Cauda Equina

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DOI: 10.

1515/folmed-2017-0038

REVIEW
Cauda Equina Syndrome Due to Lumbar Disc Herniation:
a Review of Literature
Stylianos Kapetanakis1, Constantinos Chaniotakis1, Constantinos Kazakos2,
Jannis V. Papathanasiou3
1 Department of Spine Surgery and Deformities, European Interbalkan Center of Thessaloniki, Greece
2 Department of Orthopaedic Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Greece
3 Department of Medical Imaging, Allergology and Physical Medicine, Faculty of Dental Medicine, Medical University of Plovdiv,

Plovdiv, Bulgaria

Correspondence: Cauda equina syndrome (CES) is a rare neurologic condition that is caused by com-
Jannis V. Papathanasiou, Depart- pression of the cauda equina. Cauda equina consists of spinal nerves L2-L5, S1–S5
ment of Medical Imaging, Aller- and the coccygeal nerve. The compression of these nerve roots can be caused
gology and Physical Medicine, mainly by lumbar disc herniation (45% of all causes). The diagnosis consists of
Faculty of Dental Medicine, Medical
two critical points: a) detailed history and physical examination and b) MRI or CT.
University of Plovdiv, 3 Hristo Botev
Blvd., 4002 Plovdiv, Bulgaria The gold standard of the treatment of this syndrome is the surgical approach in
E-mail: giannipap@yahoo.co.uk combination with the timing of onset of symptoms. The surgery as an emergency
Tel: +359889101178 situation is recommended in the first 48 hours of onset of symptoms. Any delay in
diagnosis and treatment leads to a poor prognosis of CES.
Received: 27 Jul 2016
Accepted: 08 March 2017
Published Online: 18 Apr 2017
Published: 22 Dec 2017
Key words: cauda equina syn-
drome, lumbar disc herniation,
lumbar disc prolapse, low back
pain, neurological disorders in the
spinal cord
Citation: Kapetanakis S, Chanio-
takis C, Kazakos C, Papathanasiou
JV. Cauda equina syndrome due
to lumbar disc herniation: a
review of literature.
Folia Medica 2017;59(4);377-86.
doi: 10.1515/folmed-2017-0038

INTRODUCTION
herniation (LDH). CES due to LDH is 1-3% of
The spinal cord is the continuation of the medulla all disc herniations.8-17 There are also other causes
oblongata, which ends at the medullary cone. A that lead to CES such as an accident that injured
bundle of spinal nerves and spinal nerve roots be- the spine, complications with spinal anesthesia,
gins from the medullary cone and forms the cauda drug side effects and vascular lesions of the spinal
equina. Specifically, the cauda equina consists of the cord.5,9,18,19 Patients usually present symptoms such
second through fifth lumbar nerve pairs, all of the as low back pain with unilateral or bilateral sciatica,
five sacral nerve pairs and the coccygeal nerve.1-3 reduced sensation in the saddle area, reduction of
One of the most common disorders of the sexual function, fecal incontinence, bladder dys-
cauda equina is presented as CES. Cauda equina function, muscular weakness in legs and sensory
syndrome is a rare and serious neurological disease loss in the perineum, buttocks and upper posterior
due to the pressure of the cauda equina.1,4-7 The thighs.1,6,8,19-23 The primary goal for the most ac-
pressure causes sensory and mobility problems in curate prognosis is early diagnosis of the symptoms
humans. The main cause of CES is the lumbar disk of CES and urgent surgical decompression.

