Cauda equina syndrome - treatment, symptoms, causes, diagnosis

Find out more about other diseases starting with the letter “C”: Compression of the brain; Senile chorea; Sensitive ataxia; Serous meningitis; "Rigid person" syndrome; Alien hand syndrome; Restless legs syndrome; Bogorad syndrome; West syndrome; Gaye-Wernicke syndrome; Guillain-Barre syndrome; Piriformis syndrome; Carpal tunnel syndrome; Carotid sinus syndrome; Kleine-Levin syndrome; Klippel-Feil syndrome; Cauda equina syndrome; Crumpy syndrome; Lambert-Eaton syndrome; Landau-Kleffner syndrome.

Cauda equina syndrome is a system of neurological symptoms in which the bundle of nerve fibers in the region of the spinal cord formed by the lumbosacral nerves of the conus medullaris is damaged. Clinically manifested by decreased tone of the legs, sensory disturbances in the area of innervation of damaged nerves, and dysfunction of the pelvic organs.

The diagnosis is established after consultation with a neurologist, based on the results of MRI, CT, and spinal puncture. Treatment can be conservative or surgical with further rehabilitation.

general information

The spinal cord ends at the level of the first lumbar vertebra. The nerves of the lumbar, sacral and coccygeal segments and the filum terminale form a bundle called the cauda equina. Vertebroneurologists distinguish damage to the cauda equina as a separate disease, regardless of the reasons that influenced it.

The syndrome appears in middle-aged people more often than in other patients. Children get cauda equina syndrome after injuries or pathologies of the lower parts of the spinal canal. In men, the disease is more common in women; it is associated with lifting heavy weights.

Relevance of the problem

Radicular syndrome or radiculopathy is a symptom complex associated with compression of nerves at the level of the spinal column [5]. For various reasons, one or more nerves leaving the spinal canal become compressed by hard tissue. The spine consists of vertebrae of different sizes, in the center of each there is a hole, the combination of which forms the spinal canal. It contains the spinal cord, which consists of motor and sensory nerves that run toward or away from the brain. Nerves extend from the vertebrae to certain organs, muscles or areas of the skin. Together, the nerve fibers and their plexuses form the spinal part of the peripheral nervous system.

Rice. 1. Diagram of the peripheral nervous system

When the distance between the vertebrae changes or bone growths appear, these branches can be pinched, which forms radicular syndrome. The spinal root includes efferent motor axons (anterior root) and afferent sensory axons of the spinal cord ganglion. Sometimes compression affects isolated sensory or motor nerves (for example, with herpes zoster or polyradiculitis), but more often both branches of the spinal root are subject to compression [6]. Also, radicular syndrome is formed by compression of the cervicobrachial and lumbosacral nerve plexuses, which are the branching and connection of mixed axons of motor and sensory nerves [1].

Rice. 2. Vertebral structure

The main manifestation of radicular syndrome is severe back pain. The vast majority of the population encounters this symptom throughout their lives, which is why the relevance of the problem cannot be in doubt.

Causes of cauda equina syndrome

The main factor in damage to the terminal nerve bundle is its compression in the spinal canal. Among the most common causes, intervertebral hernia in the lumbar spine plays a key role. Sometimes inflammatory, external causes are found. The main underlying factors of the syndrome:

Intervertebral hernia explains 15% of cases of the disease. Osteochondrosis of the spine and degenerative processes of intervertebral discs give rise to the formation of protrusion and accelerate its development. Lumbar hernias compress the cauda equina.
Injuries. Fracture of the sacral vertebrae and spinal cord injury of the corresponding part cause defects in the nerve fibers. Compression can be generated by hemorrhages and hematomas. Cauda equina syndrome can become a complication of epidural anesthesia and surgery.
Neoplasms. Tumors of a malignant nature grow into nerve bundles, damaging nerve tissue. Benign neoplasms arise from nerve sheaths (neurinoma), spinal ependymoma (ependymoma), fat cells (lipoma), meninges (meningioma) - all of them cause compression of the nerve roots.
Curvature of the spine. Inherited pathologies of the spine in the lumbosacral region can significantly narrow the terminal part of the spine, creating conditions for compression damage to nerve fibers. Acquired deformities lead to age-related destruction (spondyloarthrosis deformans), dislocation of the lumbar vertebrae (spondylosis).

