(SBQ12SP.38) A 32-year-old woman reports to the emergency department with increased back and leg discomfort for two days after experiencing a painful snap in her low back during an episode of coughing. She complains of numbness in her perianal area and bilateral buttocks, which she detects after peeing. Additionally, she reports having difficulties urinating and has had several incidents of incontinence. She complains of bilateral leg discomfort, which is more severe on the left in the anterolateral calf area. She shows a 3/5 weakness to big toe extension on physical examination and is unable to walk on her heels with her toes raised. Figures A through C depict an MRI of her spine. Which of her symptoms is least likely to improve after surgical intervention? 3736 QID
The spinal cord terminates at the level of the first or second lumbar bone (vertebra). The spinal cord's nerves then form a structure known as the conus medullaris. Below the conus medullaris, the spinal nerves continue to branch out to create the cauda equina. The corda equina is a nerve bundle that contains nerves that regulate the bladder and intestine. Additionally, the cauda equina contains nerves that govern leg mobility and nerves that detect mild touch and discomfort in the legs or in the back passage (perineum).
Cauda equina syndrome (CES) is an uncommon but deadly illness that results from the compression or squeezing of nerve roots in the lower spinal cord, impairing motor and sensory function in the bladder and lower limbs. The cauda equina (Latin for "horse's tail") is a cluster of nerve roots that transmits and receives signals to the legs, bladder, and other areas of the body. CES may arise as a result of strong pressure on the cauda equina caused by a ruptured or herniated lumbar disc. If left untreated, CES may cause significant and irreparable harm to the body, including persistent incontinence and limb paralysis. As a result, CES symptoms need prompt medical care and, in many instances, emergency surgery. Getty Images / Paul Bradbury
The cauda equina nerves control motor and sensory function in the legs and bladder. Compression of these nerves may impair their function, with potentially severe consequences. Cauda equina syndrome may result in bladder and bowel dysfunction (loss of bladder/bowel control), as well as lifelong paralysis of one or both legs' muscles. The cauda equina is derived from the Latin words for âhorse's tail.â The sac of nerve roots resembles the tail of a horse.
Cauda Equina Syndrome Recovery Time After Surgery
A lumbar spinal stenosis caused by a congenitally short spinal canal or central disc and spondylotic narrowing one or more levels below L1 may appear subtly. Lower extremity numbness or discomfort, often in an L3âS1 single or multiradicular pattern, commonly progresses gradually to restrict walking distance over months to years. Pain is often associated with weakness, yet patients may be unaware of their impairment. Clinical insight into this diagnosis and the upper degree of cauda compression is achieved by a manual muscle examination performed after the individual has been supine for a few minutes, followed by having the subject walk for about 500 feet and immediately retesting strength. Paresis, either transient or larger, in the affected root distribution is often seen immediately after the walk and resolves within a minute or two.
While leg discomfort is frequent and normally resolves without surgery, cauda equina syndrome is an uncommon condition that affects the bundle of nerve roots (cauda equina) at the lower (lumbar) end of the spinal cord.
The nerve roots, as an extension of the brain, transmit and receive information to and from the pelvic organs and lower limbs. Cauda equina syndrome develops when the nerve roots in the lumbar spine get compressed, hence impairing sensation and movement. The nerve roots that regulate the bladder and bowel function are particularly sensitive to injury.
The optimal time of surgical decompression is debatable, with immediate, early, and late decompression all producing variable effects. 12 & 13] The rule was to operate on an emergency basis within six hours in CES with acute compression, [14], but numerous writers questioned the clarity of the evidence supporting this approach. (4), (5), (6), (7), (8), (8), (8), (8) Hussain et al. found no difference between patients who received surgery within 5 hours and those who underwent surgery within 24 hours at a 16-month follow-up. [17] Furthermore, a small prospective research found no difference in outcome at three and twelve months after surgical decompression conducted less than 24 hours, between 24 and 48 hours, or within 48 hours of the beginning of CES. [18]
(SBQ12SP.38) A 32-year-old woman reports to the emergency department with increased back and leg discomfort for two days after experiencing a painful snap in her low back during an episode of coughing. She complains of numbness in her perianal area and bilateral buttocks, which she detects after peeing. Additionally, she reports having difficulties urinating and has had several incidents of incontinence. She complains of bilateral leg discomfort, which is more severe on the left in the anterolateral calf area. She shows a 3/5 weakness to big toe extension on physical examination and is unable to walk on her heels with her toes raised. Figures A through C depict an MRI of her spine. Which of her symptoms is least likely to improve after surgical intervention? 3736 QID
Cauda Equina Syndrome Timing Of Surgery
Sexual impotence. If a patient exhibits any of the âred flagâ symptoms listed above, prompt medical treatment is essential to determine if these symptoms are indicative of CES. Diagnosis and Testing Apart from a herniated disc, additional disorders that might mimic CES include peripheral nerve dysfunction, conus medullaris syndrome, spinal cord compression, and irritation or compression of the nerves as they depart the spinal column and pass through the pelvis, a condition called lumbosacral plexopathy. Examinations That Might Be Beneficial in Diagnosing CES Patient history and physical examination are critical in determining the presence of cauda equina syndrome.