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The symptoms can occur gradually (such as the cauda equina affects the aforementioned opera-
the muscular weakness and frequent incidents of tions. The cauda equina is located in an enclosed
epilepsy) or abruptly (such as bladder disorders). cavity, which is called thecal sac and is filled with
According to the literature, if symptoms are pre- cerebrospinal fluid in the subarachnoid space.1-3,7,29
sented abruptly, there must be a surgery within
EMBRYOLOGICAL DEVELOPMENT OF THE CAUDA EQUINA
the next 48 hours.6-8,12,18,24-27 After that period, the
number of permanent dysfunctions increases dras- The cauda equina in the human embryo starts
tically. However, even if a surgery occurs during developing at the beginning of the third month,
that period, there still could be some irreversible when its spinal cord extends the whole length of
outcomes. its body. After the first three months, a dispropor-
The objective of this study was to review litera- tion in the rate of growth of the bones and the
ture about cauda equina syndrome due to lumbar cartilages of the vertebral column, and the spinal
disc herniation (diagnosis, effects, treatment and cord is observed. The first two grow faster than the
incidence of disease). spinal cord. This phenomenon causes the nerves
that are located below the superior cervical region
MATERIALS AND METHODS to follow a slanted path. Therefore, the lumbar and
sacral nerves move downward and vertically inside
A research of the literature for cauda equina syn-
the spinal canal, before exiting the intervertebral
drome was made in the School of Medicine in the
foramina. The nerve roots that are created below
Democritus University of Thrace in collaboration
the L1 form the cauda equina.7,31,32
with the Department of Kinesitherapy Faculty of
Public Health, Medical University of Sofia, Bulgaria. TOPOGRAPHY OF THE NERVE ROOTS OF THE CAUDA EQUINA
For this review, we performed database search of There are two methods that visualize with great clarity
several websites such as PubMed, Google Scholar, the nerve roots of the cauda equina. They are called
and Scopus. While searching in the databases, key contrast-enhanced CT and surface-coil MRI. These
words such as cauda equina, cauda equina syn- methods are effective for the understanding of the
drome, lumbar disc herniation, low back pain and distribution of nerve roots at each disc level within
neurological disorders in the spinal cord were used. the thecal sac. Especially, at L5-S1 intervertebral
Each keyword was used alone or in combination level, the S1 root is located anterior and lateral. At
with the others so that the variety of the results in intervertebral level of L4-L5, the L5 root is placed
the research would broaden. This research includes anterolateral and it changes the location of the S1
articles that are published in English, French or root. The sacral roots are lying in the posterior
German and indicate the symptomatology, etiolo- portion. The motor roots are situated anterior and
gies, clinical approach and the treatment of CES. In medial and the sensory roots are situated posterior
addition to this, statistic surveys and clinical cases and lateral. At L3-L4 intervertebral level, an in-
are included in order to understand the frequency creased concentration of roots is observed because
of the syndrome. the L4 roots appear in the anterior portion and the
other roots (L5-S5) are moved dorsally. Finally, at
ANATOMY OF THE CAUDA EQUINA intervertebral level of L2-L3, the thecal sac consists
THE POSITION OF THE CAUDA EQUINA mostly of roots, with the motor roots being located
The spinal cord extends from the medulla oblongata anterior in regards to the sensory ones.1,2,7,29
to the level of T12-L1. The next part of the spinal The anterior and posterior roots include five in-
cord is called medullary cone. The cauda equina dividual strands. At the level of the S1, the largest
begins from the medullary cone and consists of anterior and posterior roots are found. Those roots
the spinal nerves L2-L5, S1–S5 and the coccy- can also be located from L3 to S2. The roots exit
geal nerve.3,21,22,28,30 These nerves are composed lateral to the thecal sac at an angle of approximately
of sensory (posterior) and motor (anterior) nerve 40 degrees at the level of L1-L5. However, this
roots and their functions include the sensory in- angle is reduced to 22±4 degrees at the S1 root.
nervation to the saddle area, the voluntary control The nerve roots of the cauda equina have a con-
of the outer surface of the rectum and the urinary nective tissue which is not dense. As a result, an
sphincters and the sensory and motor innervation absence of diffusion is detected (Fig. 1).1,7
of the lower limbs. Any disturbance in the area of

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Cauda Equina Syndrome Due to Lumbar Disc Herniation

