Cauda equina syndrome: Difference between revisions

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==Overview==
==Overview==


The cauda equina is a collection of [[nerve|nerves]] at the end of the [[spinal cord]]. Cauda equina syndrome first described by Hutchinson in 1889 is due to compression of these [[nerve|nerves]]. It is an emergency medical condition requiring acute intervention in the form of acute decompression surgery to prevent permanent neurological damage to the [[urinary bladder]], [[Intestine]],  [[sex organ|sex organs]]  and [[leg|lower limbs]]. The most common cause of cauda equina syndrome is [[Spinal disc herniation|lumbar disc herniation]]. It can be classified into two major groups, cauda equina syndrome complete with urinary retention and cauda equina syndrome incomplete.
The cauda equina is a collection of [[nerve|nerves]] at the end of the [[spinal cord]]. These [[nerve|nerves]] consist of the [[spinal nerve|spinal nerves]] L2-L5, S1-S5 and the coccygeal nerve. Cauda equina syndrome first described by Hutchinson in 1889 is due to compression of the cauda equina in the lumbosacral region of the spinal canal. It is an emergency medical condition requiring acute intervention in the form of acute decompression surgery to prevent permanent neurological damage to the [[urinary bladder]], [[Intestine]],  [[sex organ|sex organs]]  and [[leg|lower limbs]]. The most common cause of cauda equina syndrome is [[Spinal disc herniation|lumbar disc herniation]]. It can be classified into two major groups, cauda equina syndrome complete with urinary retention and cauda equina syndrome incomplete. Prognosis of cauda equina syndrome depends on time from onset of symptoms to decompression and the degree of nerve damage at the time of surgery.
Cauda equina syndrome incomplete. Prognosis of cauda equina syndrome depends on time from onset of symptoms to decompression and the degree of nerve damage at the time of surgery.


==Historical perspective==
==Historical perspective==


Cauda equina syndrome was first discovered by Jonathan Hutchinson, a British dermatologist and surgeon in 1889, following a [[Hemorrhoids|hemorrhoidectomy]] in a 42-year-old man in which [[General anaesthesia|general anesthesia]] of ether and a crushing clamp was used. Postop, the patient had painless [[urinary retention]] and [[constipation]]. During [[Catheter|catheterization]], he felt no pain, by postop day 3, he was [[Fecal incontinence|fecal incontinent]] without knowledge.  The patient was seen by Hutchinson 6 months later, where examination showed the anus to be patulous and acontractile. An enema or manual evacuation had to be used to empty bowel.  The patient was unaware of the passage of feces. When patient self-catheterized three times a day, he had no sensation on catheter passage. He, however, could empty his bladder by straining. The patient had partial [[anesthesia]] around the anus and buttocks. He had no problems with his bladder or bowels before to the operation, but he did have a past medical history of alternating [[sciatica]] bilaterally which, was not very common. During the [[sciatica]] attacks, he felt numb on the buttocks. There is no record of the state of the muscles of his lower limbs. Hutchinson diagnosed a form of ascending neuritis induced by crushing of his pile. He was unhappy with these findings since there was no interval between the operation and the development of the [[urinary retention]]. Hutchinson could not establish a [[diagnosis]]. Evidence is presented to suggest that this was the first case of disc prolapsed, causing a cauda equina syndrome because of [[anesthesia]] and manipulation.<ref name="pmid11224016">{{cite journal| author=Silver JR| title=The earliest case of cauda equina syndrome caused by manipulation of the lumbar spine under a general anaesthetic. | journal=Spinal Cord | year= 2001 | volume= 39 | issue= 1 | pages= 51-3 | pmid=11224016 | doi=10.1038/sj.sc.3101102 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11224016  }} </ref>
*[[Cauda equina]] was named by the French anatomist Andreas Lazarius (André du Laurens) in the 17th century after its resemblance to a horse's tail (Latin: cauda equina).
*Cauda equina syndrome was first discovered by Jonathan Hutchinson, a British dermatologist and surgeon in 1889, following a [[Hemorrhoids|hemorrhoidectomy]] in a 42-year-old man in which [[General anaesthesia|general anesthesia]] of ether and a crushing clamp was used. Postop, the patient had painless [[urinary retention]] and [[constipation]]. During [[Catheter|catheterization]], he felt no pain, by postop day 3, he was [[Fecal incontinence|fecal incontinent]] without knowledge.  The patient was seen by Hutchinson 6 months later, where examination showed the anus to be patulous and acontractile. An enema or manual evacuation had to be used to empty bowel.  The patient was unaware of the passage of feces. When patient self-catheterized three times a day, he had no sensation on catheter passage. He, however, could empty his bladder by straining. The patient had partial [[anesthesia]] around the anus and buttocks. He had no problems with his bladder or bowels before the operation, but he did have a past medical history of alternating [[sciatica]] bilaterally which was not very common. During the [[sciatica]] attacks, he felt numb on the buttocks. There is no record of the state of the muscles of his lower limbs. Hutchinson diagnosed a form of ascending neuritis induced by crushing of his pile. He was unhappy with these findings since there was no interval between the operation and the development of the [[urinary retention]]. Hutchinson could not establish a [[diagnosis]]. Evidence is presented to suggest that this was the first case of disc prolapsed, causing a cauda equina syndrome because of [[anesthesia]] and manipulation.<ref name="pmid11224016">{{cite journal| author=Silver JR| title=The earliest case of cauda equina syndrome caused by manipulation of the lumbar spine under a general anaesthetic. | journal=Spinal Cord | year= 2001 | volume= 39 | issue= 1 | pages= 51-3 | pmid=11224016 | doi=10.1038/sj.sc.3101102 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11224016  }} </ref>
*In 1977/1978, [[Magnetic resonance imaging|MRI]]  was developed by Raymond Damadian to diagnose cancer. It has since been used to diagnose other pathologies and is the gold standard for the diagnosis of cauda equina syndrome.<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref><ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref><ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref>