Etiology and pathogenesis of radicular syndrome

Radicular syndromes are included in the clinical picture of spinal osteochondrosis, traumatic injuries or compression by a tumor. Degenerative-dystrophic processes in the intervertebral discs and vertebral bodies are represented by protrusions and hernias, the appearance of osteophytes, spondyloarthrosis of the intervertebral joints and actual compression or irritation of the spinal nerve roots. Instability of the spinal motion segment leads to displacement of the vertebrae relative to each other, as a result of which the nerves are pinched under the influence of various predisposing factors, which include:

hypothermia;
holding an uncomfortable position for a long time;
violation of the rules of ergonomic movements;
increased load on the spine;
sudden movements;
premature aging of intervertebral discs;
age over 40 years;
pathological motor stereotype;
viral diseases (shingles, tick-borne radiculitis);
developmental anomalies of the spine [1,5,10, 12].

Compression of the nerve trunks is accompanied by aseptic inflammation, as a result of which the root is further compressed by edema.

Rice. 3. Anatomical diagram of nerve root compression

Causes of compression radicular syndromes:

decreased disc height, which entails a narrowing of the diameter of the intervertebral space;
hernia or protrusion of the disc, which leads to compression of the root;
spondylolisthesis (forward displacement of the vertebra) with root injury;
compression of the root by the yellow ligament or osteophytes;
compression of the root by a tumor (neurinoma, osteosarcoma, metastases of other tumors);
spinal injury and compression of the root by bone formations or hematoma [1,12].

A segmental blockade of the spinal motion segment develops, a muscular response is formed in the form of local muscle tension and myofixation—limitation of mobility in the damaged segment of the spine. It is believed that a neuroallergic or neoplastic process plays an important role in the pathogenesis of severe radicular syndrome [1].

There are other approaches to the origin of the syndrome; many doctors and researchers argue for an initially muscular or mixed pathology, where sluggish nonspecific inflammation leads to changes in both the muscles and the spine, forming a “tectonic shift” in the affected tissues, leading to pinched roots .

Pathogenesis of the disease

The lumbar and sacral nerves, which are part of the structure of the cauda equina, provide innervation to the lower extremities, bladder, external genitalia, urethra, and rectal sphincter.

At the onset of the disease, a violation of their functionality determines irritation and increased excitation of nerve endings, with the presence of severe pain. The more the destruction or compression of nerve endings progresses, the more innervating functions are inhibited, sensitivity decreases, and muscle paresis occurs. Neoplasia, which is malignant in nature, destroys the membranes of the spinal canal and provokes metastases.

Compression radicular syndromes in dorsopathies of the thoracic spine

The thoracic spine is less mobile than the cervical spine. When nerve roots are compressed at this level, the following symptoms occur:

girdling pain, aggravated by coughing, sneezing, or movement;
pain on both sides of the spine;
decreased or worsened sensitivity in certain areas of the skin;
pain when inhaling, bending and turning;
muscle tension;
Horner's syndrome: narrowing of the palpebral fissure, drooping eyelid, hypotrophy of the innervated muscles (compression of the th1 root);
decreased abdominal reflexes;
dysfunctions of the gastrointestinal tract;
myelopathic syndrome with prolonged exposure to the root and spinal stenosis: constant pain, vascular disorders;
chest pain simulating cardialgia;
itching;
muscle wasting;
changes in skin color (redness or paleness);
sweating and local increase in body temperature;
edema [10].

Rice. 6. Thoracic radiculopathies

Clinical picture

Pain appears at the very beginning of the disease. It is concentrated in the lumbar and sacral region, and is remotely felt in the leg on the side of the injury, the groin area. The patient experiences hypersensitivity and poor tactile sensations in terms of painful sensations. When coughing and sneezing, the pain increases significantly, and decreases in a semi-sitting position. A decrease in sensitivity, felt as numbness, indicates increasing hypoesthesia.

Complaints of rapid fatigue while walking and lethargy of the muscles of the lower extremities are signs of motor dysfunction. The more active the pathological process becomes, the more severe the symptoms, and the damage is distributed to the other side of the body. Over time, independent walking becomes difficult.

Disruption of the innervation of the external genitalia leads to a significant decrease in their sensitivity. This, in turn, causes anorgasmia in women and erectile disorders in men. The pelvic organs react with urinary retention and persistent constipation to sensory impairment. Patients are not aware of fullness of the bladder and rectum.

