Cauda equina syndrome

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Cauda equina syndrome ( CES ) is a condition because of damage to the nerve collections beneath the spinal cord ends known as cauda equina. Symptoms include low back pain, pain that spreads to the legs, numbness around the anus, and loss of bowel or bladder control. Onset can be rapid or gradual.

The cause is usually a disc herniation at the bottom of the back. Other causes include spinal stenosis, cancer, trauma, epidural abscess, and epidural hematoma. Diagnosis is often done with medical imaging such as MRI or CT scan.

CES is generally treated by surgery through laminectomy. Some people are left with ongoing bladder problems, sexual dysfunction or numbness. Poor results occur in about 20% of people despite treatment. About 1 in 70,000 people are affected one year. This was first described in 1934.

Video Cauda equina syndrome

Signs and symptoms

• Severe back pain
• Gable anesthesia (see diagram), ie, anesthesia or paresthesias involving S3 to S5 dermatomas, including the perineum, external genitalia and anus; or more descriptive, numb or pin-and-needles sensation of the groin and inner thighs that will contact the saddle while riding a horse.
• Bladder and intestinal dysfunction, caused by decreased urinary and anal sphincter tone. The detrusor weakness causes urinary retention and post-empty residual incontinence as assessed by the patient's bladder scan after the patient has voided.
• Sciatica type pain on one side or both sides, although pain may be completely absent
• Weakness of the lower leg muscles (often paraplegia)
• Achilles (ankle) reflexes do not exist on either side.
• Sexual dysfunction
• There is no anal reflex and bulbocavernosus reflex
• Disturbance interruption

Severe back pain, saddle anesthesia, incontinence and sexual dysfunction are considered "red flags", a feature requiring immediate investigation.

Maps Cauda equina syndrome

Cause

After the medullary cone, the channel contains nerve mass (cauda equina or "horse-tail") branched from the lower end of the spinal cord and contains nerve roots from L1-5 and S1-5. The neural roots of L4-S4 combine in the sacral plexus that affects the ski-nerve, which goes to the caudal (toward the foot). Compression, trauma or other damage to this area from the spinal canal may cause the cauda equina syndrome.

Symptoms can also appear as a temporary side effect of extra-dural sacral injection:

Trauma

Direct trauma can also cause cauda equina syndrome. The most common causes include iatrogenic lumbar puncture, fracture fracture resulting in a posterior migration of fragments from the vertebral body, severe herniation, spinal anesthesia involving trauma from the catheter and high local anesthetic concentrations around cauda equina, penetrating trauma such as knife wounds or ballistic trauma..

Spinal stenosis

CES can be caused by lumbar spine stenosis, which when the canal diameter of the spine narrows. This can be the result of degenerative processes of the spine (such as osteoarthritis) or developmental defects that are present at birth. In the most severe cases of spondylolisthesis, cauda equina syndrome may occur.

Inflammatory conditions

Chronic spinal inflammatory conditions such as Paget's disease, neurosarcoidosis, chronic inflammatory chronic inflammatory polineuropathy, ankylosing spondylitis and chronic tuberculosis can cause it. This is because the narrow spinal duct can be produced by this kind of syndrome.

Risk factors

There are no clearly defined risk factors for CES at this time. Individuals most at risk of herniation are the most likely to develop CES. Race has little effect with the notable exception that African-Americans appear to be slightly less likely to develop CES than other groups; similarly, men are slightly more likely to develop CES than women. Middle age also appears to be an important risk factor, since the population is more likely to develop a herniated disk; weight lifting can also be inferred as a risk factor for CES.

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Diagnosis

Examination for the sensation of pain, with pinprick, indicates limb analgesia (lumbar nerve) with the perineum (sacral nerve) escape. Maintenance of perineal sensation in the absence of a sensation of pain over the lumbar nerve root is typical for extra-medullary and intra-thecal (beyond the rope and in the dural process). Inability to walk, with this unusual sensory examination completes three signs and is usually a spinal tuberculosis. Triads are paraplegia with loss of sensation of lumbar pain and a perineal change sensation.

Diagnosis is usually confirmed by MRI scan or CT scan, depending on availability. Early operation on acute onset in severe cases has been reported to be important.

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Prevention

Early diagnosis may allow for preventive care. The signs that allow early diagnosis include changes in bowel and bladder function and loss of feeling in the groin.

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Management

Proper management of cauda equina syndrome often involves surgical decompression. When cauda equina syndrome is caused by early surgical decompression disc herniation is recommended.