the cauda equina constitutes an important detail


that should be mentioned.29 According to various
searches, the minimal space that is occupied by the
dural sac and is necessary for the nerve roots of
the cauda equina is about 77±13 mm2 at the level
of L3. This number constitutes almost 44% of the
normal cross sectional area. Any reduction of this
area causes an increase in the intrathecal pressure
of the cerebrospinal fluid between the nerve roots
of the cauda equina. Especially, the pressure inside
the dural sac of the cauda equina elevates when
the cross sectional area ranges between 60 and 80
mm2. As a result, if the cross sectional area of the
dural sac decreases to 63 ± 13 mm2, the pressure
is increased to 50 mmHg. In addition to this, if the
cross sectional area of the dural sac is reduced to
Figure 1. Diagrams of the cauda equina on CT and MRI. 57±11 mm2, the pressure increases to 100 mmHg.
(M=motor, S=sensory). Therefore, a small reduction can cause an abrupt
increase in the pressure inside the dural sac.6,7
VASCULAR ANATOMY OF THE CAUDA EQUINA
SYMPTOMATOLOGY OF CES DUE TO LUMBAR
In general, the vascular supply of the spinal cord DISC HERNIATION
originates from the anterior spinal artery and the
other two posterior spinal arteries. The circulation In CES, the main causes that result to the patient’s
on the major part depends on the anterior and poste- reduction of the sensory and the motor expression of
rior radicular and partial arteries, which are located the lumbosacral nerves, present symptoms such as
beside the spinal nerves. These arteries originate low back pain, unilateral or bilateral sciatica, saddle
from the cervical, spinal, posterior intercostal and anesthesia, muscular weakness in legs, disturbances
lumbar arteries.1,7,29 of bladder, loss of the tone in the anal sphincter and
The vascular supply of the cauda equina is as- decreased sexual function.4,6,8,10,16,19,27,30,33-35 CES
sociated with the arteries, which accompany the affects the reflexes as bulbocavernosus, medioplantar
anterior and posterior nerve roots of the cauda and Achilles tendon.5,9,24,25
equina. Every nerve has near it at least one small LOW BACK PAIN
artery. The crucial part of the blood circulation of More and more people begin to experience low
the cauda equina consists of the radicular arteries back pain each day. This medical condition is re-
because they surround the nerve roots.7,29 Any lated to the pain in the lumbar spine. Seventy to
compression or occlusion on the radicular arteries eighty percent of individuals experience an episode
can cause problems in the vascular supply of the of this pain during their lifetime.22,24,36 Low back
cauda equina (for example ischemia of the portion pain is caused by the degeneration of the lower
of the nerve root). The ilio-lumbar artery drains to lumbar spaces. This degeneration starts from the
the fifth lumbar artery, which originates from the creation of a lumbar disc herniation.10,36 There are
iliac artery as well as the aorta. The arteries that three types of low back pain: the acute, subacute
follow the sacral nerve roots and nerves arise from and chronic.7 Due to the fact that low back pain
the branches of the hypogastric artery, the medial is directly related to CES, the patients should not
sacral artery or directly from the hypogastric artery. ignore the sensation of the pain, while the clinical
It is also remarkable that most of the arteries of doctor suspects it for the possibility of the existence
the cauda equina are ‘end’ arteries, because they of the syndrome.
do not have anastomotic branches.7 The methods that are used for the diagnosis of
THE DURAL SAC AND THE COMPRESSION OF THE CAUDA low back pain are the MRI and the CT. The MRI
EQUINA displays all of the several causes of low back pain,
In the lumbar spine, the relation between the di- while the CT method portrays the same causes
mensions of the dural sac and the compression of but it mainly concerns the patients who may not

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undergo in a magnetic tomography.7,10,36 trauma, which is caused by a gunshot or a sharp


object, spinal or epidural anesthesia, vascular lesions
SCIATICA
of the spinal cord (such as thrombus formation or
This condition is caused by any damage in the sci- epidural/subdural hematoma), bacterial abscess,
atic nerve. This nerve originates from the primary tuberculosis, schistosomiasis, arthritis (Bechterew’s
branches of the sacral plexus (L4-S3). The mainly disease), osteoporotic collapse, rheumatoid arthritis
reason of sciatica is the lumbar disc herniation, and ankylosing spondylitis. There are other causes of
which reduces the sensation and the movability of CES that are characterized as neoplastic. These are
the legs and the buttocks. The sciatica can either ependymoma, neurofibroma, meningioma, schwan-
be unilateral or bilateral.14,24,25,34 The pain of the noma, lymphoma, and metastases of cancer (Tab-
sciatica extends from the lower back to the legs. le 2).1,5,7,9,18,29,38
At the level of L5-S1, the damages of these nerve
roots constitute the most frequent case of sciatica. EPIDEMIOLOGY OF CES
There are two types of sciatica, the peripheral and
Generally, CES is a disease of low incidence in
the proximal sciatica. The first one is referred to
humans and appears in 1 case per 33,000 to 1
lesions in the spinal cord due to lumbar disc her-
case per 100,000.11,29,30 CES due to lumbar disc
niation. The second one is referred to the pressure
herniation composes 1-3% of all herniated lumbar
outside of the spinal cord (i.e. the pressure inside of
discs.9-14,16,17,27,36 Concerning the literature, 45% of
the pelvis, the buttocks and the femur (Table 1).7,18
the cases of CES are caused by lumbar disc her-
Table 1. Symptomatology and frequency1,24 niation. Moreover, 2–6% of lumbar disc operations