Complications of the disease

If treatment is not complete or insufficiently adequate, the patient may suffer disability associated with walking pathology. A disorder in the perception of fullness of the bladder and rectum can provoke the formation of a diverticulum, infected urethritis, cystitis, pyelonephritis along the ascending route of infection. Untimely removal of metabolic products can cause the accumulation of toxins in the intestines and general poisoning of the body. Fecal blockage and acute urinary retention are conditions that require urgent medical attention.

Diagnosis of cauda equina syndrome

The initial signs of cauda equina syndrome can be mistaken for clinical symptoms of femoral nerve neuropathy, radiculitis, and lumboischialgia. It should be remembered that the manifestations of cauda equina syndrome have bilateral manifestations. It is necessary to question the patient in detail about the presence of disorders of the pelvic and genital organs.

To confirm the diagnosis, be sure to perform:

Neurological examination. During a consultation with a neurologist, mono or paraparesis, decreased muscle tone, and degenerative disorders are discovered. Physiological reflexes (Achilles, anal, in men - bulbocavernosus) are not expressed. Sensitive disorders that occur in areas of innervation of nerve endings indicate injury to several lumbosacral nerves.
CT scan. Spinal stenosis and pathologies of bone structures are clearly visible on CT images.
Magnetic resonance imaging. Insufficient detection of soft tissue pathologies on CT requires MRI. The resulting images determine the presence of hematomas and neoplasia. The level of narrowing of the spinal canal is determined more accurately.
Spinal tap. If during the procedure it is not possible to obtain cerebrospinal fluid (dry puncture), it is clear that the cerebrospinal fluid pathways are blocked by a tumor or hernia. There may be blood in the cerebrospinal fluid, which indicates hemorrhage. An increase in the amount of protein indicates neoplasia, signs of inflammation - arachnoiditis, myelitis.
Histological analysis. It is performed in the presence of tumors to determine their structure, malignant or benign nature. The examination is carried out after the operation by examining the removed tissue.

Differential diagnosis is carried out to exclude polyneuropathies, mononeuropathies of the lower extremities, and lumbosacral plexitis. To eliminate other pathologies, the results of magnetic resonance imaging and computed tomography are important.

Medical Scientific and Practical Center for Vertebrology and Neuroorthopedics, Professor M.L. Kurganov

Severe and intense back pain may be a symptom of a serious illness that may not be immediately recognized. Cauda equina syndrome occurs when there is compression (pressure) of the nerve roots, and there is a violation of the sensory and motor function of the legs and bladder. Such patients often end up in the hospital in emergency conditions. The syndrome can lead to urinary and fecal incontinence and even temporary paralysis of the legs.

The cauda equina is a bundle of nerve roots of the terminal sections of the spinal cord - starting from the first lumbar segment and below. This bun got its name for its resemblance to a ponytail. The cauda equina is a continuation of the nerve roots of the spinal cord, which begin, as already mentioned, from the lumbar segments. These nerve roots are responsible for the innervation of the lower extremities and pelvic organs (bladder).

Causes of the syndrome:

The most common cause of cauda equina syndrome is a herniated disc in the lumbar spine. A herniated disc can be caused by overuse or injury. In addition, with age, degenerative processes are observed in the intervertebral disc itself and weakening of the ligaments. As these processes progress, a relatively small load can cause the disc to rupture.

Other causes of the syndrome:

spinal cord injury and tumors;
infectious and inflammatory processes of the spinal cord;
narrowing of the lumbar vertebrae;
severe injuries to the lower back (gunshot wounds, falls from a height, car accidents);
congenital anomalies;
arteriovenous malformations of the spinal cord;
hemorrhages in the spinal cord (subarachnoid, subdural, epidural);
complications after surgery on the lumbar spine;
spinal anesthesia.

Symptoms and diagnosis of cauda equina syndrome

Manifestations of cauda equina syndrome can vary in intensity and get worse over time. Symptoms depend on the degree of compression of the nerve roots and which roots are compressed. In addition to intervertebral disc herniation, manifestations of cauda equina syndrome are observed in conditions such as pathology of the peripheral nerves (namely, sciatic, femoral and other nerves), conus medullary syndrome, compression of the spinal cord, inflammation or compression of nerves after they exit the vertebral pillar, as well as lumbosacral plexopathy.

