Cauda equina

syndrome
• Cauda equina syndrome (CES) is a serious neurological condition in
which damage to the cauda equina 
• The spinal cord terminates around the level of L1
• After the conus medullaris, the canal contains a mass of nerves (the 
cauda equina or "horse-tail") that branches off the lower end of the
spinal cord and contains the nerve roots from L1-5 and S1-5
• The nerve roots from L4-S4 join in the sacral plexus which affects the
sciatic nerve, which travels caudally (toward the feet)
• causes loss of function of the lumbar plexus (nerve roots) of the spinal
canal below the termination (conus medullaris) of the spinal cord
Signs and symptoms

• Severe back pain

• Saddle anesthesia , i.e., anesthesia or paraesthesia including the perineum, 
external genitalia and anus; or more descriptively, numbness or "pins-and-
needles" sensations of the groin and inner thighs which would contact a saddle
when riding a horse.
• Bladder and bowel dysfunction, caused by decreased tone of the urinary and
anal sphincters. Detrusor weaknesses causing urinary retention and post-void
residual incontinence
• Sciatica-type pain on one side or both sides
• Weakness of the muscles of the lower legs (often paraplegia)
• Sexual dysfunction
Saddle anesthesia
Causes

• INTERVERTEBRAL DISC PROLAPSE- A large central rupture may cause compression of

the cauda equina
• Acute injury- Vertebral fractures/ Fracture-dislocation
• Trauma- Most common causes include iatrogenic lumbar punctures, spinal
anaesthesia involving trauma from catheters and high local anaesthetic concentrations
around the cauda equina, penetrating trauma such as knife wounds or ballistic trauma
• Spinal stenosis- Congenital stenosis or Acquired stenosis
• Inflammatory conditions- Chronic spinal inflammatory conditions such as 
Paget disease, epidural abscess, neurosarcoidosis, 
chronic inflammatory demyelinating polyneuropathy, ankylosing spondylitis and
chronic tuberculosis
• Spinal cord tumours – Neurofibroma/ Meningioma/ metastasis
Diagnosis

• History- Severe back pain, saddle anesthesia, incontinence and sexual

dysfunction are considered "red flags", i.e. features which require
urgent investigation.
• Clinical examination
• Weakness of the muscles of the lower legs (often paraplegia)- wasting
• Achilles (ankle) reflex absent on both sides
• Absent anal reflex and bulbocavernosus reflex
• Straight leg raising test
• Ix- xray, Myelography (radiculography), CT scan, MRI, CSF analysis
Management

• The management of true cauda equina syndrome frequently involves

surgical decompression. When cauda equina syndrome is caused by a
herniated disk early surgical decompression is recommended
• Surgical decompression by means of laminectomy or other approaches
may be undertaken within 24 to 48 hours of symptoms developing if a
compressive lesion, e.g., ruptured disc, epidural abscess, tumour or
haematoma is demonstrated. Early treatment may significantly improve
the chance that long-term neurological damage will be avoided
• Lifestyle issues may need to be addressed post - treatment. Issues could
include the patients need for physiotherapy and occupational therapy due
to lower limb dysfunction
ASIA score
• ASIA score is the score developed by the American Spinal Injury
Association for essential minimal elements of neurologic assessment
for all patients with a spinal injury 
• These minimal elements are power assessment of 10 muscles on each
side of the body and sensory assessment at 28 specific sensory
locations on each side
How To Calculate ASIA Score?

• Sensory Examination 
• The sensory levels are scored on a 0 to 2 scale for each dermatome
• Each dermatome is tested for light touch and pinprick sensations
• Following scores are given to each sensory point
• 0 – The sensation is absent
• 1 – The sensation is present but impaired
• 2 – The sensation is normal
• labeled as NT (not testable) if cannot be tested.
• Scores are individually tested for both light touch and pin prick. A
maximum possible score is 112 points for each of them for a patient
with normal sensation.

• In addition, presence or absence of anal sensation is also noted

Key Sensory Points In ASIA Score
Motor Examination

• 10 key muscles, 5 in the upper limb and 5 in the lower limb are tested,
one from each respective segment of the cervical cord, are scored on
a 5-point muscle grading scale
• Muscle strength is graded as
 
• 0 Total paralysis
• 1 – Palpable or visible contraction
• 2 – Active movement, full range of motion, gravity eliminated
• 3 – Active movement, full range of motion, against gravity
• 4 – Active movement, full range of motion, against gravity and provides some resistance
• 5 – Active movement, full range of motion, against gravity and provides normal resistance
 
• NT – not testable. Patient unable to reliably exert effort or muscle unavailable for testing
due to factors such as immobilization, pain on effort or contracture.
• The sum of all 20 muscle yields a total motor score for each patient,
with a maximum possible score of 100 points for patients with no
weakness
• Voluntary anal contraction is also noted
Key Muscle Groups In ASIA Score
Determine Single Neurological Level

• After motor and sensory levels have been determined, the

information is assimilated for determining a single neurological levels
• The neurological level is the lowest segment where motor and
sensory function is normal on both sides, and is the most cephalad of
the sensory and motor levels determined in sensory and motor
examination
Complete or incomplete spinal cord injury

• Injury is complete if there is

• No voluntary anal contraction
• S4-5 sensory scores = 0
• Anal sensation = No
• Otherwise injury is incomplete.
ASIA Impairment Scale

• A = Complete: No sensory or motor function is preserved in sacral segments

S4-S5
• B = Incomplete: Sensory function is preserved below the neurologic level and
extends through sacral segments S4-S5
• C = Incomplete: Motor function is preserved below the neurologic level, and
most key muscles below the neurologic level have a muscle grade of less than
3
• D = Incomplete: Motor function is preserved below the neurologic level, and
most key muscles below the neurologic level have a muscle grade that is
greater than or equal to 3
• E = Normal: Sensory and motor functions are normal
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