A rare but debilitating condition sometimes diagnosed is Cauda Equina Syndrome (“CES”), a neurologic disorder that can be devastating, limiting one’s ability to ambulate (walk unassisted); have control of one’s bladder; effectively have control of one’s bowels and suffer neuropathic pain in one’s back and/or legs. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration. Some of the “red flag” symptoms are as follows:
· Severe Low Back Pain
· Sciatica (Often Bilateral, but sometimes absent, especially at L5/S1 with an interior sequestration
· Saddle and/or Genital Sensory Disturbance
· Bladder, Bowel and Sexual Dysfunction
These symptoms are debilitating and limit a patient’s ability to carry out acts
of daily living. CES can alter our lifestyle.
The CE (from Latin horse tail) is a bundle of spinal nerves and spinal nerve rootlets .The onset of CES may present in stages. Cauda Equina (Impingement of certain nerves in the “horsetail”) Syndrome Evolving (CESE) is descriptive of a slow chronic evolution. The disc herniation, prolapse or sequestration occurs over time. As the herniation, prolapse or sequestration begins, so does the encroachment of the nerves that comprise the horse’s tail that creates the CES.
The symptoms of CES can manifest in various ways. A loss of bladder control; saddle paresthesia; and the loss of control of one’s legs are some of the symptoms of CES. In the Evolving stage, symptoms may vary in the number and intensity. The critical factor from a prognosis standpoint is whether the CES is complete with retention or is CES incomplete (i.e. CES-E or CES-I). In those cases of CES-R, surgical recovery is not likely to occur while in general terms, one’s recovery is much better with CES-E or CES-I. There is no doubt that early decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage. The timing of the surgical intervention is a prominent factor in the success of the surgery. Is CES complete or incomplete? It is evident that the onset of CES may be either acute within hours or gradual over weeks or months and within these groups, CES may be complete with painless incontinence or incomplete with some sphincter atrophy.
Although the above description is clinically useful, in medico-legal and also clinical terms the important distinction is whether, at any given time, CES is complete or incomplete in relation to urinary function and perineal sensation. A useful test is the test for “Trigone Sensitivity” in which an inflated foley catheter is gently pulled with the patient unaware. This should produce the urge to micturate. This will help to distinguish patients with a genuine neurological deficit from those who have purely pain related retention which is not uncommon as a result of constipation. It is well established that the outcome for patients with CES-I at the time of surgery more is favorable, where as those who have deteriorated to CES-R at the time the compression is relieved, have a poorer prognosis.
General opinion suggests that a proven CES requires prompt and appropriate surgical treatment. The analysis of all the variables in CES may be simplified in view of the fact that the most regrettable and damaging consequence of CES is a bladder dysfunction. CES may develop relatively acutely, usually with severe lower back pain and complete anal and bladder motor and sensory loss and usually but not always, with motor and sensory deficits in the lower limbs, all within 24 hours. The consensus is that the longer compression continues, the more likely is long term neurological damage initially to the autonomic, and subsequently to the somatic components of the Cauda Equina. A further factor may be at work apart from mechanical and time factors, and that is the possibility of chemical interference with the function of nerves in contact with the irritating components in prolapsed nuclear material. There is a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of CES. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.
It is a tragedy and usually preventable that CES –E or CES-I is allowed to progress to CES-R while under medical supervision. However, if that progression has already taken place then it seems reasonable and in the patient’s best interest to undergo surgery not as an emergency, but under optimal conditions on the next available operating list, preferably within 24 hours of arrival at the hospital. Recovery from CES can be long and difficult but usually is complete after 1.5 years of rehab, at least to the point that recovery will occur.