Therapy®
holds, with 3 repetitions. The patient’s
home exercise program remained un-
changed from the initial evaluation.
Upon presenting for his third day of
in-clinic treatment (10 days after initial
evaluation), the patient had a new com-
plaint of numbness and tingling in the
evaluation. A straight-leg raise test bilat-
erally continued to provoke symptoms
only in the low back region. No sensory
deficiencies to light touch or sharp-dull
stimuli were noted throughout the lower
extremities bilaterally, including the L4-
S1 dermatomes. Strength was reduced in

cal therapy intervention in the clinic was
initiated at that time. The therapist chose
to continue with a supervised exercise
program and adjunct pain-relieving mo-
dalities, because the high-load demands
of this patient’s work duties up to that
point made accurate assessment of the
patient’s response to treatment difficult.
Intervention consisted of interferential
electrical stimulation with 4 pads brack-
eting the symptomatic area of the lumbar
spine, the patient positioned in prone,
and the intensity at the patient’s level of
tolerance. Treatment was combined with
moist heat for 20 minutes, followed by
supervised extension exercises and left
lumbar rotation stretches, both of which
provided mild relief of the lower extrem-
ity pain. Lumbar extension exercises con-
sisted of 3 sets of 10 repetitions, with a
2- to 3-second hold at end range, without
manual overpressure. Lumbar left rota-
tion stretching consisted of 30-second
saddle region and a change in bowel and
bladder function. Although he denied any
incontinence, he stated that it was diffi-
cult to control initiation and cessation
of urination and bowel movements. The
patient also described new symptoms
in the right lower extremity (previously
asymptomatic), with an inability to rise
up onto his toes and constant tingling in
the right calf, while his left lower extrem-
ity symptoms were unchanged from the
last evaluation. <?=KH;( shows the body
chart associated with the new symptom
presentation. He stated, however, that his
pain level had decreased to 4/10 at rest
and 5/10 at worst since he stopped wear-
ing his protective gear 2 days prior.
A detailed physical examination was
performed, with an orthopaedic physi-
cian assistant on staff providing further
guidance on neurological assessment of
the S3-4 levels. Lumbar spine range of
motion was unchanged from the initial
right ankle plantar flexion to 3–/5. The
right ankle jerk (S1) reflex was absent. A
rectal examination revealed decreased
anal sphincter tone and an absent anal
wink reflex. The cremasteric reflex was
intact. The Babinski reflex was normal.
Gait was severely impaired with a de-
creased step length bilaterally and im-
paired toe-off present on the right.
Referral
Because of his rapidly progressive neu-
rological symptoms and a suspicion of
cauda equina compression, the physi-
cal therapist scheduled the patient for
medical evacuation and referral to a
neurosurgeon. No advanced imaging was
performed, as magnetic resonance imag-
ing (MRI) and computed tomography
(CT) scan capabilities were not available
at the local facility. Evacuation to neuro-
surgery care and advanced medical imag-
ing occurred within 48 hours.

544 | july 2009 | volume 39 | number 7 | journal of orthopaedic & sports physical therapy
 ing 1.6 km daily, doing pool exercises at
Radiology Impression of Computed Tomography
J78B;( home, and using 1- to 2-kg weights for
(CT) Scan Prior to Surgical Intervention
upper extremity exercises. At 4-month
L1-2: No disk bulge, central canal, or neuroforaminal stenosis follow-up he had no residual neurological
L2-3: No disk bulge, central canal, or neuroforaminal stenosis or functional deficits and reported a cur-
L3-4: Broad-based disk bulge with no sadistic and central canal or neural foraminal stenosis rent walking program with a 5-kg back-
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L4-5: Moderate disk space narrowing; degenerative changes of the inferior endplate of L4; large disk protrusion with pack. He was cleared by neurosurgery for
moderate central canal stenosis, difficult to tell, but likely some extruded fragments posterior to L5; moderate to full return to military duties, including
severe lateral recess stenosis bilaterally; exiting nerve roots in the neural foramina appear relatively normal redeployment.
L5-S1: No significant disk bulge, central canal, or neural frontal stenosis
:?I9KII?ED
D[kheikh]_YWbWdZ?cc[Z_Wj[ and, to enhance functional recovery, with
Postoperative Care lower extremity exercises aimed to main-

