Recognition and management of Cauda Equina Syndrome APM

Recognition and management of Cauda

Equina Syndrome

James BoothConsultant Spine Practitioner

* Cauda Equina first described in 1600

(Andreas Lazarius)-Syndrome not described

until 1934 (Mixter and Barr)

v CE provides innervation to lower limbs,

sphincters, sensory innervation to saddle area and

parasympathetic innervation to bladder and

distal bowel

* L4-5 (57%), L5-S1 (30%), L3-4(13%)

Background to CES

* It occurs as a consequence of the loss of functionof two or more of the eighteen nerve roots whichcomprise the cauda equina (Woolsley & Martin 2003)

* CE nerve roots vulnerable; no Schwann cell cover and due to microvascular system have region of relative hypovascularity

* Nerve roots show mild demyelination after mild cauda equinacompression

* CES is considered a potential emergency within spinal surgery(Fraser et al, 2009)

Background to CES

* Relies on establishing:* Nature of symptoms* Chronicity* Aetiology* Sphincter dysfunction* Radiological confirmation

Only by careful history taking and examination ofthe patient can CES be diagnosed early andtherefore treated early to avoid life-long disability – Bin et al 2009

Clinical Diagnosis

* Diagnosis can be challenging and worrying process* Only 10% of suspected CES are confirmed by radiology* There is still no broadly accepted definition or diagnostic

criteria for CES (Fraser et al 2009)* Initial signs and symptoms can be subtle and vague (Bin

et al 2009)

Clinical diagnosis

* One or more of the following must be present in order to make a provisional diagnosis of CES:

* bladder and/or bowel dysfunction* sexual dysfunction* reduced sensation in the saddle area!!!

Definition (Fraser et al 2009)

* Significantly more patients are referred on for further investigation compared with those having a radiologically confirmed diagnosis of CES (Balasubramaniani et al, 2010)

* Retrospective review of 753 consecutive LBP patients;* 14% had saddle anaesthesia* 28% altered bladder and bowel function* 27% bladder and bowel control had changed with the onset

of their LBP…….

Reliable Detection

* … only one of these patients had a radiologically confirmed CES that was managed by emergency surgery (Buchanan 2013)

* The cause of these symptoms can be misattributed to CES when the source of the problem may be something less serious

Reliable Detection

* Opioid Salts can cause constipation (e.g. Tramadol, Codeine)

* Anticonvulsants may cause urinary incontinence (e.g. Gabapentin, Pregabalin)

* Antidepressants; retention, sexual dysfunction(e.g. Amitriptyline, Nortriptyline)

Bladder, bowel and sexual dysfunction- Red Herrings

* Stress incontinence

* Pain inhibition* Prostate dysfunction; BPH 30% of 60-69 year olds and

40% of 70-79 year olds

* Erectile dysfunction; (ED) in males with CVD has been reported as high as 65%

Bladder, bowel and sexual dysfunction – Red Herrings

Medications causing urinary retention

Causes of urinary retention

Neurological causes of retention

* Analysis by Korse et al (2013) – 15 studies and 464 patients identified that:* Bladder dysfunction was prevalent in 88.9% of patients with

CES at initial presentation to a healthcare setting* 80.8% of patients complained of saddle anaesthesia during

their initial clinical assessment* Only 47.1% of those with CES had a defaecation

dysfunction at initial presentation

Bladder and bowel Dysfunction

Saddle Anaesthesia

* Incomplete Cauda Equina Syndrome (CESI)* Altered urinary sensation* Loss of desire to void* Need to strain to micturate* Increased frequency of micturition* Increased urgency of micturition

* SURGICAL EMERGENCY

CES – Complete vs Incomplete

* Complete Cauda Equina Syndrome (CESR)* Painless urinary retention* Lack of awareness of need to void* Overflow incontinence (dribbling)* Anorectal continence lost* Penile erection may be achieved at times* Ejaculation weak or lost

* SURGICAL EMERGENCY WINDOW GONE

CES – Complete vs Incomplete

* Symptoms* Back pain (86%)* Perineal numbness (86%)* Unilateral sciatica (57%)* Loss of urinary sensation (46%)

Common Presentation (Ng 2004)

* Signs* Bilateral loss of perineal sensation (53%)* Unilateral loss of perineal sensation (31%)* Unilateral absent ankle jerk (40%)* Absent anal tone (38%)

Common Presentation (Ng 2004)

* “I am going to ask you some really important questions”

* Patients report that some questions do not appear to have face validity when they are in a lot of pain i.e. What has my bladder got to do with my severe back pain? My sexual function normal??