==Classification==
==Classification==
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==Pathophysiology==
==Pathophysiology==
Cauda equina syndrome is caused by compression of the [[spinal cord|lumbar]] and [[conus medullaris|sacral]] [[nerve|nerves]] roots arising below the [[conus medullaris]].<ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref>
*It is thought that cauda equina syndrome is the result of direct mechanical compression of the [[spinal cord|lumbar]] and [[conus medullaris|sacral]] [[nerve|nerves]] roots arising below the [[conus medullaris]] and venous congestion or ischemia.<ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref><ref name="pmid18664636">{{cite journal| author=Spector LR, Madigan L, Rhyne A, Darden B, Kim D| title=Cauda equina syndrome. | journal=J Am Acad Orthop Surg | year= 2008 | volume= 16 | issue= 8 | pages= 471-9 | pmid=18664636 | doi=10.5435/00124635-200808000-00006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18664636  }} </ref>
The proximal region of the cauda equina is relatively hypovascular leading to neuroischemic symptoms with compression <ref name="pmid7005240">{{cite journal| author=Parke WW, Gammell K, Rothman RH| title=Arterial vascularization of the cauda equina. | journal=J Bone Joint Surg Am | year= 1981 | volume= 63 | issue= 1 | pages= 53-62 | pmid=7005240 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7005240  }} </ref>
*Mechanical compression can be due to space-occupying lesion such as
**[[Spinal disc herniation]]
**[[Infections]]/[[abscess]]
**[[Hematoma]]
**[[bone fracture|Fractured]] vertebrae
**[[Metastasis]]
**Lumbosacral and pelvic [[Echinococcosis|hydatid cyst]] within lumbosacral  region of the [[spinal canal]]
*The proximal region of the cauda equina is relatively hypovascular leading to neuroischemic symptoms with compression. <ref name="pmid18664636">{{cite journal| author=Spector LR, Madigan L, Rhyne A, Darden B, Kim D| title=Cauda equina syndrome. | journal=J Am Acad Orthop Surg | year= 2008 | volume= 16 | issue= 8 | pages= 471-9 | pmid=18664636 | doi=10.5435/00124635-200808000-00006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18664636  }} </ref><ref name="pmid7005240">{{cite journal| author=Parke WW, Gammell K, Rothman RH| title=Arterial vascularization of the cauda equina. | journal=J Bone Joint Surg Am | year= 1981 | volume= 63 | issue= 1 | pages= 53-62 | pmid=7005240 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7005240  }} </ref>


==Causes==
==Causes==
Cauda equina syndrome  may be caused by<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref>
Cauda equina syndrome  may be caused by<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref>
*[[Spinal disc herniation|Lumbar disc herniation]]<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref>
*[[Spinal disc herniation|Lumbar disc herniation]]<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref>
* conus medullaris [[infarction]]<ref name="pmid31847829">{{cite journal| author=Weng YC, Chin SC, Wu YY, Kuo HC| title=Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction. | journal=BMC Neurol | year= 2019 | volume= 19 | issue= 1 | pages= 328 | pmid=31847829 | doi=10.1186/s12883-019-1566-1 | pmc=6916224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31847829  }} </ref>
* Conus medullaris [[infarction]]<ref name="pmid31847829">{{cite journal| author=Weng YC, Chin SC, Wu YY, Kuo HC| title=Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction. | journal=BMC Neurol | year= 2019 | volume= 19 | issue= 1 | pages= 328 | pmid=31847829 | doi=10.1186/s12883-019-1566-1 | pmc=6916224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31847829  }} </ref>
*Complication of  lumbar spinal surgery<ref name="pmid31335689">{{cite journal| author=Yuan T, Zhang J, Yang L, Wu J, Tian H, Wan T | display-authors=etal| title=Cauda equina syndrome without motor dysfunction following lumbar spinal stenosis surgery: A case report. | journal=Medicine (Baltimore) | year= 2019 | volume= 98 | issue= 29 | pages= e16396 | pmid=31335689 | doi=10.1097/MD.0000000000016396 | pmc=6709168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31335689  }} </ref>
*Complication of  lumbar spinal surgery<ref name="pmid31335689">{{cite journal| author=Yuan T, Zhang J, Yang L, Wu J, Tian H, Wan T | display-authors=etal| title=Cauda equina syndrome without motor dysfunction following lumbar spinal stenosis surgery: A case report. | journal=Medicine (Baltimore) | year= 2019 | volume= 98 | issue= 29 | pages= e16396 | pmid=31335689 | doi=10.1097/MD.0000000000016396 | pmc=6709168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31335689  }} </ref>
*[[Spinal stenosis|Lumbar spinal stenosis]]<ref name="pmid31335689">{{cite journal| author=Yuan T, Zhang J, Yang L, Wu J, Tian H, Wan T | display-authors=etal| title=Cauda equina syndrome without motor dysfunction following lumbar spinal stenosis surgery: A case report. | journal=Medicine (Baltimore) | year= 2019 | volume= 98 | issue= 29 | pages= e16396 | pmid=31335689 | doi=10.1097/MD.0000000000016396 | pmc=6709168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31335689  }} </ref>
*[[Spinal stenosis|Lumbar spinal stenosis]]<ref name="pmid31335689">{{cite journal| author=Yuan T, Zhang J, Yang L, Wu J, Tian H, Wan T | display-authors=etal| title=Cauda equina syndrome without motor dysfunction following lumbar spinal stenosis surgery: A case report. | journal=Medicine (Baltimore) | year= 2019 | volume= 98 | issue= 29 | pages= e16396 | pmid=31335689 | doi=10.1097/MD.0000000000016396 | pmc=6709168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31335689  }} </ref>
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==Differentiating cauda equina syndrome from other Diseases==
==Differentiating cauda equina syndrome from other Diseases==