Frequency,
Symptoms
%
Low back pain 83
Micturition dysfunction 88
Dysfunction of defecation 47
Saddle anesthesia 81
Unilateral or bilateral sciatica 95.50
Erectile dysfunction 5

PATHOPHYSIOLOGY OF CES
There are many causes that lead to CES. The most
common cause is lumbar disc herniation (LDH)
(Fig. 2).4,18,19,25 The intervertebral disc is located
between two vertebrae. This disc is composed of Figure 2. Normal disc.
the annulus fibrosus, which is situated on the out-
side, and the nucleus pulposus, which is situated
on the inside.20,29 LDH is created when an area of
the annulus fibrosus is destroyed and the nucleus
pulposus is directed through the annulus fibrosus
to the spinal canal (Fig. 3). In the spinal canal, the
nucleus pulposus causes the pressure of the nerves.2,20
The most common levels for the creation of an
LDH are L4-L5 and L5-S1.20,29,30,34,37 Furthermore,
the degenerative causes are spondylolisthesis and
lumbar spinal stenosis. Other causes are also quite
important as a penetrating injury, which is caused
by an accident (for example by a vehicle), a blunt Figure 3. Lumbar disc herniation.

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Cauda Equina Syndrome Due to Lumbar Disc Herniation

Table 2. Causes and frequency4,9 physical examination. The gold standard, during
the diagnosis, is composed of many points as the
Most common causes of CES duration of the symptoms, the nature of the com-
plaints, sexual and bladder dysfunction (urinary
Frequency
Cause retention), the mechanism of injury, the medication
(%)
and surgical history. Regarding the physical exami-
Lumbar disc herniation 45 nation, the doctor examines the perineal sensation
and sphincter (the retention of feces), the muscular
Tumor 29
weakness, the saddle anesthesia and the existence of
Infection 28 low back pain and sciatica. In addition, the doctor
examines the function of the bladder palpating the
Stenosis 21
suprapubic region. The urodynamic testing leads to
Hematoma 20 an early diagnosis of CES.1,7,9,25,34
There are two reflexes which should be exam-
Inflammatory 12
ined, the anal wink (a superficial reflex) and the
Vascular 11 bulbocavernosus reflex.5,24,25,33 In the first reflex,
the stimulation of the tone of the sphincter and the
perirectal area is checked. This examination leads
cause CES. Patients that have had a surgery because
to the involuntary contraction of the anus.25,35 The
of HNP are predisposed to CES (incidence 1-10%).4
second reflex is elicited by an applied pressure in
The incidence of many of the symptoms is: saddle
the glans of the penis or the clitoris or via traction
anesthesia - 80%, low back pain - 70-80%, sciatica
on a Foley catheter, so the retraction of the anus
- 95%, and micturition dysfunction - 88%.1,24 Even
is caused as a physiological reaction.1,7,9,18,25,34
though sphincter paralysis appears in an incidence of
The methods that help to identify the reasons
2%, it is a destructive complication of the prolapse
of CES are the MRI and the CT. Generally, the
of the lumbar intervertebral disc.16,24
MRI is performed to prove any compression of the
CLINICAL APPROACH thecal sac.19,24,25,30,41 The MRI is the first clinical
examination in the spinal cord for the patients who
THE CLASSIFICATION OF CES present the symptoms of CES.5,15,18,20,42,43 Lumbar
The classification includes the incomplete CES (CES- disc herniation, tumor, hematoma and infection
I) and the complete CES (CES-R). According to the are illustrated in the MRI. In the infection or in
first case, patients present with urinary difficulties, the neoplastic etiology of CES, the administration
limited urinary sensation and loss of ability to void. of intravenous contrast offers more detail in the
This shows that these patients do not present a com- imaging. But this method has many disadvantages.
plete dysfunction of the bladder. Motor sensation Claustrophobic patients cannot be inside a tube for
is reduced with bilateral sciatica, lower extremity a long time. Also, the MRI should be avoided in
weakness and saddle anesthesia.6,25,29,39 For the some cases as the presence of pacemakers, an-
urination, the patients use the abdominal compres- eurysm clips and metal fragments in the eyes or
sion (neurogenic origin).18 According to the second near vital structures. The CT myelography is an
case, patients present a complete urinary retention. invasive procedure, which is used when the MRI
CES-R is characterized by overflow incontinence, cannot be implemented (Fig. 4).1,2,7,26,29
absence control of the bladder and complete deficit
PHARMACOLOGY AND TREATMENT OF CES
of saddle anesthesia.1,6,18 The clinical doctor must
pay attention to this classification of CES, because There are three methods which lead to the treat-
CES-I can evolve in CES-R. CES-I is presented in ment of CES. The first method is related to surgical
30-50% and CES-R is presented in 50-70%.18 The methods. It aims the decompression of the cauda
outcome of CES-I is generally favorable if there is equina and it is accomplished by laminectomy or
an urgent surgical decompression within 48 hours. discectomy. The treatment of CES with the above
CES-R has unsatisfying prognosis, regardless the method requires an urgent surgery, within 24-48
timetable of the surgical technique.7,25,40 hours from the time of the appearance of the
symptoms.1,3,6,12,16-18,25,28,44,45 In contrast to this,
THE DIAGNOSIS OF CES-DIAGNOSTIC TOOLS there are two cases of CES, which should not be
The diagnosis requires a detailed history and a treated by surgery. These are the chronic innate