Upon arrival at a Combat Support Hos-
pital, the patient was evaluated by a mili-
tary neurosurgeon. Physical examination
findings were consistent with those at the
medical aid station. Additionally, bladder
function was evaluated and the patient
was found to have a postvoid residual
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tain nervous tissue mobility to prevent
postoperative nerve root scarring. After
3 days in Germany, the patient was then
evacuated to his final destination, Brooke
Army Medical Center, Fort Sam Houston,
TX, for follow-up neurosurgical care and
recovery.
T
his resident’s case problem de-
scribes what could be considered a
classic presentation of CES, recog-
nized by a physical therapist practicing
in a direct-access setting. By a continual
medical-screening process over multiple
visits, the therapist recognized an atypi-
cal progression of mechanical LBP, which

of 300 cc. Although MRI is the recom-
mended imaging modality for CES, be-
cause of the detail provided to the soft
tissues and spinal canal,11 it was not avail-
able in that location either. Instead, a CT
of the lumbar spine with contrast, an al-
ternate recommendation to image CES,11
was performed. The findings reported by
the radiologist were suggestive of under-
Journal of Orthopaedic & Sports Physical Therapy®
H[Yel[hoWdZEkjYec[
The patient arrived at Brooke Army Med-
ical Center 6 days after surgery. An MRI
performed on admission demonstrated
normal postoperative changes and no
residual disc herniation. During his first
neurosurgery postoperative evaluation,
he presented with right buttock pain,
then acutely manifested itself as CES.
Early recognition, confirmation, referral,
and surgical intervention were associated
with a good outcome, consistent with lit-
erature that suggests a good prognosis
with early detection and treatment.1,43,44
C[Y^Wd_YWbB8F
The patient in this case initially present-

lying pathology that could be clinically
correlated with CES (J78B;().
Following neurosurgical evaluation,
he was prepped for immediate surgi-
cal intervention. A L4-5 laminectomy
and decompression was performed and
a large extruded disc fragment was re-
moved from the epidural space. The next
day the patient was evacuated to Land-
stuhl Regional Medical Center in Ger-
many for inpatient recovery. Three days
postsurgery, he was evaluated by a physi-
cal therapist. He had an NPRS of 2/10,
continued complaints of bowel and blad-
der dysfunction, and continued right calf
weakness. He was independent in bed
mobility, edge-of-bed activities, and sit-
to-stand transfers. Right ankle plantar
flexion was 3+/5, but the patient was able
to independently ambulate approximately
18 m. The patient was instructed in ankle
pumps along with progressive ambula-
tion to prevent deep venous thrombosis2,9
resolving saddle paresthesia, numbness
of the right lateral foot region and toes,
bladder incontinence, and erectile dys-
function. Ankle and knee muscle stretch
reflexes on the right were hypoactive, but
he had 5/5 strength throughout both low-
er extremities. Within 1 week he returned
to neurosurgery with some residual right
buttock and foot symptoms, resolved sad-
dle paresthesia, and normal reflexes. He
was cleared by the surgeon for medical
convalescent leave for 30 days, with an
intended referral to a physical therapist
upon return. Upon return from convales-
cent leave (approximately 6 weeks after
surgery), he had regained full sensory
function and continued to demonstrate
normal motor function. No referral was
made to physical therapy, and the patient
was cleared by the surgeon to progress his
walking distance as tolerated and start
stationary bike exercising. By 12 weeks,
the patient had self-progressed to walk-
ed with a history and physical examina-
tion findings consistent with nonspecific
mechanical LBP and no red flag signs
or symptoms. Recent research supports
the use of a treatment-based classifica-
tion approach for acute LBP of this na-
ture.6,7,10,18,24 Due to centralization of his
symptoms with repeated movement in
extension, this patient was classified into
the specific exercise classification based
upon the first step in the algorithm de-
scribed by Fritz et al.18 Browder et al7
examined the effectiveness of an exten-
sion-oriented treatment approach in a
subgroup of patients with LBP extend-
ing distal to the buttocks that centralized
with extension movements. In patients
meeting these criteria, treatment using
extension-oriented exercises resulted in
significantly greater reduction of pain
and disability than treatment using lum-
bar stabilization exercises. Additionally,
Long et al32 demonstrated that patients