* Explain time frame and seriousness* Chronology is critical – is the picture changing?

Framing your questions

* Loss of feeling/pins and needles between your inner thighs or genitals* Numbness in or around your back passage or buttocks* Altered feeling when using toilet paper to wipe yourself* Difficulty when you try to urinate* Loss of sensation when you pass urine* Leaking urine or recent need to use pads* Difficulty to stop or control your flow of urine* Not knowing when your bladder is either full or empty* Inability to stop a bowel movement or leaking* Loss of sensation when you pass a bowel motion* Change in ability to achieve an erection or ejaculate* Loss of sensation in genitals during sexual intercourse* Bilateral leg pain

CES – Warning Signs

* Determined by the clinical setting* If you suspect – refer* Only perform PR/Bladder scan if within scope* Make it clear if you have concerns regarding CES* Supporting documentation incl:* Relevant history* Neurological exam - motor

- sensory- reflexes- long tract signs (clonus, babinski etc)- neural tension signs

Clinical Assessment

* Influenced by multiple factors, aetiology, speed of onset, duration of compression, degree of neurological deficit, signs and symptom & spinal level

* Severity of bladder dysfunction at the time of surgery is key factor to bladder function recovery

Prognosis

* Clock begins at the onset of urinary or bowel dysfunction* Early bowel dysfunction poor prognosis* CES presenting to A&E only 19% had bilateral sciatica,

lower limb weakness, saddle anaesthesia and sphincter tone disturbance ie. Good surgical opportunity(Jalloh, 2007)

Surgical Window

* Lumbar spine stenosis (LSS) results from degenerative

changes in spine and is common (Kalichman 2009)

* 45-60% of over 65s have MRI evidence of LSS (Haig

2006)

* Sx vary from mild, intermittent leg discomfort to severe

and disabling pain, sensory and motor dysfucntion

(Genevay & Atlas 2010)

* Attributed to transient ischaemia of CE nerves by

combination of mechanical pressure, intraneural root

oedema and venous congestion (Pronin 2019)

CES in older patients



* Differs from acute CES presentation in <50s * Canal compromised by combination of disc, FJA and

LFH* Sx in LSS has a dynamic component, dependant on

posture (Kobayashi 2014)* Typical presentation – increasing LBP

* Increasing LBP* Insidious onset uni/bilat LL sensory disturbance* With or without motor weakness


* As well as neurogenic claudicant sx, patients with LSS may also report

* Nocturnal leg cramps (Matsumoto 2009)* Bladder and bowel sx (Inui 2004)* Erectile dysfunction (Gempt 2010)

* Bladder sx particularly common (incomplete emptying, hesitancy, incontinence, nocturia and UTI – be specific when questioning pt

* Reporting of these sx may be vague and inconsistent due to grumbling nature, and pt may think they’re irrelevant as they are ‘age related’ changes

* 57% of >70s have moderate to severe urinary sx with no CES (Lieberman 2018)


* MRI is gold standard, however sensitivity is HIGH (96%) but specificity is not (68%) for diagnosing LSS (Wassenaar 2012)

* Symptoms and disability correlate poorly with severity of changes seen on MRI (Lurie and Tompkins 2016)

* Weak correlation between severity of stenosis on MRI and bladder dysfunction (Tsai 2010)

* Bladder scan may be of value, but unclear (Venkatesan 2019)


* Mx is challenging, but as a rule, no urgent need to treat* Monitoring is best as sx may wax and wane over time* Full blown CES is rare in this group

* Do not treat unless new or progressing sx of CES

* Safety netting is important with instructions to seek urgent advice if sx change


* Plethora of complexities surrounding reliable CES detection from clinical assessment

* The importance and depth of skilled subjective assessment in the screening and exploration of potential red flags in CES cannot be underestimated in clinical practice

* Red flags in LBP should always be taken seriously. * CES is highly litigious condition with delayed diagnosis

causing significant disability and medical costs (£400m/3yrs)

Conclusion

Conclusion

vs

Recognition and management of Cauda Equina Syndrome APM

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