Cauda equina syndrome must be differentiated from [[spinal disc herniation]], [[epidural hematoma]], [[spinal tumor]],  [[spinal stenosis]], and [[diabetic amyotrophy]].
*Cauda equina syndrome must be differentiated from [[spinal disc herniation]], [[epidural hematoma]], [[spinal tumor]]/[[metastasis]],  [[spinal stenosis]], and [[diabetic amyotrophy]].<ref name="pmid27268102">{{cite journal| author=Panos G, Watson DC, Karydis I, Velissaris D, Andreou M, Karamouzos V | display-authors=etal| title=Differential diagnosis and treatment of acute cauda equina syndrome in the human immunodeficiency virus positive patient: a case report and review of the literature. | journal=J Med Case Rep | year= 2016 | volume= 10 | issue=  | pages= 165 | pmid=27268102 | doi=10.1186/s13256-016-0902-y | pmc=4895963 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27268102  }} </ref><ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref><ref name="pmid31480126">{{cite journal| author=Jiménez-Ávila JM, Castañeda-Huerta JE, González-Cisneros AC| title=[Bruns Garland syndrome. Report of a case and differential diagnosis with cauda equina syndrome]. | journal=Acta Ortop Mex | year= 2019 | volume= 33 | issue= 1 | pages= 42-45 | pmid=31480126 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31480126  }} </ref><ref name="pmid29515655">{{cite journal| author=Zhou ZN, Canon C, Matrai C, Chapman-Davis E| title=Cauda equina syndrome secondary to leptomeningeal metastases from recurrent primary peritoneal carcinoma. | journal=Ecancermedicalscience | year= 2018 | volume= 12 | issue=  | pages= 814 | pmid=29515655 | doi=10.3332/ecancer.2018.814 | pmc=5834310 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29515655  }} </ref>


==Epidemiology and Demographics==
==Epidemiology and Demographics==
*The incidence of cauda equina syndrome is 2 per 100,000 /year.<ref name="pmid31923259">{{cite journal| author=Srikandarajah N, Noble A, Clark S, Wilby M, Freeman BJC, Fehlings MG | display-authors=etal| title=Cauda Equina Syndrome Core Outcome Set (CESCOS): An international patient and healthcare professional consensus for research studies. | journal=PLoS One | year= 2020 | volume= 15 | issue= 1 | pages= e0225907 | pmid=31923259 | doi=10.1371/journal.pone.0225907 | pmc=6953762 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31923259  }} </ref><ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref>
*The incidence of cauda equina syndrome is 2 in 100,000/year.<ref name="pmid31923259">{{cite journal| author=Srikandarajah N, Noble A, Clark S, Wilby M, Freeman BJC, Fehlings MG | display-authors=etal| title=Cauda Equina Syndrome Core Outcome Set (CESCOS): An international patient and healthcare professional consensus for research studies. | journal=PLoS One | year= 2020 | volume= 15 | issue= 1 | pages= e0225907 | pmid=31923259 | doi=10.1371/journal.pone.0225907 | pmc=6953762 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31923259  }} </ref><ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref>
*Patients of all age groups may develop cauda equina syndrome.  
*Patients of all age groups may develop cauda equina syndrome.  
*There is no racial predilection to cauda equina syndrome.  
*Cauda equina syndrome usually affects individuals of all races, although African American individuals are less likely to develop cauda equina syndrome.<ref name="pmid22402198">{{cite journal| author=Schoenfeld AJ, Bader JO| title=Cauda equina syndrome: an analysis of incidence rates and risk factors among a closed North American military population. | journal=Clin Neurol Neurosurg | year= 2012 | volume= 114 | issue= 7 | pages= 947-50 | pmid=22402198 | doi=10.1016/j.clineuro.2012.02.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22402198  }} </ref><ref name="pmid21889419">{{cite journal| author=Radcliff KE, Kepler CK, Delasotta LA, Rihn JA, Harrop JS, Hilibrand AS | display-authors=etal| title=Current management review of thoracolumbar cord syndromes. | journal=Spine J | year= 2011 | volume= 11 | issue= 9 | pages= 884-92 | pmid=21889419 | doi=10.1016/j.spinee.2011.07.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21889419  }} </ref><ref name="pmid15765336">{{cite journal| author=Small SA, Perron AD, Brady WJ| title=Orthopedic pitfalls: cauda equina syndrome. | journal=Am J Emerg Med | year= 2005 | volume= 23 | issue= 2 | pages= 159-63 | pmid=15765336 | doi=10.1016/j.ajem.2004.03.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15765336  }} </ref>
*Cauda equina syndrome affects men and women equally.
*Cauda equina syndrome affects men and women equally.


==Risk Factors==
==Risk Factors==


The most potent risk factor in the development of cauda equina syndrome is [[spinal disc herniation]]. Other risk factors include [[trauma]], a spinal [[tumor]], severe [[infection]], and spinal stenosis.
*The most potent risk factor in the development of cauda equina syndrome is [[spinal disc herniation]].<ref name="pmid29341941">{{cite journal| author=Kapetanakis S, Chaniotakis C, Kazakos C, Papathanasiou JV| title=Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature. | journal=Folia Med (Plovdiv) | year= 2017 | volume= 59 | issue= 4 | pages= 377-386 | pmid=29341941 | doi=10.1515/folmed-2017-0038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29341941  }} </ref>
*Other risk factors include [[trauma]], a spinal [[tumor]], severe [[infection]], spinal stenosis,  spinal [[anesthesia]],<ref name="pmid12428328">{{cite journal| author=Yorozu T, Matsumoto M, Hayashi S, Yamada T, Nakaohji T, Nakatsuka I| title=[Dibucaine for spinal anesthesia is a probable risk for cauda equina syndrome]. | journal=Masui | year= 2002 | volume= 51 | issue= 10 | pages= 1151-4 | pmid=12428328 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12428328  }} </ref> [[obesity]]<ref name="pmid28756300">{{cite journal| author=Cushnie D, Urquhart JC, Gurr KR, Siddiqi F, Bailey CS| title=Obesity and spinal epidural lipomatosis in cauda equina syndrome. | journal=Spine J | year= 2018 | volume= 18 | issue= 3 | pages= 407-413 | pmid=28756300 | doi=10.1016/j.spinee.2017.07.177 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28756300  }} </ref> and  female sex.<ref name="pmid31471075">{{cite journal| author=Long B, Koyfman A, Gottlieb M| title=Evaluation and management of cauda equina syndrome in the emergency department. | journal=Am J Emerg Med | year= 2020 | volume= 38 | issue= 1 | pages= 143-148 | pmid=31471075 | doi=10.1016/j.ajem.2019.158402 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31471075  }} </ref>


==Screening==
==Screening==


There is insufficient evidence to recommend routine screening for cauda equina syndrome.
*There is insufficient evidence to recommend routine screening for cauda equina syndrome.