journal of orthopaedic & sports physical therapy | volume 39 | number 7 | july 2009 | 545
 [ RESIDENT’S CASE PROBLEM ]
with a movement directional preference compression. Although his finger-to-floor :_W]dei_ie\9;I
for symptom reduction (extension in this distance was severely limited, this physi- CES often has a rapid clinical progression
case) significantly improved when per- cal examination finding may also be as- from other forms of LBP, which makes
forming specific exercises in that direc- sociated with nonspecific LBP, which was timely diagnosis extremely important.
tion as opposed to general exercise, and his initial classification. CES must be included in the differential
worsened performing exercises in the op-
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posite direction.
Diagnostic Test Properties for
TABLE 3
D[hl[Heej:oi\kdYj_ed Tests of Nerve Root Dysfunction
The current case describes mechanical
 I[di_j_l_jo If[Y_ÓY_jo !BH ÅBH
LBP without initial evidence of nerve root
Patient history
dysfunction, which rapidly progressed to
Presence of sciatica15 0.95
CES. A thorough evaluation is essential
Lower extremity pain greater than back pain50 0.82 0.54 1.74 0.33
for accurate identification of LBP with
Dermatomal distribution of pain50 0.89 0.31 1.3 0.34
nerve root syndrome and CES. The pa-
Physical examination
tient history should include any potential
Paresis (weakness, not specific)50 0.27 0.93 4.11 0.78
mechanisms of injury, the location, de-
Absent knee jerk or ankle jerk50 0.14 0.93 2.21 0.78
scription, nature, and intensity of pain,
Finger-to-floor greater than 25 cm50 0.45 0.74 1.71 0.75
the presence or absence of any sensory
Straight-leg raise11,12,15,15,29* 0.91 0.26 1.23 0.35
abnormalities, aggravating factors, eas-
Crossed straight-leg raise11,12,14,23,29† 0.29 0.88 2.42 0.81
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ing factors, and past medical history. The

Ankle dorsiflexion weakness15 0.35 0.7 1.17 0.93
physical examination should include a
Great toe extension weakness12,15,31 0.50-0.61 0.55-0.70 1.36-1.67 0.71
neurologic screen, an assessment of lum-
Impaired ankle jerk12,15,23,31 0.47-0.50 0.6-0.90 1.25-4.70 0.83
bosacral range of motion, assessment of
Ankle plantar flexion weakness15 0.47-0.60 0.76-0.95 1.96-12.0 0.42-0.70
passive vertebral motion, the straight-leg
Quadriceps weakness15 0.01-0.40 0.89-0.99 1.00-3.64 0.67-1.00
raise test, tests for muscle flexibility, and
Abbreviations: +LR, positive likelihood ratio; –LR, negative likelihood ratio.
tests for sacroiliac dysfunction. Sensitiv- * Positive straight-leg raise defined as reproduction of radicular symptoms with elevation of the ipsi-
ity, specificity, and likelihood ratios for lateral lower extremity between 30° and 70° of hip flexion.
†
various physical examination and his- Positive crossed straight-leg raise defined as reproduction of radicular symptoms with elevation of the
Journal of Orthopaedic & Sports Physical Therapy®

contralateral lower extremity between 30° and 70° of hip flexion.

torical items with respect to nerve root
syndrome are listed in TABLE 3.
In general, information from the pa-
Differential Diagnosis of Low Back Pain (LBP)
tient history is better for ruling out nerve TABLE 4
With Potential Neurologic Involvement
root syndromes and the physical exami-
nation is better for ruling in.50 Significant HWZ_YkbefWj^o<hec
indicators of nerve root syndrome include 7Ykj[:_iY>[hd_Wj_ed Spinal Stenosis Cauda Equina Syndrome
focal muscle weakness and limited lum- Age (y) 30-55 60 40-60
bar flexion, as indicated by a large finger- History Acute or recurrent episodes Insidious onset of Insidious onset of severe LBP
to-floor distance.23 Other predictors may chronic, progressive with or without saddle
LBP; more recent anesthesia, bowel/bladder
include lower extremity pain that is great- onset of lower extrem- function changes, possible
er than back pain, a dermatomal pattern ity symptoms history of chronic LBP
of pain location, and increased pain with Pain pattern Pain and/or numbness Lower extremity symptoms Usually presents with radiating
coughing, sneezing, and straining.23 radiating to 1 lower increased with lumbar pain and numbness/tingling
extremity below the extension, relieved by in both lower extremities,
The patient in this case report did not knee, usually increased lumbar flexion increased with lumbar flexion
clearly fit into a nerve root classification with lumbar flexion
during the initial visits. He presented Neurological exam Sensory and/or motor Sensory and motor Bilateral sensory and/or motor
with symptoms proximal to the knee, changes, diminished/ changes changes, diminished/absent
absent deep tendon deep tendon reflexes, sensory
and neurologic screening did not reveal reflexes unilaterally and motor changes at S3-4
either motor loss, sensory impairment, levels
or diminished reflexes. Straight-leg raise Range of motion Guarded, limited Pain and limited extension Guarded, limited
testing did not produce lower extrem- Other tests Straight-leg raise Stage treadmill test Straight-leg raise
ity symptoms consistent with nerve root