Patients with pain in the lower back should be alert when the following “sign” symptoms :

severe pain in the lower back;
muscle weakness, loss of sensation, or pain in one or both lower extremities;
“saddle anesthesia” – lack of sensitivity in the leg area, which corresponds to sitting in the saddle;
bladder dysfunction (incontinence or urinary retention); constipation;
sensory disturbances in the bladder or rectum;
violations in the sexual sphere;
loss of reflexes in the legs.

Conditions preceding cauda equina syndrome:

recent severe back injury;
recent surgical interventions in the lumbar spine;
malignant tumors;
recent severe infections.

Diagnosis of the syndrome. In the diagnosis of cauda equina syndrome, the following is essential:

Magnetic resonance imaging is a type of research that allows you to obtain layer-by-layer images of internal organs with very high accuracy. It is based on irradiating a person with electromagnetic waves in a strong magnetic field, after which the electromagnetic radiation is recorded. It is then processed using a computer.

Myelography is an x-ray method for studying the spinal cord and its structures. It consists of injecting a contrast agent into the spinal canal, after which an X-ray of the spine is taken. This method allows you to determine the presence of intervertebral hernias and other structures that compress the nerve roots.

Treatment of cauda equina syndrome

In the treatment of cauda equina syndrome, both conservative and surgical methods are used.

The basis of treatment for cauda equina syndrome is surgery, which is aimed at eliminating compression of the elements of the cauda equina. Once the diagnosis of cauda equina syndrome is made and its cause is determined, immediate surgical intervention is usually performed. The purpose of the operation is to eliminate the symptoms of the disease. If the intervention is not performed on time, there is a risk of developing permanent paralysis and dysfunction of the bladder and rectum.

Conservative treatment

Conservative treatment for cauda equina syndrome is aimed at eliminating pain. Non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids are used for this.

Among the non-steroidal drugs that can be used: ibuprofen, indomethacin, prixam, diclofenac, ortofen, Celebrex. Among these drugs, there are those that act throughout the day and therefore require only a single dose. This, in addition, helps reduce the side effects of NSAIDs.

In cases where cauda equina syndrome is caused by infectious processes, antibiotics are used.

For spinal cord tumors or metastases, chemotherapy is used, usually in combination with radiation therapy. Radiation therapy, in particular, is used specifically for metastases in the vertebrae.

It should be understood that if signs of cauda equina syndrome appear: numbness of the skin in the scrotum (perineum), muscle weakness in the lower extremities, dysfunction of the bladder and intestines, urgent medical attention is required within the next 24 hours. If conservative measures do not help during this period of time, then surgery is recommended to reduce the risk of developing permanent paralysis.

Surgical treatment of cauda equina syndrome

In most cases, when cauda equina syndrome occurs, the most optimal emergency measure is urgent decompression, that is, the removal of compression of the nerve root. Cauda equina syndrome is usually considered an emergency and requires surgical treatment within 24 hours of the onset of symptoms.

If “signature” symptoms occur, you should immediately contact a neurosurgeon. In these cases, urgent surgery is considered the best treatment method. Treatment within the first 48 hours of the onset of the syndrome provides significant benefits in eliminating symptoms of sensory and motor function, as well as bladder and rectal function. And even if the operation is performed 48 hours after the onset of the disease, an improvement may be noted.

In patients with cauda equina syndrome, which is caused by a herniated disc, the part of the vertebra that is compressing the nerve root is removed (laminectomy), as well as part of the intervertebral disc (discectomy).

Many researchers note that there is no difference in the degree of functional restoration depending on the time of surgery. However, despite this, they all recommend surgery as early as possible to increase the chance of full recovery of neurological function.

Researchers have attempted to identify specific criteria that help determine the clinical outcome of patients with cauda equina syndrome.

People with pain in both lower extremities are less likely to recover full function than people with pain in one leg.

Patients with complete numbness in the scrotum (perineum) are more likely to develop bladder paralysis.

The degree of numbness in the scrotum (perineum) is the most important predictor of recovery.

Although recovery of bladder function may be delayed compared to recovery of motor function of the legs, it will also return to normal over several years. Drug therapy after surgery contributes to the gradual slow restoration of all lost functions of the pelvic organs. Surgery for cauda equina syndrome involves carefully isolating the nerve roots from the adhesions. This is the so-called neurolysis operation.

