Cauda Equina
Cauda Equina
Cauda Equina
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.
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
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.
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
the following topics: anatomy of the cauda equina, case report and review of the literature. Eur Spine J
symptomatology, pathophysiology, epidemiology, 2011;20(1):S128-31.
clinical approach and medicolegal. The clinical 6. Chan Am, Xu LL, Pelzer NR, et al. Timing of
doctor has to acknowledge the following three surgical intervention in cauda equina syndrome:
parameters in order to be able to make a favor- a systematic critical review. World Neurosurg
able prognosis: surgical techniques, the treatment 2014;81(3-4):640-50.
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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.
and doctors need to be informed because it is a 9. Fraser S, Roberts L, Murphy E. Cauda equina
rare neurological syndrome. Nevertheless, with syndrome: a literature review of its definition
the use of the appropriate treatment, complica- and clinical presentation. Arch Phys Med Rehabil
tions can be greatly reduced. The timing of the 2009;90(11):1964-8.
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of CES. The medical doctor considers the pa- treatment of lumbar disk herniations: a systematic
tient’s history and his/her physical examination review and risk assessment. J Manipulative Physiol
as his first points in order to diagnose CES. The Ther 2004;27(3):197-210.
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with the examination of MRI and CT. The di- syndrome secondary to lumbar disc herniation.
Spine (Phila Pa 1976) 2000;25(3):348-51; discus-
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The desired timing of the decompression of 13. Bednar DA. Cauda equina syndrome from lumbar
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Греция
3 Кафедра образной диагностики, аллергологии и физиотерапии, Факультет дентальной медицины, Медицинский универ-
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