546 | july 2009 | volume 39 | number 7 | journal of orthopaedic & sports physical therapy
 diagnosis for patients presenting with
LBP with or without signs/symptoms of
nerve root compression,45 and the patient
history should include special questions
that attempt to identify patients with se-
rious spinal pathology. TABLE 4 describes
Downloaded from www.jospt.org at Univ Of The Sciences In Philadelphia on February 8, 2017. For personal use only. No other uses without permission.
common subjective and objective find-
ings useful for the differential diagnosis
of possible neural involvement. Approxi-
mately 30% of patients present with
CES as the first manifestation of lumbar
disc herniation.1,44 More often, however,
patients will present with chronic LBP
that progresses rapidly to CES within 24
hours.43 Over a 10-day period of general
worsening but neurologic stability, the
patient in this case rapidly progressed
over 24 hours from a history without any
red flag symptoms to all of the red flags
associated with CES, including difficulty
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
with micturition, loss of anal sphincter
tone, saddle anesthesia, and severely im-
paired gait.
The physical examination to identify
CES must include assessment of the L1
to S3-4 levels, including anal sphincter
tone (S3-4), perianal sensation (S3-4),
the anal wink reflex (S3-4), and the cre-
masteric reflex (L1-2) (TABLE 5). The most
Journal of Orthopaedic & Sports Physical Therapy®
frequent physical exam finding is urinary
retention.11,15,23,45 A residual volume great-
er than 100 to 200 cc is considered posi-
tive for urinary retention.45 Decreased
anal sphincter tone is present in 60% to
80% of individuals with CES.15,45
Patients who present with severe or
progressive neurologic deficits should
have a prompt imaging work-up, with
MRI (preferred) or CT.11 While the ad-
vanced diagnostic imaging was delayed
in this case due to lack of availability, the
CT images demonstrating the patient’s
midline herniation at the L4-5 level were
consistent with the most common loca-
tion and type of disc herniation associ-
ated with CES.11,15
Referral and Treatment of CES
The primary indicators for neurosurgical
referral for this patient were the presence
of bowel and bladder function changes,
saddle anesthesia, decreased anal sphinc-
journal of orthopaedic & sports physical therapy | volume 39 | number 7 | july 2009 | 547
Diagnostic Test Properties of
TABLE 5
Tests for Cauda Equina Syndrome
 I[di_j_l_jo
Urinary retention11,15,23,45 0.9
Unilateral or bilateral sciatica 15,23
0.80
Unilateral or bilateral motor/sensory deficits15,23 0.80
Positive straight-leg raise15,23* 0.80
Sensory deficit: buttocks, posterior-superior
thigh, perianal region3,15 0.75
Abbreviations: +LR, positive likelihood ratio; –LR, negative likelihood ratio.
* Positive straight-leg raise defined as reproduction of radicular symptoms with elevation of the ipsi-
lateral lower extremity between 30° and 70° of hip flexion.
ter tone, and progressive neurological
changes (new onset of significant motor
weakness in the S1 myotome).
CES is the primary absolute indication
for acute surgical treatment of lumbar
spine pathology.3 Rapid recognition cou-
pled with timely referral and surgical care
provides the best chance of functional re-
covery.45 The treatment of choice is surgi-
cal decompression, usually a laminectomy
followed by discectomy.43,44 Performing
the laminectomy first allows excision of
the extruded disc material without undue
manipulation of the neural elements.43
The patient in this case had an emergent
laminectomy and decompression with re-
moval of the extruded disc fragment from
the epidural space, confirming the diag-
nosis of CES. Surgical intervention was
performed within 72 hours of diagnosis,
which was extremely close to the length
of time where the risk of permanent neu-
rologic deficit is increased. Although not
optimal, this delay was related to the re-
alities of medical care in a combat envi-
ronment, and every effort was made to
ensure a rapid evacuation of this patient
to a neurosurgeon. Even under standard
conditions, Shapiro44 previously reported
that only 45% of patients presenting to
the emergency room or primary care
physician underwent surgery within 48
hours.
Following surgery, the patient had lim-
ited inpatient physical therapy and was