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


If left untreated, 100% progress to permanent [[nerve]] damage and neurological deficit.
*If left untreated, 100% progress to permanent [[nerve]] damage and neurological deficit.


Common complications of cauda equina syndrome include<ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref><ref name="pmid28102451">{{cite journal| author=Korse NS, Pijpers JA, van Zwet E, Elzevier HW, Vleggeert-Lankamp CLA| title=Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction. | journal=Eur Spine J | year= 2017 | volume= 26 | issue= 3 | pages= 894-904 | pmid=28102451 | doi=10.1007/s00586-017-4943-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28102451  }} </ref>
*Common complications of cauda equina syndrome include<ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref><ref name="pmid28102451">{{cite journal| author=Korse NS, Pijpers JA, van Zwet E, Elzevier HW, Vleggeert-Lankamp CLA| title=Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction. | journal=Eur Spine J | year= 2017 | volume= 26 | issue= 3 | pages= 894-904 | pmid=28102451 | doi=10.1007/s00586-017-4943-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28102451  }} </ref>
*micturition dysfunction 48%  
**Micturition dysfunction 48%  
*defecation dysfunction 42%,
**Defecation dysfunction 42%,
*sexual dysfunction 53%
**Sexual dysfunction 53%
* sciatica 48%
**Sciatica 48%
*altered sensation of the saddle area 57%.
**Altered sensation of the saddle area 57%.


Prognosis of cauda equina syndrome depends on a number of factors, example time from onset of symptoms to decompression and the degree of nerve damage at the time of surgery. Following surgery, the extent of recovery is variable.<ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref>
*Prognosis of cauda equina syndrome depends on a number of factors, example time from onset of symptoms to decompression, the degree of nerve damage at the time of surgery and the type of cauda equina syndrome; with incomplete being more favourable.<ref name="pmid21193933">{{cite journal| author=Gardner A, Gardner E, Morley T| title=Cauda equina syndrome: a review of the current clinical and medico-legal position. | journal=Eur Spine J | year= 2011 | volume= 20 | issue= 5 | pages= 690-7 | pmid=21193933 | doi=10.1007/s00586-010-1668-3 | pmc=3082683 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21193933  }} </ref> Following surgery, the extent of recovery is variable.<ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref> Long term outcomes postsurgery are [[Urinary incontinence|bladder]], [[Sexual dysfunction|sexual]], and [[Cerebral palsy|motor]] dysfunction especially in patients with cauda equina syndrome complete  with [[urinary retention]].<ref name="pmid31263950">{{cite journal| author=Hazelwood JE, Hoeritzauer I, Pronin S, Demetriades AK| title=An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome. | journal=Acta Neurochir (Wien) | year= 2019 | volume= 161 | issue= 9 | pages= 1887-1894 | pmid=31263950 | doi=10.1007/s00701-019-03973-7 | pmc=6704093 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31263950  }} </ref>


==Diagnosis==
==Diagnosis==
'''Diagnostic Study of Choice'''
'''Diagnostic Study of Choice'''
*There are no established criteria for the diagnosis of cauda equina syndrome. However, in the presence of [[low back pain|Lower back pain]], [[urinary retention]], decreased [[Muscle weakness|muscle strength]], and [[saddle anesthesia]], [[Magnetic resonance imaging|MRI]] should be ordered to rule out cauda equina syndrome.
{|
! colspan="1" style="background: #4479BA; color: #FFFFFF; " align="center"|Radiological imaging
! colspan="1" style="background: #4479BA; color: #FFFFFF; " align="center"| Sensitivity
! colspan="1" style="background: #4479BA; color: #FFFFFF; " align="center"| specificity
! colspan="1" style="background: #4479BA; color: #FFFFFF; " align="center"| PPV
! colspan="1" style="background: #4479BA; color: #FFFFFF; " align="center"| NPV
|-
! style="background: #4479BA; color: #FFFFFF; " align="center"|CT<ref name="PeacockTimpone2017">{{cite journal|last1=Peacock|first1=J.G.|last2=Timpone|first2=V.M.|title=Doing More with Less: Diagnostic Accuracy of CT in Suspected Cauda Equina Syndrome|journal=American Journal of Neuroradiology|volume=38|issue=2|year=2017|pages=391–397|issn=0195-6108|doi=10.3174/ajnr.A4974}}</ref>
|style="background: #DCDCDC; | 98%
|style="background: #DCDCDC; | 86%
|style="background: #DCDCDC; |72%
|style="background: #DCDCDC; |99%
|-
! style="background: #4479BA; color: #FFFFFF; " align="center"|MRI<ref>{{cite journal|doi=10.1302/0301-620X}}</ref>
|style="background: #DCDCDC; | 68%
|style="background: #DCDCDC; | 78%
|style="background: #DCDCDC; |84%
|style="background: #DCDCDC; |58%
|}
*Although [[Computed tomography|CT]] is shown to be more [[sensitive]] and [[specific]] for the diagnosis of cauda equina syndrome, [[Magnetic resonance imaging|MRI]] is considered the goal standard because it can depict soft tissue clearer.<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref><ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref><ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref>


'''History and Symptoms'''
'''History and Symptoms'''
Line 103: Line 134:


'''Physical Examination'''
'''Physical Examination'''
Common physical examination findings of cauda equina syndrome include
*[[Hypesthesia]]<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref><ref name="pmid31847829">{{cite journal| author=Weng YC, Chin SC, Wu YY, Kuo HC| title=Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction. | journal=BMC Neurol | year= 2019 | volume= 19 | issue= 1 | pages= 328 | pmid=31847829 | doi=10.1186/s12883-019-1566-1 | pmc=6916224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31847829  }} </ref>
*[[Hypesthesia]]<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref><ref name="pmid31847829">{{cite journal| author=Weng YC, Chin SC, Wu YY, Kuo HC| title=Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction. | journal=BMC Neurol | year= 2019 | volume= 19 | issue= 1 | pages= 328 | pmid=31847829 | doi=10.1186/s12883-019-1566-1 | pmc=6916224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31847829  }} </ref>
*Saddle dysesthesia<ref name="pmid31847829">{{cite journal| author=Weng YC, Chin SC, Wu YY, Kuo HC| title=Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction. | journal=BMC Neurol | year= 2019 | volume= 19 | issue= 1 | pages= 328 | pmid=31847829 | doi=10.1186/s12883-019-1566-1 | pmc=6916224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31847829  }} </ref>
*Saddle dysesthesia<ref name="pmid31847829">{{cite journal| author=Weng YC, Chin SC, Wu YY, Kuo HC| title=Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction. | journal=BMC Neurol | year= 2019 | volume= 19 | issue= 1 | pages= 328 | pmid=31847829 | doi=10.1186/s12883-019-1566-1 | pmc=6916224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31847829  }} </ref>
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'''Laboratory findinds'''
'''Laboratory findinds'''


There are no diagnostic laboratory findings associated with cauda equina syndrome.  
*There are no diagnostic laboratory findings associated with cauda equina syndrome.  


'''Echocardiography'''
'''Echocardiography'''


There are no ECG findings associated with cauda equina syndrome.  
*There are no ECG findings associated with cauda equina syndrome.  


'''X-ray'''
'''X-ray'''


There are no x-ray findings associated with cauda equina syndrome.  
*There are no x-ray findings associated with cauda equina syndrome.  


'''Ultrasound'''
'''Ultrasound'''


There are no ultrasound findings associated with cauda equina syndrome.  
*There are no ultrasound findings associated with cauda equina syndrome.  


'''CT Scan'''
'''CT Scan'''


[[Lumbar vertebrae|Lumbosacral]] CT scan may be helpful in the diagnosis of cauda equina syndrome. Findings on CT scan suggestive of/diagnostic of cauda equina syndrome include
*[[Lumbar vertebrae|Lumbosacral]] [[Computed tomography|CT]] scan may be helpful in the diagnosis of cauda equina syndrome.  
*CT scans show herniated nucleus pulposus at the L4/5 level.
 
*[[Computed tomography|CT scan]] [[sensitivity]] for cauda equina syndrome has been estimated to be 98%; [[specificity]], 86%; [[positive predictive value]], 72%; and [[negative predictive value]], 99%.<ref name="PeacockTimpone2017">{{cite journal|last1=Peacock|first1=J.G.|last2=Timpone|first2=V.M.|title=Doing More with Less: Diagnostic Accuracy of CT in Suspected Cauda Equina Syndrome|journal=American Journal of Neuroradiology|volume=38|issue=2|year=2017|pages=391–397|issn=0195-6108|doi=10.3174/ajnr.A4974}}</ref>
 
*Findings on [[Computed tomography|CT]] scan suggestive of/diagnostic of cauda equina syndrome include
**This [[Computed tomography|CT]] scan shows compression of the [[spinal cord]] due to a fractured [[Vertebra]].
[[File: CES SAGITAL VIEW.gif|400px|left|thumb|Sagittal view CT demonstrates [[spinal cord]] compression due to Vertebra fracture after fall from a height (yellow arrow). Case courtesy of Dr Ian Bickle (Picture courtesy: [https://radiopaedia.org/cases/burst-fracture-with-cauda-equina-syndrome?lang=gb Radiopedia])]]
<br style="clear:left">
 
 


'''MRI'''
'''MRI'''


[[Lumbar vertebrae|Lumbosacral]] MRI is the gold standard in the diagnosis of cauda equina syndrome.<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref><ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref><ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref> Findings on MRI suggestive of/diagnostic of cauda equina syndrome include  
*[[Lumbar vertebrae|Lumbosacral]] [[Magnetic resonance imaging|MRI]] is the gold standard in the diagnosis of cauda equina syndrome.<ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref><ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref><ref name="pmid30725885">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725885 | doi= | pmc= | url= }} </ref>  
 
*[[Magnetic resonance imaging|MRI]] [[sensitivity]] for cauda equina syndrome has been estimated to be 68%, [[specificity]] 78%, [[positive predictive value]] 84% and [[negative predictive value]] 58%.<ref>{{cite journal|doi=10.1302/0301-620X}}</ref>
 
