CAUDA EQUINA SYNDROME

Disusun oleh:
Fitri Sasmita Kusuma B
C111 12 291

Supervisor pembimbing:
dr. Jainal Arifin, M.Kes, Sp.OT(K)-Spine

Residen Pembimbing:
dr. William Limoa
dr. Ricky F. Tambunan
dr. Moh. Asri Abidin
WHAT IS CAUDA EQUINA
SYNDROME ??
 Cauda equina syndrome is caused by a
significant narrowing of the spinal canal that
compresses the spinal cord and causes nerve
problems bellow the level of the compression

Rothman-Simeone THE SPINE

 Incidence of CES

Incidence of CES is estimated between 4 and 7 cases

per 10,000-100.000 patients with chief complaint which
includes LBP.

Rothman-Simeone THE SPINE

 ANATOMY
 Spinal cord ends between
vertebrae L1 & L2
 Originates after Conus
Medullaris
 L2 to S5 nerve roots looks
like horse’s tail
 Includes motor nerves,
sensory nerves and
parasympathetic
innervation of the
bladder

Netter’s Concise Atlas of Orthopaedic; Atlas of Netter

 Motoric: Hip,
knee,
ankle, toe &
sphincter
 Sensoric: “saddle
region”

Innervation of Cauda Equina

Rothman-Simeone THE SPINE
Urinary
Contraction of detrusor muscle
innervated by S2-3-4
Initially flaccid and distended
bladder  retention

Ask about urination, palpate

bladder for fullness, bladder
scan and Foley insertion to
document urine volume

Sheerwood Physiology
 ETIOLOGY

 Herniated lumbar disc

 Tumor
 Trauma
 Spinal canal stenosis
 Infection

Rothman-Simeone THE SPINE

 PATHOPHYSIOLOGY

 Nerve roots of the Cauda Equina are susceptible to

injury from compression partly due to a poorly
developed epineurium (less protection from “outside
stresses” or tension).

Rothman-Simeone THE SPINE

 The microvascular systems of nerve roots have a
region of relative hypovascularity in their proximal
third. Increased vascular permeability and subsequent
diffusion from the surrounding cerebral spinal fluid
supplement the nutritional supply. This property of
increased permeability may be related to the tendency
toward edema formation of the nerve roots, which
may result in edema compounding initial and
sometimes seemingly slight injury.
SYMPTOMS
 back pain
 unilateral or bilateral leg pain is the most common
presenting symptom after back pain
 saddle anesthesia
 impotence
 sensorimotor loss in lower extremity
 neurogenic bladder dysfunction
◦ disruption of bladder contraction and sensation leads to
urinary retention and eventually to overflow incontinence

Miller’s review of orthopaedics

PHYSICAL EXAM
 inspection
◦ lower extremity muscle atrophy with insidious presentations
(e.g. spinal stenosis)

 palpation
◦ lower back pain/tenderness is not a distinguishing feature
◦ palpation of the bladder for urinary retention

Miller’s review of orthopaedics

 neurovascular examination
• bilateral lower extremity weakness and sensory disturbances
• decreased or absent lower extremity reflexes

 rectal/anal examination
• reduced or absent sensation to pinprick in the perianal
region (S2-S4 dermatomes), perineum, and posterior thigh
• decreased rectal tone or voluntary contracture
• diminished or absent anal wink test and a bulbocavernosus
reflex

Miller’s review of orthopaedics

 Radiks Pain Sensory Motoric Reflex
Nerve Deficit Deficit Deficit

L2 Anterior medial Upper Mild quadriceps Mild suprapatella

Thigh Thigh weakness, pelvic shrinkage
flexion, thigh
adduction
L3 Anterior lateral Lower Quadriceps Patella or
Thigh Thigh weakness, suprapatella
Knee extension,
thigh adduction
L4 Posterolateral Medial Extenxuion pedis Patella
thigh, tibia leg and knee
anterior
L5 Dorsum pedis Dorsum Dorsofleksi from Hamstrings
pedis pedis and heel
S1 Lateral pedis Lateral Plantar flexion Achiles
pedis from pedis and
heel
S2-5 Perineum Saddle Sphincter Bulbocavernosus;
anal

neurological deficit that occurs

Netter’s Concise Atlas of Orthopaedic; Atlas of Netter
  MRI Imaging

Rothman-Simeone THE SPINE

Netter’s Concise Atlas of Orthopaedic; Atlas of Netter

 Netter’s Concise Atlas of Orthopaedic;
OrthoBullets2017 Atlas of Netter
 TREATMENT

 urgent surgical decompression within 48 hours

indications
◦ significant suspicion for CES
◦ severity of symptoms will increase the urgency of
surgical decompression

Miller’s review of orthopaedics

COMPLICATIONS
 Sexual dysfunction
 Urinary dysfunction requiring chateterization
 Chronic pain
 Persisten leg weakness

OrthoBullets2017
 PROGNOSIS

studies have shown improved outcomes in bowel and

bladder function and resolution of motor and sensory
deficits when decompression performed within 48 hours
of the onset of symptoms

OrthoBullets2017
Thank you