Cauda Equina

By Hugh Pelc
Bsc, MBBS, MRCS, MRCGP
 This is a serious business

 Cauda equina syndrome occurs in approximately 2% of cases of

herniated lumbar discs
 The cauda equina are LOWER motor neurones and sensory nerve

roots.
 They do not show good healing compared to UPPER motor

neurones
 Good evidence suggests surgery should be performed within 24h of

the onset of symptoms

 Complications of untreated/delayed treatment include incontinence

and sexual dysfunction.

 More than 1000 operations/y performed in England alone i.e. NOT

RARE
 Average litigation payout 336,000 GBP
 Aims

Understand anatomy pertinent to Cauda Equina syndrome

Understand what Cauda Equina Syndrome is
Know the important symptoms of Cauda Equina
Know the important aspects of examination for Cauda Equina
Know when referral is indicated

Educators love aims and objective slides

What is the cauda equina and why is it so special anyway?
What is Cauda Equina Syndrome?
Disc Bulge
Cauda Equina
 Why is it so bad?

 The disc squishes all of the nerve roots

 This therefore includes those innervating the bladder,
bowels and genitals
 Consequently incontinence, global weakness/paralysis and
sexual dysfunction are risks
 Don't forget these are lower motor neurones and heal badly

This is a “chunk and check” slide

 Classic History

 Develops rapidly over hours-days

 Sometimes on background of established sciatica
 Here are the “classic signs”:

Paraesthesiae
Motor abnormality
1)Bilateral sciatica
2)Altered perineal (peri-anal) sensation
3)Absence of urge to micturate
4)Urinary retention/incontinence (overflow)
5)Faecal incontinence/constipation
6)Altered genital sensation
7)Sexual dysfunction (i.e. erectile dysfunction)
 Hang on a minute...

How do we know that altered perianal sensation or any other

“classic sign” is not from normal sciatica?
i.e. from a paracentral disc bulge
Because there aren't any discs below the L5/S1 disc

So the S2 root cannot be

compressed by a
paracentral disc bulge
Nor can the S3,4 or 5 roots!

Innervation of perianal
sensation/bladder
function/bowel
function/genital sensation is
all from lower sacral nerve
roots
 HISTORY: What to ask

Step 1: Confirm that this really is sciatica – i.e. dermatomal

shooting pain extending below the knee
It is unlikely to be sciatica if there is no pain below the knee
95% disc prolapse occurs at L4/5 or L5/S1
If there is no pain below the knee establish the dermatome
carefully

Step 2: Ask for the “classic signs”.

 HISTORY: What do we really need to ask?

“You might have trapped a nerve”

“The nerve causes pain in your leg but it might also control your
bladder, bowel or private parts”
 “Do you still notice the urge to pee?”
 “Have you wet yourself at all”
 “Do your privates still feel normal when you wipe?” (female)
 “Does your penis feel tingly?” and “Have you started
having trouble getting erections?” (male)
 “Do you ever get the pain in the other leg?”
 “How are your bowels?”
 “Have you noticed any pins and needles around your back
passage?”

BEWARE: codeine, previous incontinence/ED, pain that isn't

sciatica
 HISTORY: Summary

Establish a history of dysfunction in a nerve supplied by S2 or

lower.

Bladder
Bowel
Genitals
Perineum

“This is a chunk and check slide”

 EXAMINATION: What should we do?

STEP 1: Establish sciatica

Check for dermatomal paraesthesiae
Check for myotomal weakness

STEP 2: Special tests to help establish sciatica

SLR until pain ellicited
Does ankle dorsiflexion worsen pain?
Does knee flexion improve pain?

STEP 3: Consider testing hip rotation/knee

movements.
If they admitted to any “classic signs”

Glove up people, you're going in.

 EXAMINATION: Summary

Establish Sciatica
PR if they admitted to “classic signs” in the history

“This is a chunk and check slide”

 Indications for Referral/MRI

Presence of any “classic signs”

Just 1 will do.
Lower Limb Neuro Examination

L2 – Hip flexion
L3 – Knee extension
L4 – Ankle Dorsiflexion
L5 – Hallux dorsiflexion
S1 – Ankle Plantarflexion

All posterior muscles are S1 (e.g.

knee flexion)