*Findings on MRI suggestive of cauda equina syndrome include  
*In [[Spinal disc herniation|Lumbar disc herniation]], [[Magnetic resonance imaging|MRI]] shows a disc mass filling most of the spinal canal compressing the cauda equina.
*In [[Spinal disc herniation|Lumbar disc herniation]], [[Magnetic resonance imaging|MRI]] shows a disc mass filling most of the spinal canal compressing the cauda equina.
[[File: MRI Herniated disc.gif|400px|left|thumb| T2-weighted images in non-contrast [[Magnetic resonance imaging|MRI]] of the lumbar region at L4/5 level demonstrating a huge isointense lesion (herniated disc) compressing the spinal cord. Sagittal view (Left) and axial view (Right) (Picture courtesy: [https://journals.lww.com/md-journal/FullText/2020/02140/Intradural_disc_herniation_at_L4_5_level_causing.25.aspx Medicine])]]
[[File: MRI Herniated disc.gif|400px|left|thumb| T2-weighted images in non-contrast [[Magnetic resonance imaging|MRI]] of the lumbar region at L4/5 level demonstrating a huge isointense lesion (herniated disc) compressing the spinal cord. Sagittal view (Left/yellow arrow) and axial view (Right/yellow arrowhead) (Picture courtesy: [https://journals.lww.com/md-journal/FullText/2020/02140/Intradural_disc_herniation_at_L4_5_level_causing.25.aspx Medicine])]]
<br style="clear:left">
*In [[Pott's disease]], [[Magnetic resonance imaging|MRI]] shows [[spinal cord]] compression by destroyed bone.
[[File:POTS DX CES MRI GIF.gif|400px|left|thumb|Sagittal view MRI of the spine demonstrating a lumbar vertebra destruction due to [[Tuberculosis|TB]] and [[spinal cord]] compression (yellow arrowhead). Case courtesy of Dr Rishi Ramaesh (Picture courtesy: [https://radiopaedia.org/cases/pott-disease-causing-cauda-equina-syndrome?lang=gb Radiopedia])]]
<br style="clear:left">
<br style="clear:left">


'''Other Imaging Findings'''
'''Other Imaging Findings'''


There are no other imaging findings associated with cauda equina syndrome.  
*There are no other imaging findings associated with cauda equina syndrome.  


'''Other Diagnostic  Findings'''
'''Other Diagnostic  Findings'''
*[[Myelography|Myelogram ]]
*[[Myelography|Myelogram ]] which demonstrates [[spinal cord]] compression due to [[Spinal disc herniation]]
[[File: Myelography ces.jpg|400px|left|thumb|Sagittal view of CT myelogram demonstrates [[spinal cord]] compression due to [[Spinal disc herniation]] (white arrow). (Picture courtesy: [https://www.bmj.com/content/338/bmj.b936 Thebmj])]]
<br style="clear:left">
 
*[[Electromyography]]
*[[Electromyography]]
*Pre and post-void bladder scan; if the post-void residual volume is >200ml, the probability of cauda equina syndrome is 43% (P < 0.000003) making bladder scan an adjunct in the diagnosis of cauda equina syndrome.<ref name="pmid31479434">{{cite journal| author=Venkatesan M, Nasto L, Tsegaye M, Grevitt M| title=Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome. | journal=Spine (Phila Pa 1976) | year= 2019 | volume= 44 | issue= 18 | pages= 1303-1308 | pmid=31479434 | doi=10.1097/BRS.0000000000003152 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31479434  }} </ref>
*Pre and post-void bladder scan; if the post-void residual volume is >200ml, the probability of cauda equina syndrome is 43% (P < 0.000003) making bladder scan an adjunct in the diagnosis of cauda equina syndrome.<ref name="pmid31479434">{{cite journal| author=Venkatesan M, Nasto L, Tsegaye M, Grevitt M| title=Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome. | journal=Spine (Phila Pa 1976) | year= 2019 | volume= 44 | issue= 18 | pages= 1303-1308 | pmid=31479434 | doi=10.1097/BRS.0000000000003152 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31479434  }} </ref>
Line 157: Line 209:
*0.5 mg of mecobalamin tablets (oral) every 8 h
*0.5 mg of mecobalamin tablets (oral) every 8 h
*[[Chemotherapy]] for cases due to [[tumor|tumors]]
*[[Chemotherapy]] for cases due to [[tumor|tumors]]
*[[Antibiotics]] for cases due to [[infection]]


'''Surgery'''
'''Surgery'''


Surgery is the mainstay of treatment for cauda equina syndrome.<ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref><ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref> Immediate surgical decompression is the best intervention associated with positive patient outcome.<ref name="pmid31415897">{{cite journal| author=Hogan WB, Kuris EO, Durand WM, Eltorai AEM, Daniels AH| title=Timing of Surgical Decompression for Cauda Equina Syndrome. | journal=World Neurosurg | year= 2019 | volume= 132 | issue=  | pages= e732-e738 | pmid=31415897 | doi=10.1016/j.wneu.2019.08.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31415897  }} </ref> Procedures used include
*Surgery is the mainstay of treatment for cauda equina syndrome.<ref name="pmid29432394">{{cite journal| author=Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T| title=Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review. | journal=Spine (Phila Pa 1976) | year= 2018 | volume= 43 | issue= 17 | pages= E1005-E1013 | pmid=29432394 | doi=10.1097/BRS.0000000000002605 | pmc=6104724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29432394  }} </ref><ref name="pmid32049799">{{cite journal| author=Luo D, Ji C, Xu H, Feng H, Zhang H, Li K| title=Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. | journal=Medicine (Baltimore) | year= 2020 | volume= 99 | issue= 7 | pages= e19025 | pmid=32049799 | doi=10.1097/MD.0000000000019025 | pmc=7035013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32049799  }} </ref> Immediate surgical decompression is the best intervention associated with positive patient outcome.<ref name="pmid31415897">{{cite journal| author=Hogan WB, Kuris EO, Durand WM, Eltorai AEM, Daniels AH| title=Timing of Surgical Decompression for Cauda Equina Syndrome. | journal=World Neurosurg | year= 2019 | volume= 132 | issue=  | pages= e732-e738 | pmid=31415897 | doi=10.1016/j.wneu.2019.08.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31415897  }} </ref> Procedures used include
*[[Laminectomy]] and [[discectomy]] (most common)
**[[Laminectomy]] and [[discectomy]] (most common)
*[[Hemilaminectomy]]
**[[Hemilaminectomy]]
*Transforaminal lumbar interbody infusion
**Transforaminal lumbar interbody infusion
*Microdiscectomy
**Microdiscectomy
Long term outcomes postsurgery are [[Urinary incontinence|bladder]], [[Sexual dysfunction|sexual]], and [[Cerebral palsy|motor]] dysfunction especially in patients with cauda equina syndrome complete  with [[urinary retention]].<ref name="pmid31263950">{{cite journal| author=Hazelwood JE, Hoeritzauer I, Pronin S, Demetriades AK| title=An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome. | journal=Acta Neurochir (Wien) | year= 2019 | volume= 161 | issue= 9 | pages= 1887-1894 | pmid=31263950 | doi=10.1007/s00701-019-03973-7 | pmc=6704093 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31263950  }} </ref>
*positive outcomes in bladder and bowel functions, sensory and motor deficit are seen if decompresssion is performed within 48hours of symptoms.  


