List view
SpineNot started
Not started
Deformity
Spinal tumours
Definition: (Lavy et al 2022)
CESincomplete | CESR (w/ retention) |
Lumbar +/- leg pain | Lumbar +/- leg pain |
Motor or sensory deficit in lower limbs | Motor or sensory deficit in lower limbs |
Urinary issues of neurogenic origin including loss of desire to void, altered urinary sensation and hesitancy | Painless urinary retention with overflow incontinence |
Partial saddle anaesthesia | Complete perianal sensory loss |
Anal sphincter tone reduced | Faecal incontinence |
Name | Abbreviation | Definition |
Suspected CES | CESS | No bladder/bowel/genital/perineal symptoms, but bilateral sciatica or motor/sensory loss in legs. (this is clinical CESS) OR known large disc herniation on existing MRI (this is radiological CESS) |
Symptom-only CES (early CES) | CESE | Normal bladder, bowel and sexual function but some sensory loss in perineum or change in micturition frequency |
Incomplete CES | CESI | Alteration in bladder/urethral sensation or function, but maintenance of executive bladder control. +/- perineal sensory changes, or sexual or bowel sensory or functional changes |
CES with retention | CESR | As in 3 but with painless bladder retention and overflow |
Complete CES | CESC | Insensate bladder with overflow incontinence, no perineal personal or sexual sensation, no anal tone |
Numbers
- Annual incidence between 1 in 33 000–100 000
- rare (e.g. only affecting 1-3% of lumbar disc herniations)
- Most commonly at L4/ 5
- Woodfield et al 2023
- Catheterisation for urinary retention was required pre-operatively in 31% (191/615).
- At discharge, only 13% (78/616) required a catheter.
- Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h.
- Earlier surgery was associated
- with catheterisation (OR:2.2, 95%CI:1.5–3.3)
- not with
- admission ODI
- radiological compression.
- Multivariable analyses catheter requirement at discharge was associated with
- pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4)
- one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4),
- but neither outcome was associated with time to surgery or radiological compression.
- Additional healthcare services were required by 65% (320/490) during one year follow up.
Pathology
- Smaller diameter preganglionic and sensory fibres of the sacral nerves are more prone to damage from mechanical compression and inflammation --> urinary and bowel recovery is poorer (40-50% do not recover even at 1 year)
- 4 mech of injury
- Axonal injury
- Axonal viability is said to decline rapidly 6 h after compression and prolonged compression induces secondary mechanisms of cell death.
- Blocked Axoplasmic flow --> Wallerian degeneration in motor nerve roots and sensory nerve roots proximal to the constriction site, AND degeneration of the posterior column.
- Hypoxic insult from arterial stenosis
- local inflammation from endoneural venous congestion,
- disruption of remyelination also occur.
- deteriorate in a continuous rather than stepwise manner. It is probably more likely, therefore, that the earlier the intervention, the more beneficial the effects for the compressed nerves.
- This is probably especially so in acute/traumatic CES (i.e. type I).
Clinical features
- It may present in 3 manners
- Suddenly and without a history of back problems
- As acute bladder dysfunction in the setting of lower back pain and/or radiculopathy
- As slow and insidious visceral impairment as the end point of chronic lower back pain and/or radiculopathy
- Woodfield et al 2023
- Severe lower back pain (95%)
- Bilateral radicular leg pain (46%)
- pain may be absent with an inferiorly displaced sequestered L5/ S1 disc fragment
- Disturbance of urinary function (80%)
- Catheterisation occurs in 30%
- 30% unable to feel catheter tug
- Myotomal weakness (42%)
- Saddle and genital sensory disturbance. (67%)
- Late finding
- Loss of anal sphincter tone resulting in faecal incontinence
- Bowel symptoms 23%
- Bowel incontinence 40%
- complete saddle, and genital anaesthesia
- loss of trigonal sensation
- sexual dysfunction (25%)
- Erection issues (63%)
Bladder symptoms | Count/Total (Percentage) |
Bladder symptoms | 80% |
New symptoms | 79% |
Retention | 41% |
Incontinence | 40% |
Altered sensation | 22% |
Poor stream | 37% |
Urgency/Frequency | 9% |
Investigation
- Bladder scan
- For diagnosis of Urinary retention >200mls (Woodfield 2023)
- For successful TWOC <100mls
- For failed TWOC if
- prevoid
- not pee for 6hrs or
- >500mls of urine
- Post void
- >100mls of urine
- CT
- Peacock 2017: Detection of significant spinal stenosis (Defined as MR percentage thecal sac effacement of ≥50%)
- Sensitivity 0.98
- Specificity, 0.86
- Positive predictive value, 0.72
- Negative predictive value, 0.99
- No cases read as CT percentage thecal sac effacement of <50% were found to have cauda equina impingement.