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a simple radiculopathy could lead to bowel and


bladder dysfunction due to the compression of the
nerves as a complication of PRM treatment.5 Physi-
cians should be able to diagnose CES and refer the
patients to PRM specialists to cure the damage and
start the treatment of syndrome without delays. CES
should be treated with surgery performed by spinal
surgeons, because it belongs to a category of the
most serious diseases of spinal cord known as “red
flags”. Therefore, CES is an absolute indication for
urgent surgery.40,46
SURGICAL METHOD AND TIMING OF DECOMPRESSION
The surgical technique is the most common method
for the treatment of CES.3,5,8,14,19,28,41 According to
the literature, a wide laminectomy and the extensive
decompression of the nerves of CES is one of the
methods which are the “key role” in the treat-
ment of CES.1,8,12,25,27,29,45 Several authors report
that a removing of the disc space material “takes
Figure 4. Epidural syndrome in patient with L3-L4 place” after the decompression. In the case where
central spinal stenosis. a hematoma or abscesses exist, the clinical doctor
performs a thorough evacuation. Another surgical
arachnoiditis and CES due to chronic ankylosing technique is the discectomy or the combination of
spondylitis.1,7,11,25,26,45 laminectomy and discectomy.1,5,12,25,41 The lami-
The other two methods are related to the phar- notomy/ hemilaminectomy with micro-discectomy,
maceutical therapy. For the first pharmaceutical is a technique which is not recommended because
method, anti-inflammatory drugs are administered, of retraction of the thecal sac, which leads to ag-
while for the second one the use of vasodilator gravated damages of nerves during the decompres-
drugs is broad. The vasodilatory agent is a bolus sion. In few instances, the clinical doctor uses the
treatment with lipoprostaglandin E1, which aims transthecal decompression.1,7,9,25,27 During the last
to the systematic relief of lower limbs pain and years, a new method was created in order to mini-
numbness. Experimental studies in dogs mention mize the damages of normal tissues. It is a minimal
that the intravenous treatment with OP- 1206 invasive surgery under local anesthesia, known as
(prostaglandin E1 derivative) improves the nerve endoscopic and provides huge expectancies for the
conduction velocity. In rats, the same union, led to treatment of CES.14
the increase of the local flow of the spinal cord. Generally, CES due to LDH is an urgent surgi-
This method has efficacy only in patients with cal situation. The timing of surgical technique is
moderate narrowing, which is related in neurogenic related to the prognosis of CES.2,6,12,17,18,23,25,44 If
claudication. In an urgent situation, the pharmaceuti- the symptoms appear in a dramatic rhythm, the
cal therapy does not offer any results. Drugs with surgical technique should be performed within the
the same action are the adenosine or the adenosine next 48 hours.9,22,24,26,27,45 After that period, the
kinase inhibitors (A2 adenosine receptor). The last chances for permanent damage to the bladder, the
method is the administration of steroids. Steroids intestine and the ambulation increase. In addition to
are administered epidurally or intrathecally with this, the sexual impotence and the permanent pain
the combination of local anesthetics.2,7 are presented after 48 hours. Especially, there is a
better prognosis for the bladder dysfunction within
THE ROLE OF PHYSICAL AND REHABILITATION MEDICINE
48 hours than after that period.4,38,39,45
(PRM) IN CAUDA EQUINA SYNDROME
CES seems to be a potential complication of PRM PROGNOSIS
interventions. Patients, who were diagnosed with The prognosis presents important and critical in-
low back pain or lumbar disc herniation, devel- formation regarding the progress of each disease.
oped CES due to spinal manipulation. Especially, Concerning the literature, the prognosis of the acute