'''Primary Prevention'''
'''Primary Prevention'''


There are no established measures for the primary prevention of cauda equina syndrome.
*There are no established measures for the primary prevention of cauda equina syndrome.


'''Secondary Prevention'''
'''Secondary Prevention'''


There are no established measures for the secondary prevention of cauda equina syndrome.
*There are no established measures for the secondary prevention of cauda equina syndrome.


==References==
==References==

Latest revision as of 15:10, 16 July 2020

Cauda equina syndrome
Cauda equina and filum terminale seen from behind.
ICD-10 G83.4
ICD-9 344.6
DiseasesDB 31115
MeSH C10.668.829.800.750.700

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Joanna Ekabua, M.D. [2]

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Overview

The cauda equina is a collection of nerves at the end of the spinal cord. These nerves consist of the spinal nerves L2-L5, S1-S5 and the coccygeal nerve. Cauda equina syndrome first described by Hutchinson in 1889 is due to compression of the cauda equina in the lumbosacral region of the spinal canal. It is an emergency medical condition requiring acute intervention in the form of acute decompression surgery to prevent permanent neurological damage to the urinary bladder, Intestine, sex organs and lower limbs. The most common cause of cauda equina syndrome is lumbar disc herniation. It can be classified into two major groups, cauda equina syndrome complete with urinary retention and cauda equina syndrome incomplete. Prognosis of cauda equina syndrome depends on time from onset of symptoms to decompression and the degree of nerve damage at the time of surgery.

Historical perspective

  • Cauda equina was named by the French anatomist Andreas Lazarius (André du Laurens) in the 17th century after its resemblance to a horse's tail (Latin: cauda equina).
  • Cauda equina syndrome was first discovered by Jonathan Hutchinson, a British dermatologist and surgeon in 1889, following a hemorrhoidectomy in a 42-year-old man in which general anesthesia of ether and a crushing clamp was used. Postop, the patient had painless urinary retention and constipation. During catheterization, he felt no pain, by postop day 3, he was fecal incontinent without knowledge. The patient was seen by Hutchinson 6 months later, where examination showed the anus to be patulous and acontractile. An enema or manual evacuation had to be used to empty bowel. The patient was unaware of the passage of feces. When patient self-catheterized three times a day, he had no sensation on catheter passage. He, however, could empty his bladder by straining. The patient had partial anesthesia around the anus and buttocks. He had no problems with his bladder or bowels before the operation, but he did have a past medical history of alternating sciatica bilaterally which was not very common. During the sciatica attacks, he felt numb on the buttocks. There is no record of the state of the muscles of his lower limbs. Hutchinson diagnosed a form of ascending neuritis induced by crushing of his pile. He was unhappy with these findings since there was no interval between the operation and the development of the urinary retention. Hutchinson could not establish a diagnosis. Evidence is presented to suggest that this was the first case of disc prolapsed, causing a cauda equina syndrome because of anesthesia and manipulation.[1]
  • In 1977/1978, MRI was developed by Raymond Damadian to diagnose cancer. It has since been used to diagnose other pathologies and is the gold standard for the diagnosis of cauda equina syndrome.[2][3][4]

Classification

Cauda equina syndrome may be classified into complete and incomplete.[5][3]

  • Cauda equina syndrome complete with urinary retention
  • Cauda equina syndrome incomplete
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cauda equina syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete with urinary retention
 
 
 
 
 
 
 
 
 
 
 
Incomplete
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lumbar +/- leg pain, sensory and motor deficency in lower extremities, painless urine retention with overflow incontinence, total perianal sensory loss, and fecal incontinece.
 
 
 
 
 
 
 
 
 
 
 
Lumbar +/- leg pain, sensory and motor deficency in lower extremities, loss of micturition reflex, altered urinary sensation and hesitancy, partial saddle anesthesia, and decreased anal sphinter tone.
 
 
 
 
 
 
 
 
 
 

Pathophysiology

Causes

Cauda equina syndrome may be caused by[2]

Differentiating cauda equina syndrome from other Diseases

Epidemiology and Demographics

  • The incidence of cauda equina syndrome is 2 in 100,000/year.[5][4]
  • Patients of all age groups may develop cauda equina syndrome.
  • Cauda equina syndrome usually affects individuals of all races, although African American individuals are less likely to develop cauda equina syndrome.[20][21][22]
  • Cauda equina syndrome affects men and women equally.

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for cauda equina syndrome.

Natural History, Complications, and Prognosis

  • If left untreated, 100% progress to permanent nerve damage and neurological deficit.
  • Common complications of cauda equina syndrome include[4][27]
    • Micturition dysfunction 48%
    • Defecation dysfunction 42%,
    • Sexual dysfunction 53%
    • Sciatica 48%
    • Altered sensation of the saddle area 57%.
  • Prognosis of cauda equina syndrome depends on a number of factors, example time from onset of symptoms to decompression, the degree of nerve damage at the time of surgery and the type of cauda equina syndrome; with incomplete being more favourable.[28] Following surgery, the extent of recovery is variable.[4] Long term outcomes postsurgery are bladder, sexual, and motor dysfunction especially in patients with cauda equina syndrome complete with urinary retention.[29]

Diagnosis

Diagnostic Study of Choice

Radiological imaging Sensitivity specificity PPV NPV
CT[30] 98% 86% 72% 99%
MRI[31] 68% 78% 84% 58%
  • Although CT is shown to be more sensitive and specific for the diagnosis of cauda equina syndrome, MRI is considered the goal standard because it can depict soft tissue clearer.[2][3][4]

History and Symptoms

The most common symptoms of cauda equina syndrome include

Physical Examination

Common physical examination findings of cauda equina syndrome include

Laboratory findinds

  • There are no diagnostic laboratory findings associated with cauda equina syndrome.