- MRI
- Gold standard
- MRI confirms CES in 20% of clinically suspected cases
Management
GRIFT guidelines
Surgery
Timing of surgery
- Controversial
- 48-h time point was associated with an adverse legal decision against the treating surgeon, which was not necessarily correlated with the degree of functional loss suffered.
- Ahn et al. (2000): meta-analysis (N=322)
- Surgery within 48 hours of the onset of symptoms increases chance resolution of sensory and motor deficits as well as urinary and rectal function
- >48hrs
- Todd 2005
- onset of CES are more likely to recover bladder function than those treated beyond 24 h (p = 0.03);
- patients treated within 48 h after the onset of CES are more likely to recover bladder function than those treated beyond 48 h (p = 0.005)
- General consensus
- Sooner the cauda equina is decompressed the more likely the chance of recovery.
- Issues with timing
- Defining time of symptom onset can be challenging in a condition with multiple changing symptoms and no clear definition, and differing start points have been used in previous studies.
- Woodfield et al 2023
- No association between early surgery and better outcomes
- But 90% of pt in study had surgery within 24 hrs
Consent form
- Operative approach
- Bilateral: laminectomy.
- Unilateral: Hemilaminectomy and medial facetectomy, or laminotomy and fenestration,
- the advantage being preservation of midline structures,
- less muscle atrophy
- proposed reduction in postlaminectomy back pain.
- Surgical complications:
- Woodfield et al 2023
- Total complications 26%
- Durotomy or CSF leak (12%, 73/619)
- Neurological worsening post-operatively (12%, 76/619)
- Medical complications (4%, 26/619)
- Wound problems (2%, 12/619)
- Re-operation within one year occurred in 7% (45/612)
- recurrent/residual disc (35)
- infection (4)
- haematoma (3)
- CSF leak (1)
- instrumentation (2)
- Re-operation occurred within 2 weeks in 49%
Outcome
- Complete lesions have a poor prognosis and are defined by a neurogenic bladder (insensate and distended secondary to low tone and inability to contract and coordinate sphincter function leading to retention and overflow incontinence).
- Woodfield et al 2023
- Complete symptom resolution
- At discharge 45%
- Ongoing back pain
- At discharge 18%
- At 1 yr: same
- Ongoing sciatica
- At discharge 8%
- At 1 yr: same
- Presence Leg weakness
- At 1 yr: 66%
- Presence Bladder symptoms
- At d/c: 49%
- At 1 yr: same
- Presence Bowel symptoms
- At d/c: 49%
- At 1 yr: 43%
- Normal Sexual function
- At d/c: 25%
- At 1 yr: 44%
- Normal saddle sensation
- At d/c: 45%
- At 1 yr: 54%
- Functional
- Remained employed
- At 1 yr: 79%
- ODI
- At 1 yr: 63--> 31
- Level 3 evidence
- CESi:
- an adequate decompression is performed, up to 90% will avoid the most serious complications of socially unacceptable bladder and/or bowel dysfunction.
- CESR:
- bladder/bowel symptoms may improve in anywhere from 20% to 90% according to reported series, and these observations have been both correlated and not correlated with surgical timing.
- Gardner 2011:
- Approximately 20% will require ongoing support with catheterization, colostomy, sexual function, physical rehabilitation, and psychosocial issues such as depression and employment.
- Dhatt 2011:
- Even in late-presenting CES (mean 12.2 days), 90% of patients may eventually have partial (80%) or complete (10%) re covery of bladder/bowel function long term (mean 34.5 months of follow-up)
Differential diagnosis
Symptoms | CES | Conus medullaris syndrome |
Low back pain with uni/bilateral radiculopathy | Y | Y |
Lower extremity weakness | Asymmetrical | Symmetrical |
Sensory loss (saddle area) | Asymmetrical | Symmetrical |
Bladder and rectal sphincter dysfunction | Later atonic bladder and flaccid sphincter | Earlier atonic bladder and flaccid sphincter |
Lower extremity deep tendon reflex (DTR) | Dependent on level of injury | Absent |
Anal wink/bulbocavernosus reflex | Absent/dependent on location of injury | Absent |
Made with Bullet