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Cauda Equina Syndrome Due to Lumbar Disc Herniation

CES is generally considered favorable within 48 surgical decompression of CES within 24 to 48


hours.12,17,23,26,44 70% of the patients who are sub- hours leads to an advantageous prognosis. However,
mitted in a surgery of discectomy, present a com- many lesions remain for a long time. In that case,
plete recovery of the bladder’sfunction.9,13,18,21,38,39 the relatives of the patient believe that the clinical
Postoperative improvements, after an ablation of doctor has failed the surgery, although he/she has
the lumbar disc herniation, are the following: 83% faced CES appropriately.18,48 As a result, medicolical
pain relief, 75% motor function, 73% urinary con- does not impose compensation to the clinical doctor.
tinence, 67% sexual function, 64% rectal function
and 56% sensory restoration.25 Patients of CES-I DISCUSSION
have an improvement prognosis in relation to the The clinical picture of CES presents symptoms such
patients of CES with urinary retention.14,18,25,29,39 If as low back pain, sciatica (unilateral or bilateral),
the patient experiences leg pain, it is considered to saddle anesthesia, muscular weakness in legs, bladder
be an unfavorable sign. The bilateral sciatica has dysfunction, decreased sexual function and loss of
worse results than the unilateral sciatica.2,6,9,18,25,34,38 the tone in the anal sphincter.4,8,16,33,35 These symp-
The history of the patient affects largely the prog- toms appear in several frequencies. The focus should
nosis of CES. Patients that have a surgical history be on the urinary retention because it provides the
of chronic low back pain present a poor outcome classification of CES which is CES-R (a complete
in the urination and the bowel.13,25,26,29 Especially, urinary retention) and CES-I (an incomplete uri-
patients who present this specific symptom develop nary retention).6,18,25 The symptomatology of CES
a hazard of maintaining urinary incontinence and is characteristic. If the clinical doctor is aware of
poor recovery of the anal function 11 and 25 times CES, he/she can lead to the correct diagnosis. In
respectively, more than those who do not experi- the diagnosis, the gold standard is a detailed history
ence this situation. Furthermore, the history of and a physical examination. The main cause that
anal dysfunction leads to 10 times more sensory leads to CES is lumbar disc herniation.4,9 There are
deficits. Older people present a poor prognosis of two methods that help to identify the LDH. These
the sexual function. Men show reduced sensitivity methods are the MRI and the CT.19,24,41 The MRI
to the penis and dysfunction of the erection, while depicts detailed pictures of spine. The CT is used
women present reduced sensitivity and urinary in- when there are obstacles to the implementation of
continence during the intercourse.8,25 Each patient MRI, such as claustrophobic patients.1,2,26
presents a different level of pain and/ or residual Concerning the treatment of CES, the most com-
neurological deficits. According to a survey, 20% mon method is the surgical approach. According
of patients require a continued support with the to several authors these methods are:
catheterization and the colostomy.18 Also, patients a) The wide laminectomy and the extensive de-
need support from their family because they might compression of the nerves of CES.1,8,12,29
develop psychological problems as anxiety and b) removing of the disc space material, after the
depression.6,18,25,38 decompression,
c) the discectomy or the combination of laminec-
MEDICOLEGAL CONSIDERATIONS
tomy and discectomy1,5,25,41 and
Medicolegal is a critical point of CES because it d) the endoscopic, a minimal invasive surgery under
is related to its diagnosis and treatment.37,47 The local anesthesia.14
reasons that lead to Medicolegal, are: 1) failure These methods are used for the surgical treat-
of the clinical doctor to identify the syndrome, ment of CES due to lumbar disc herniation. After
2) inadequate physical examination of the neuro- the decompression, if there is a traumatic or an
surgeon, orthopedic or another specialist clinical iatrogenic instability, the surgical approach is a
doctor (indifference to any symptoms), 3) failure of lumbar interbody fusion.25,49 The gold standard
communication between the staff, 4) deficiency of of the surgical technique is the timing of onset
an emergency room physician in order to recognize of symptoms. The surgical treatment leads to a
CES, 5) deficiency of diagnostic methods, as MRI, favorable prognosis, if the surgery is performed
CT, and specialist spinal surgical facilities, 6) delay within 24-48 hours of onset of symptoms.12,23,26,44
of the surgery, 7) failure of physical examination The aim of this review is the analysis of a rare
of the patient in a timely manner and 8) inadequate neurological syndrome - cauda equina syndrome
postoperative examination.18,37 As mentioned, the due to lumbar disc herniation. This project contains