Treatment of cauda equina syndrome

Therapeutic measures aim to eliminate the main root cause, compression of nerve endings. Medications are most often unable to cope with all symptoms, so surgical treatment is required. Complex therapy of cauda equina syndrome is determined by the following methods:

Conservative treatment. The doctor prescribes analgesics, glucocorticosteroid drugs, and muscle relaxants. In case of intense pain, therapeutic blockades are provided - injections of an anesthetic solution together with corticosteroids into the area of the nerve plexuses. Acute urinary retention requires urgent catheterization of the bladder, prolonged constipation requires a cleansing enema.
Surgery. Depending on the MRI results, tumor removal, hematoma, and discectomy are performed for herniated intervertebral spaces. Surgical correction is necessary for native pathologies. It is possible to perform spinal stabilization. After neoplasia is diagnosed, laminectomy is performed - expansion of the spinal space. Disorders of the pelvic organs and intensive progression of lower paraparesis are indications for urgent surgical operations.
Rehabilitation. Measures to restore lost neurological qualities consist of massages, physiotherapy, and exercise therapy complexes. If tumors are detected, all of the above measures, except physical therapy, are contraindicated.

Cervical radiculopathies

The disease begins acutely, less often gradually. The clinical picture includes:

pain - aching or shooting, spreading from the neck to the fingers, aggravated by head movements, sneezing, coughing, squeezing the neck,
pain when tilting the head to the affected side,
numbness of the neck, shoulder girdle and arms,
forced position (bending forward and on the side opposite to the lesion),
reduction of pain when stretching the neck and the “hands behind the head” position,
paresthesia and hyperesthesia in the neck, scapula, shoulder girdle, throughout the arm,
wasting of the muscles of the shoulder girdle, neck, arms,
decreased reflexes [12].

Occasionally, the patient feels that the tongue is somewhat swollen, dysarthria-type speech, chewing and swallowing are difficult (C3 radicular syndrome), pain and numbness in the crown and occiput and hypotrophy of the sublingual muscles (C2 radicular syndrome) [12].

Rice. 5. Cervical radiculopathy

Prognosis and prevention

The prognosis of the disease directly depends on the root cause and the level of spread of damage. Complex treatment allows you to reverse the neurological deficiency. Lack of treatment causes irreversible destructive changes. Preventive measures are aimed at preventing spinal injuries and accurately performing spinal surgeries.

A single registration center for MRI/CT provides a convenient service for choosing a clinic for diagnostics of the body. On the mrt-v-msk website you can find out the prices for the examination and sign up for a diagnostic service online at a convenient time. Telephone operators will answer all your questions and provide up to 1,000 rubles for diagnostics.

ESWT as a method of pain relief: review of scientific literature

Among the indications for the use of extracorporeal shock wave therapy, the leading place is occupied by pain, with muscle-joint pain being the most sensitive to the effects. L.M. Shteh et al described the effects of ESWT on pain trigger points. Of the 86 patients, at the end of the course, consisting of five weekly procedures, 80% noted significant improvement [14].

A massive study of 650 units demonstrated pain relief and increased spinal mobility in myofascial pain syndromes in 96% of cases [2].

Zuev et al described the use of ESWT in combination with osteopathy in 120 patients with myofascial pain syndrome. The method allowed maintaining the clinical effect throughout the year in 77.1%, which exceeds the same indicator when using isolated ESWT by 24.3%, and when using isolated osteopathy – by 14.9% [7].

E.V. worked with the same category of patients. Kostenko. She prescribed shock wave therapy to patients in combination with Tizanidine. Of the 110 patients, in 90% of cases the intensity of the pain syndrome regressed to 3.3 ± 0.9 points on the VAS scale, muscle tone normalized, and range of motion in the spine expanded. The author performed from three to eight procedures using a stable-labile technique with a frequency of 4-6 Hz, a power of 0.037–0.399 mJ/mm2, and the daily dose of Serdalut was 8 mg [8].

Chistov and Serov influenced trigger zones (or trigger points - TT) of chronic pain syndrome, and the diagnosis of TT is optimally performed using ESWT. The device allows you to treat several pain and trigger zones at different levels, since its therapeutic depth in the form of a “candle flame” reaches 125 mm. In this case, the first procedure ensures the extinction of the pain syndrome by 20%, then, after a slight exacerbation, the pain is completely relieved within a week after the course [1,13].

Thus, shock wave therapy, used alone or in combination with drug or non-pharmacological treatment, can relieve pain as the main manifestation of radicular syndrome