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Cauda Equina Syndrome: It’s a Pressing Matter

The cauda equina is a collection of nerves located at the lumbar end of the spinal cord. The 17th century anatomist, Andreas Lazarius, saw that this nerve bundle resembled a horse’s tail and named them the cauda equina (Latin for “horse’s tail”). The mechanical compression of any of the cauda equina nerve roots (L1–L5 and S1–S5) can result in cauda equina syndrome. Permanent injury can develop to the lower extremities and pelvic organs if compression of the nerve roots is not relieved.
Cauda Equina Syndrome: It’s a Pressing Matter

Cause

Compression of the cauda equina nerve roots is usually associated with trauma or injury (fall, car crash, sports injury) that may have caused fractures of the vertebra or the formation of a large blood clot (hematoma). Cauda equina syndrome may also be caused by:

  • A tumor growing on or near the spinal cord
  • A spinal infection with the formation of a swollen pocket of pus (abscess)
  • A large disc herniation (can occur from wear and tear or sudden injury) where the disc’s jelly-like contents spills out and pushes back towards the spinal canal
  • Localized narrowing of the spinal canal (spinal stenosis) that may be caused by degenerative changes, congenital deformity, or trauma
  • Operative or postoperative complication of lumbar surgery

Symptoms

Symptoms of cauda equina syndrome can be sudden (acute) or occur gradually over days or weeks. Most patients with cauda equina syndrome will have severe back pain as well as leg and buttock pain; the pain may be difficult to control. Other symptoms may include:

  • Sensory abnormalities, such as numbness, can occur in the legs or in the genital area (saddle anesthesia)
  • Motor abnormalities such as weakness or paralysis in the leg or foot
  • Reduced or absent lower extremity reflexes
  • The inability to empty the bladder or bowel, but the loss of bowel or bladder control can also occur
  • Sexual dysfunction including erectile dysfunction, lack of sensation in the glans penis or clitoris

Diagnosing

Cauda Equina Syndrome: It’s a Pressing Matter

The diagnosis of cauda equina syndrome is based on presenting symptoms and diagnostic results. The treating provider will:

  • Obtain the patient’s medical history
  • Perform a physical examination paying attention to the patient’s lower extremity muscle strength, reflexes, and sensation to pinprick or vibration
  • Order imaging studies (X-Ray, CT, MRI) and possibly blood tests (complete blood count, Lyme disease, sedimentation rate)

Treatment

Cauda equina syndrome involves prompted treatment to correct nerve compression. It is generally accepted that surgical decompression should be performed as soon as possible after the onset of symptoms.

The goal of treatment is to relieve pressure on the spinal nerves, prevent further injury to the spinal nerves, and to restore sensory and motor function to the pelvic organs and legs. The type of treatment or surgery performed is dependent on the cause of the nerve compression.

Rehabilitation will be necessary, especially if the spinal cord has been injured. The patient will need physical therapy, occupational therapy, and may require leg or ankle braces (orthotics) or other assistive devices for ambulation (crutches, walker, wheelchair). The patient may require in-home care.

Medical Legal Matters

A delay in diagnosis of cauda equina syndrome or surgical trauma that causes cauda equina syndrome, often leads to a malpractice claim.

The Medical Malpractice Verdicts, Settlements & Experts (April 2018) reported on a plaintiff verdict for a 61-year-old man with a history of rheumatoid arthritis, who, because of cauda equina syndrome, suffers from severe numbness and constant nerve pain in both of his legs, is confined to a wheelchair, and has permanent bladder dysfunction requiring self-catheterization, all because of a failure to surgically decompress an L3 disc herniation in a timely manner.

When analyzing the medical records of a case involving cauda equina syndrome it is important to seek answers to the following questions:

  • Was the patient admitted to the appropriate service?
  • What were the patient’s symptoms or complaints, and when did they start?
  • Was there prior treatment for the presenting problem?
  • Were the appropriate consults obtained (neurology, neurosurgery)? Were consults obtained in a timely manner?
  • Was imaging obtained and provided to the appropriate physician in a timely manner?
  • Did nursing staff perform thorough neurologic assessments, including vital signs, at regular intervals? And were abnormal findings reported to the physician?
  • How much time passed between symptoms of cauda equina syndrome and decompression?

When reviewing a case for merit is important to keep in mind that it is possible to have only slight improvement from surgical correction of cauda equina syndrome, even when surgical correction is performed immediate of the symptoms.

For meritorious cases where cauda equina syndrome has a negative outcome (gait disturbance, pain, bladder and bowel dysfunction, sexual dysfunction), a thorough evaluation of the medical record should not stop at hospital discharge. Records from rehabilitation, home care, and follow up physician visits should also be closely reviewed to fully appreciate the patient’s physical and emotional response to treatment and his circumstance.

References

American Academy of Orthopaedic Surgeons. Cauda equine syndrome. Accessed 12/20/18.
https://orthoinfo.aaos.org/en/diseases--conditions/cauda-equina-syndrome

American Academy of Orthopaedic Surgeons. Herniated disk. Accessed 12/20/18.
https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk/

Duncan JW and Bailey RA. Cauda equina syndrome following decompression for spinal stenosis. Global Spine Journal 2011; 1:15-18. Accessed 12/20/18.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3864468/pdf/10-1055-s-0031-1296051.pdf

Kaplow R and Iyere K. Understanding spinal cord compression. Nursing 2016. 46(9): 44-51.

William B (Ed), “Failure to Surgically Decompress L3 Disc Herniation in Timely Manner Results in Cauda Equina Syndrome.” Anonymous Sixty-One-Year-Old Man v. Anonymous Physician), ___ Co. (MI) Circuit Court, No. ___ Medical Malpractice Verdicts, Settlements and Experts, April 2018, 13-14.

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