Cauda Equina Syndrome

The cauda equina consists of 20 nerve roots that originate at the base of the spinal cord. The cauda equina is responsible for sensory and motor innervation to the pelvis and lower limbs, as well as bowel and bladder function. If the cauda equina is damaged by inflammation or compression in the lower back, symptoms may be severe and may develop quickly. Early medical attention and treatment are crucial for making as full a recovery as possible ⁽²⁾.

Cauda equina syndrome is a medical emergency and requires immediate referral for investigation (typically an MRI scan) ⁽⁷⁾. Therefore, whilst extremely rare, it is important that patients and medical professionals identify the possible symptoms suggestive of cauda equina syndrome and take appropriate action.

• Herniation of a lumbar disc – the most common cause of cauda equina syndrome is compression arising from a large central lumbar disc herniation (prolapsed/slipped disc) at the two lowest levels of the spine ⁽⁶⁾.
• Spinal conditions – late-stage ankylosing spondylitis, spondylolisthesis, spinal stenosis.
• Infections of the spinal canal (osteomyelitis) – such as a spinal epidural abscess, which in turn may potentially press into the spinal canal, producing neurological symptoms.
• Post-operative complications from lumbar surgery – a small number of patients experience cauda equina syndrome following surgery to repair a lumbar herniated disc.
• Tumours/neoplasms – tumours may originate in the spine, but it is more likely that cancer from another part of the body spreads toward the spine (malignancy) ⁽⁵⁾.

Cauda equina syndrome is an extremely rare condition. It is reported in approximately 0.04% of all patients presenting with low back pain. Cauda equina syndrome occurs in approximately 2% of cases of herniated lumbar discs ^(2,9).

The diagnosis of cauda equina syndrome is primarily based on a thorough history and clinical examination, assisted by appropriate radiological investigation ⁽⁷⁾. The only way to exclude the diagnosis of cauda equina syndrome is with an emergency MRI scan. About 40% of requested scans show no evidence of cauda equina compression ⁽¹⁾.

Cauda equina syndrome is often categorised as a progressive problem with worsening back pain, sometimes affecting one leg and then the other. There are various, less-alarming reasons for some of the above symptoms, therefore a thorough assessment is necessary to establish the likely cause.

The following is what constitutes an objective exam to assess for cauda equina syndrome. Your physiotherapist will assess your sensation, muscle power, reflexes and will also perform upper and lower neuron testing.

Cauda equina syndrome is not a condition that can be managed by yourself as it requires urgent medical attention. As already mentioned, the important thing is that if you suspect you have the symptoms of the condition you contact your GP or call 111 immediately.

Due to the severity of cauda equina syndrome, please go to A&E as soon as possible if you suspect you have symptoms that suggest this condition.

The ability to return to sporting activities and activities of daily life will be dependent on the success of the surgery. However, in all cases working alongside your physiotherapist on a comprehensive rehabilitation programme will provide you the best outcome possible ⁽¹⁰⁾.

Patients should be referred immediately for a neurosurgical consultation if diagnosed with cauda equina syndrome. Urgent surgical spinal decompression is indicated for most patients to prevent permanent neurological damage ⁽⁷⁾. Following surgery, the extent of recovery is variable. Patients may continue to experience some low back or leg pain, bladder or bowel dysfunction, and other physical problems depending on the duration of nerve compression and the severity of symptoms at the time of surgery. The data suggests that the severity of bladder dysfunction at the time of surgery is the dominant factor in recovery of bladder function ⁽¹⁰⁾.