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the following topics: anatomy of the cauda equina, case report and review of the literature. Eur Spine J
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doctor has to acknowledge the following three surgical intervention in cauda equina syndrome:
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able prognosis: surgical techniques, the treatment 2014;81(3-4):640-50.
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medicolegal. na syndrome. Proq Neurobiol 2001;64(6):613-37.
8. Tamburelli FC, Genitiempo M, Bochicchio M,
CONCLUSION et al. Cauda equina syndrome: evaluation of the
clinical outcome. Eur Rev Med Pharnacol Sci
CES due to LDH is a crucial situation. Patients 2014;18(7):1098-105.
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S. Kapetanakis et al

Cauda Equina синдром, вызванный межпозвоночной грыжей:


литературный обзор
Стилианос Капетанакис1, Константинос Каниотакис1, Константинос Казакос2,
Янис В. Папатанасиу3
1 Кафедра спинальной хирургии и деформаций, Европейский межбалканский медицинский центр, Салоники, Греция
2 Кафедра ортопедической хирургии, Университетская больница - Александруполис, Фракийский университет „Демокрит“,

Греция
3 Кафедра образной диагностики, аллергологии и физиотерапии, Факультет дентальной медицины, Медицинский универ-

ситет – Пловдив, Пловдив, Болгария

Адрес для корреспонденции: Cauda equina синдром (синдром конского хвоста) (КЕС) является редко встре-
Янис Папатанасиу, Кафедра об- чающимся неврологическим состоянием, причиной появления которого
разной диагностики, аллерголо- является сдавление cauda equine. Cauda equine состоит из спинномозговых
гии и физиотерапии, Факультет нервов L2-L5, S1–S5 и копчикового нерва. Сдавление данных нервных кореш-
дентальной медицины, Меди-
ков вызвано в основном межпозвоночной грыжей (45% всех случаев). Диа-
цинский университет – Плов-
див, бул. „Христо Ботев” гноз обосновывается на основании двух основных факторов: а) подробного
№ 3, 4002, Пловдив, Болгария анамнеза и физикального обследования и б) ЯМР или КТ. Золотой стандарт
E-mail: giannipap@yahoo.co.uk лечения данного синдрома включает в себя хирургический подход в соче-
Тел: +359889101178 тании со временем проявления симптомов. Хирургическое вмешательство в
Дата получения: 27 июля 2016
качестве неотложной меры рекомендуется в течение первых 48 часов с мо-
Дата приемки: 08 марта 2017 мента проявления симптомов. Любое промедление с уточнением диагноза и
Дата онлайн публикации: 18 лечением чревато плохими последствиями для КЕС.
апреля 2017
Дата публикации: 22 декабря
2017
Ключевые слова: cauda equina
синдром, межпозвоночная
грыжа, пролапс межпозвоноч-
ного диска, боли в пояснице,
неврологические нарушения
спинного мозга
Образец цитирования:
Kapetanakis S, Chaniotakis C,
Kazakos C, Papathanasiou JV.
Cauda equina syndrome due to
lumbar disc herniation: a review
of literature.
Folia Medica 2017;59(4);377-86.
doi: 10.1515/folmed-2017-0038

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