The optimal time of surgical decompression is debatable, with immediate, early, and late decompression all producing variable effects. 12 & 13] The rule was to operate on an emergency basis within six hours in CES with acute compression, [14], but numerous writers questioned the clarity of the evidence supporting this approach. (4), (5), (6), (7), (8), (8), (8), (8) Hussain et al. found no difference between patients who received surgery within 5 hours and those who underwent surgery within 24 hours at a 16-month follow-up. [17] Furthermore, a small prospective research found no difference in outcome at three and twelve months after surgical decompression conducted less than 24 hours, between 24 and 48 hours, or within 48 hours of the beginning of CES. [18]
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. This is not to say that symptoms may be disregarded and ascribed to medicine; nonetheless, medication may be a factor in bladder, bowel, and sexual dysfunction. Likewise, discomfort might result in retention. Investigate the patient's pharmaceutical regimen and the possibility of progression up the analgesic ladder? Is medicine being utilized and titrated properly? This may provide insight on the degree of pain and its management. Determine the kind and degree of pain using a VAS. What is the patient's prior medical history; previous disc disease or spinal stenosis, for example, may be crucial. Prior history of life-threatening illnesses such as cancer should be documented and may be significant. Similarly, several co-morbidities, such as diabetes, multiple sclerosis, benign prostatic hyperplasia, and pregnancy, may present as CES.
Cauda Equina Syndrome Surgery
When a patient complains of bilateral leg discomfort, indicators of involvement of the upper motor neurons should be explored (babinski and clonus). The reader is directed to the following book for a full description of neurological integrity testing: 'Neuromusculoskeletal examination and evaluation' [16]. When a patient reports sensory alterations in the perineal region, this area should be evaluated for any sensory loss.
Thecauda equina (Latin for âhorse's tailâ) refers to the lumbar and sacral nerve roots that extend caudal to the conus medullaris inside the dural sac. Although not a genuine âcord syndrome,â cauda equina syndrome reflects nerve root dysfunction, the anatomic clustering of nerve roots inside the lumbar dural sac enables damage to several nerve roots to occur concurrently. The cauda equina syndrome is often caused by a midline disk rupture, most frequently at the L4–L5 level. Tumors and other compressive masses may potentially contribute to the syndrome's development. As with conus medullaris syndrome, patients often appear with increasing fecal or urine incontinence, impotence, distal motor weakness, and sensory loss in a saddle distribution. Muscle stretch reflexes may also be diminished. With a sensitivity of 90%, urinary retention is the most consistent observation. Cauda equina syndrome may or may not be associated with low back discomfort.
CES is often caused by a large herniated disc in the lumbar area. While a single extreme strain or injury may result in a herniated disc, many disc herniations may not have a known etiology. The size of the disc herniation that causes cauda equina is often considerably bigger than usual; but, if the spinal canal is narrowed by disorders such as arthritis, a smaller disc herniation might cause CES. Causes of CES Lesions and malignancies of the spine Infections or inflammation of the spine
The spinal cord is a bundle of nerve fibers that runs through the vertebral canal in a central direction. This organized arrangement of fibers taper to a point at the conus medullaris. This is often located at the L2 vertebral level in adults. A bundle of spinal nerve roots located inferior to this point is referred to as the cauda equina or âhorse's tailâ of the spinal cord. The filum terminale, seen below, denotes the termination of the spinal meninges at S2.