later placed on a convalescent leave status
for 30 days. He was released with instruc-
tions to complete a progressive walking
If[Y_ÓY_jo !BH ÅBH H[\[h[dY[i
0.95 18 0.01 Chou, Deyo, Haswell, Small
Deyo, Haswell
Deyo, Haswell
Deyo, Haswell
Arce, Deyo
program and given activity restrictions
consistent with discharge instructions for
patients receiving lumbar spine discecto-
my surgery. The patient was not referred
to outpatient physical therapy services as
part of his rehabilitation, possibly due to
his rapid symptom recovery, high level of
motivation to return to full function, and
ability to carefully progress on a general
home exercise program. Although this
patient did not receive postoperative out-
patient physical therapy, there is strong
evidence to support intensive exercise
training beginning 4 to 6 weeks after
nonfusion lumbar spine surgery,13,16,37,42
which focuses on trunk/pelvis and lower
extremity strengthening,13,28,37 cardiovas-
cular conditioning,41 and stretching of the
lumbopelvic musculature.41
Fhe]dei_ie\9;I
At his 18-week follow-up appointment,
the patient had an excellent result, with
no motor deficits, normal bowel and
bladder function, and return to full oc-
cupational duties. The excellent outcome
in this case highlights the importance of
early recognition of symptoms and im-
mediate surgical referral.
Recent research has shown a signifi-
cant advantage to treatment within 48
hours of onset.1,44 The risk of permanent
neurologic deficits is increased when
more than 72 hours elapses before de-
finitive treatment1 and longer delays
correlate with worsening functional out-
comes.8 In a meta-analysis of surgical
outcomes of CES, 3 factors suggestive
 [ RESIDENT’S CASE PROBLEM
of a poor outcome were identified: his-
tory of chronic LBP, preoperative rectal
dysfunction (diminished motor or sen-
sory function), and surgical intervention
greater than 48 hours after onset of CES.1
The patient in our case clearly recovered
Downloaded from www.jospt.org at Univ Of The Sciences In Philadelphia on February 8, 2017. For personal use only. No other uses without permission.
better than expected, considering that all
3 of the items suggestive of a poor prog-
nosis were present.
Attaching a numerical value to the
prognosis for patients with CES is diffi-
cult. A common problem in current re-
search is the limited number of patients
studied, secondary to the rarity of the dis-
order. Subsequently, studies of CES often
have limited power to detect significant
differences in prognosis.1
F^oi_YWbJ^[hWfo:_h[Yj7YY[ii
During deployment in support of com-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
bat operations, military physical thera-
pists provide direct access and primary
care for injured soldiers. The case of CES
presented here, however, is not neces-
sarily unique to the military or combat
environment and a very similar presen-
tation could be seen in any clinic with or
without direct access. Recent research
has shown that direct access to physical
Journal of Orthopaedic & Sports Physical Therapy®
therapy services does not compromise
patient safety. Physical therapists have
proven themselves able to identify serious
pathology that mimics a musculoskeletal
complaint4,17,19,21,36,38,49,51 and possess diag-
nostic accuracy equivalent to orthopaedic
surgeons.36,46
9ED9BKI?ED
P
hysical therapists must con-
tinually monitor patient status and
act appropriately when conditions
emerge that require immediate referral.
Physical therapists often treat a high vol-
ume of patients with LBP, the majority of
which are nonspecific and benign in na-
ture. Although CES is a rare disorder, the
potential devastating consequences of a
missed diagnosis make a thorough evalu-
ation and continuous medical screening
throughout the patient management
cycle essential. The current case problem
548 | july 2009 | volume 39 | number 7 | journal of orthopaedic & sports physical therapy
describes a unique episode of nonspecific
LBP with rapid progression to CES during
ongoing management, and correct diag-
nosis and referral by a physical therapist
in a direct-access setting. Timely referral
and surgical intervention in this case was
associated with an excellent outcome and
full functional recovery. T
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Journal of Orthopaedic & Sports Physical Therapy®

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