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A 65-year-old female retired school teacher presents to the emergency department with progressive weakness in both legs with lower back pain which is down both legs. She also describes reduced sensation in her legs bilaterally. She has been experiencing urinary incontinence for the last day and some faecal incontinence needing pads and a change of underwear which has caused distress.
A cauda equina syndrome - key symptoms and signs include lower back pain, reduced anal tone, leg weakness and altered sensation, urinary retention.
Cauda Equina compression is a medical emergency as if there is a compressive lesion pressing on the cauda, and this might be treatable and this can enable the patient to regain function. Early decompression may save neurology. Cauda equina syndrome is a severe, rare and complex condition. The longer it goes untreated, the greater the chance it will lead to permanent paralysis and incontinence for the patient.
The cauda is a bundle of lower nerve roots that have left the spinal cord and have yet to exit through the spinal foramina. They carry motor to the legs and sensory from lower lumbar and sacral nerve roots back to the brain, and they also supply urinary and rectal sphincters.
Below L1 there will be no UMN signs - NO hyperreflexia, No upgoing plantars and no brisk reflexes. If you find these, you will need to review your findings and diagnosis. Such signs in both legs suggest a cord lesion above L1.
If you remember, the spinal cord ends at L1. So remaining in the canal are the roots for L2, L3, L4, L5, S1, S2, S3. S4. S5, which exit at their corresponding foramina. The lower the lesion in the lumbar spine, the more distal the damage.
Answer
The sole of the foot for s1 and then the back of the legs and buttocks and perianal region and the genitals. This is called the saddle area. Numbness here is a possible sign of root compression above S2/3 in the lumbar canal. With time the genitals and buttocks become numb and at risk of pressure damage.
There may be a weakness of the legs, which can be asymmetrical, and the sphincters will also be flaccid. This means faecal and urinary incontinence and loss of control. Urinary retention may also occur as patients cannot sense that the bladder is full and so do not micturate. This can also apply to bowel movements.
Red flags for Cauda Equina syndrome are
There are several
There are several
There are several
The imaging of choice would be MRI. For those who cannot have MRI then CT would be appropriate.
There are several
She slipped when rushing and had a simple fall down her 2-3 stairs 2 days ago and landed hard on her bottom. The neurological symptoms had worsened until this morning when her husband called 999 as she could not walk. She is just about able to stand but cannot walk. There is some asymmetrical but bilateral leg weakness and anaesthesia on her buttocks. On rectal examination, there was reduced anal tone, and she does not feel the exam. She takes Warfarin for AF.
What are your initial concerns and what diagnosis concerns you
In this syndrome is leg weakness Upper or Lower motor neurone and what so what would you expect to find on the exam.
What spinal nerve roots are typically affected
Where are the dermatomes for the lower sacral roots for S1-S5. Where might sensation be reduced ?
What is the motor deficit that would be expected
What are the Red flags for this syndrome
What are the clues that might suggest an infective cause for this syndrome
What are the clues that might suggest a malignant cause for this syndrome
What are the clues that might suggest a Fracture as the cause for this syndrome
What is the gold standard investigation in patients with suspected CES?
What are some causes for this syndrome
What is the result of a severe CES
What is the management
References
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Case #19 Weakness
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The motor loss will be Lower Motor neuron.
The patient will have difficulty walking and mobilising. They may have difficulty with bowel and bladder function and incontinence and retention, needing ongoing active bladder and bowel management. Their loss of buttocks sensation can lead to pressure sores if not regularly turned. This can be compounded by urine and being wet. There will also be sexual dysfunction and impotence.