Cauda equina syndrome sudden onset is considered a medical/surgical emergency. Surgical decompression by way of laminectomy or other approach may be performed in 6, 24 or 48 hours of developing symptoms if compression lesions, eg disk rupture, epidural abscess, tumor or hematoma are shown. Early treatment can significantly increase the likelihood of long-term neurological damage to be avoided.

Surgery may be needed to remove blood, bone fragments, tumors or tumors, herniated discs or abnormal bone growth. If the tumor can not be removed surgically and it is malignant then radiotherapy can be used as an alternative to reduce the pressure, with spinal neoplasm chemotherapy can also be used. If the syndrome is caused by an inflammatory condition eg, ankylosing spondylitis, anti-inflammatory, including steroids can be used as an effective treatment. If a bacterial infection is the cause then the right antibiotic can be used to treat it.

Cauda equina syndrome can occur during pregnancy due to lumbar herniation; the age of the mother increases the risks. Surgery can still be performed and pregnancy does not affect treatment. Treatment for those with cauda equina can and should be done at any time during pregnancy.

Lifestyle issues may need to be addressed after treatment. Problems may include the patient's need for physiotherapy and occupational therapy due to lower limb dysfunction. Obesity may also need to be addressed.

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Rehabilitation

Physical therapy can be useful for patient recovery from surgery. The main focus of rehabilitation is focused on controlling bladder and bowel function and decreasing muscle weakness in the lower extremities.

Bowel and bladder control

CES rehabilitation depends on the severity of the injury. If permanent damage occurs, damage to the bladder and bowel control may occur. After surgery, rest is needed until bladder and bowel dysfunction can be assessed. Urine catheterization may help control the bladder. Gravity and exercise can help control bowel movements (Hodges, 2004). Pelvic floor exercises help in controlling bowel movements (Pelvic Floor Exercises, 2010). These exercises can be done standing, lying, or crawling with slightly apart knees. Full recovery of bowel and bladder controls can last for two years.

Physical therapy

Physical therapists can help in the stability of sitting and transferring by doing strength training. The therapist will work on balance, gait, and transfer due to muscle weakness or paralysis can occur in the lower extremities (Dawodu, 2013). In addition, electrical stimulation also helps increase muscle tone (Dawodu, 2013).

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Prognosis

The prognosis for complete recovery depends on many factors. The most important of these is the severity and duration of compression on the damaged nerve (s). Generally, the longer the time before the intervention to remove the compression that causes nerve damage, the greater the damage inflicted on the nerve.

Damage can be so severe that nerve regrowth is not possible, and nerve damage will be permanent. In cases where nerves have been damaged but still able to regrow, recovery times vary widely. Surgical intervention by decompression of cauda equina may aid recovery. Delayed or severe neurological damage can mean up to several years of recovery time because nerve growth is very slow.

The literature review shows that about 50-70% of patients have urinary retention (CES-R) at presentation with 30-50% having incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires an emergency MRI to confirm the diagnosis followed by rapid decompression. CES-I with its more favorable prognosis could be CES-R at a later stage.

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Epidemiology

CES etiologies include fractures, abscesses, hematomas, and compression of relevant nerve roots. Injuries to the thoracolumbar spine do not necessarily result in a clinical diagnosis of CES, but in all such cases need to be considered. Several epidemiological studies of CES have been conducted in the United States, due to difficulties such as collecting sufficient cases and determining the affected population, therefore this is an area that is worthy of additional checks.

Traumatic spinal cord injury occurs in about 40 people per million annually in the United States, resulting from trauma due to motor vehicle accidents, sports injuries, falls, and other factors. An estimated 10 to 25% of vertebral fractures will cause injury to the spinal cord. A thorough physical examination is required, as 5 to 15% of trauma patients experience a fracture that is initially undiagnosed.

The most common injury to the thoracolumbar region is to the conus medullaris and cauda equina, especially between T12 and L2. Of these two syndromes, CES is more common. CES primarily affects middle-aged individuals, especially those in their forties and fifties, and is more often present in men. This is not a typical diagnosis, developing only 4 to 7 out of every 10,000 to 100,000 patients, and is more likely to occur proximally. Disk herniation is reported to be the most common cause of CES, and it is estimated that 1 to 2% of all surgical disc herniation cases produce CES.

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Cost

CES often coincides with congenital or degenerative diseases and is a high cost of care for those hospitalized for surgery. The hospital generally lasts 4 to 5 days, and costs an average of $ 100,000 to $ 150,000 unless the person lives in a country where free health care is at the point of delivery.

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References

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External links

• 06-093c. in Merck Manual Diagnosis and Home Edition Therapy
• Cauda_equina_syndrome on the Duke University Health Systems Orthopedic program

Source of the article : Wikipedia