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Cauda Equina Syndrome (CES)
Case Presentation
- Patient Profile:
- 51-year-old male with acute onset lower back pain after a gym session.
- Symptoms: Weakness in lower extremities, pain/numbness in legs (right worse than left).
- Pain unrelieved by parenteral diclofenac.
- Key Findings on Examination:
- Inability to walk on heels.
- Distended urinary bladder palpable below umbilicus.
- Absence of active/passive anal tone on rectal exam.
Diagnosis
- Primary Diagnosis: Cauda Equina Syndrome (CES).
- Common Cause: Herniated intervertebral disc (most often at L4/5 level).
- Clinical Features:
- Lower extremity weakness and pain.
- Urinary retention or bowel incontinence.
- Loss of anal tone and saddle anesthesia.
- Pathophysiology:
- Compression of cauda equina nerve roots (S2–4) affecting bladder, sphincters, and perineal sensation.
Imaging Studies
- Preferred Imaging: MRI of the lumbar spine.
- Identifies compression of cauda equina and loss of CSF signal around nerve roots.
- Sagittal and axial T2-weighted images are critical.
- Alternative Imaging:
- Non-contrast CT scan if trauma or bony fractures are suspected.
- Faster scan time (seconds to minutes) compared to MRI (30–60 minutes).
- Extended Imaging Considerations:
- Include thoracic/cervical spine and brain if clinical findings suggest higher-level lesions.
Differential Diagnosis
- Conditions Mimicking CES:
- Stroke.
- Vascular claudication.
- Deep venous thrombosis (DVT).
- Muscle cramps.
- Peripheral neuropathy.
- Key Differentiator: Detailed history and physical examination.
Management
- Immediate Actions:
- Recognize CES as a neurosurgical emergency.
- Perform rectal exam to assess anal tone and saddle anesthesia.
- Confirm urinary retention using post-void bladder scan.
- Timing of Symptoms:
- Foot drop developing over 24 hours responds better to urgent decompression.
- Chronic symptoms (e.g., weeks of bowel incontinence) may still require surgery to prevent further deterioration.
- Preoperative Workup:
- Full blood count, electrolytes, coagulation studies, and blood grouping/crossmatching.
Key Takeaways
- History and Examination:
- A thorough history and rectal exam are essential for diagnosing CES.
- Imaging:
- MRI is the gold standard; extend imaging if needed to rule out higher lesions.
- Timing Matters:
- Early surgical intervention improves outcomes, especially for acute symptoms (within 24 hours).
- Laboratory Tests:
- Obtain preoperative labs early to address abnormalities promptly.
Conclusion
- Summary:
- CES is a rare but serious condition requiring prompt recognition and intervention.
- Maintain a high index of suspicion for CES in patients with lower back pain, weakness, and urinary/bowel dysfunction.
- Call to Action:
- Prioritize timely diagnosis and surgical referral to prevent irreversible neurological deficits.