Echocardiography

  • There are no ECG findings associated with cauda equina syndrome.

X-ray

  • There are no x-ray findings associated with cauda equina syndrome.

Ultrasound

  • There are no ultrasound findings associated with cauda equina syndrome.

CT Scan

  • Lumbosacral CT scan may be helpful in the diagnosis of cauda equina syndrome.
  • Findings on CT scan suggestive of/diagnostic of cauda equina syndrome include
Sagittal view CT demonstrates spinal cord compression due to Vertebra fracture after fall from a height (yellow arrow). Case courtesy of Dr Ian Bickle (Picture courtesy: Radiopedia)



MRI

  • Findings on MRI suggestive of cauda equina syndrome include
  • In Lumbar disc herniation, MRI shows a disc mass filling most of the spinal canal compressing the cauda equina.
T2-weighted images in non-contrast MRI of the lumbar region at L4/5 level demonstrating a huge isointense lesion (herniated disc) compressing the spinal cord. Sagittal view (Left/yellow arrow) and axial view (Right/yellow arrowhead) (Picture courtesy: Medicine)


Sagittal view MRI of the spine demonstrating a lumbar vertebra destruction due to TB and spinal cord compression (yellow arrowhead). Case courtesy of Dr Rishi Ramaesh (Picture courtesy: Radiopedia)



Other Imaging Findings

  • There are no other imaging findings associated with cauda equina syndrome.

Other Diagnostic Findings

Sagittal view of CT myelogram demonstrates spinal cord compression due to Spinal disc herniation (white arrow). (Picture courtesy: Thebmj)


  • Electromyography
  • Pre and post-void bladder scan; if the post-void residual volume is >200ml, the probability of cauda equina syndrome is 43% (P < 0.000003) making bladder scan an adjunct in the diagnosis of cauda equina syndrome.[33]

Treatment

Medical Treatment

Cauda equina syndrome is a medical emergency and requires prompt treatment. Although the mainstay of treatment is surgery, The following medications are used.[9]

  • 5.4 mg/kg·h of methylprednisolone (intravenous) for 2 days
  • 5 mg of dexamethasone (intravenous) every 12 h for 3 days
  • 0.5 mg of mecobalamin tablets (oral) every 8 h
  • Chemotherapy for cases due to tumors
  • Antibiotics for cases due to infection

Surgery

  • Surgery is the mainstay of treatment for cauda equina syndrome.[3][2] Immediate surgical decompression is the best intervention associated with positive patient outcome.[34] Procedures used include
  • positive outcomes in bladder and bowel functions, sensory and motor deficit are seen if decompresssion is performed within 48hours of symptoms.

Primary Prevention

  • There are no established measures for the primary prevention of cauda equina syndrome.

Secondary Prevention

  • There are no established measures for the secondary prevention of cauda equina syndrome.

References

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  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Luo D, Ji C, Xu H, Feng H, Zhang H, Li K (2020). "Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report". Medicine (Baltimore). 99 (7): e19025. doi:10.1097/MD.0000000000019025. PMC 7035013 Check |pmc= value (help). PMID 32049799 Check |pmid= value (help).
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Srikandarajah N, Wilby M, Clark S, Noble A, Williamson P, Marson T (2018). "Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review". Spine (Phila Pa 1976). 43 (17): E1005–E1013. doi:10.1097/BRS.0000000000002605. PMC 6104724. PMID 29432394.
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  10. Li P, Qiu D, Shi H, Song W, Wang C, Qiu Z; et al. (2019). "Isolated Decompression for Transverse Sacral Fractures with Cauda Equina Syndrome". Med Sci Monit. 25: 3583–3590. doi:10.12659/MSM.916483. PMC 6532556 Check |pmc= value (help). PMID 31089068.
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  12. Wu HY, Xu WB, Lu LW, Li HH, Tian JS, Li JM; et al. (2018). "Imaging features of spinal atypical teratoid rhabdoid tumors in children". Medicine (Baltimore). 97 (52): e13808. doi:10.1097/MD.0000000000013808. PMC 6314652. PMID 30593171.
  13. Tello Díaz C, Allegue Allegue N, Gil Sala D, Gonçalves Martins G, Boqué Torremorell M, Bellmunt Montoya S (2019). "Cauda Equina Syndrome Caused by Epidural Venous Plexus Engorgement in a Patient with May-Thurner Syndrome". Ann Vasc Surg. 60: 480.e7–480.e11. doi:10.1016/j.avsg.2019.04.002. PMID 31200048.
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  16. Cohen DB (2004). "Infectious origins of cauda equina syndrome". Neurosurg Focus. 16 (6): e2. doi:10.3171/foc.2004.16.6.2. PMID 15202872.
  17. Panos G, Watson DC, Karydis I, Velissaris D, Andreou M, Karamouzos V; et al. (2016). "Differential diagnosis and treatment of acute cauda equina syndrome in the human immunodeficiency virus positive patient: a case report and review of the literature". J Med Case Rep. 10: 165. doi:10.1186/s13256-016-0902-y. PMC 4895963. PMID 27268102.
  18. Jiménez-Ávila JM, Castañeda-Huerta JE, González-Cisneros AC (2019). "[Bruns Garland syndrome. Report of a case and differential diagnosis with cauda equina syndrome]". Acta Ortop Mex. 33 (1): 42–45. PMID 31480126.
  19. Zhou ZN, Canon C, Matrai C, Chapman-Davis E (2018). "Cauda equina syndrome secondary to leptomeningeal metastases from recurrent primary peritoneal carcinoma". Ecancermedicalscience. 12: 814. doi:10.3332/ecancer.2018.814. PMC 5834310. PMID 29515655.
  20. Schoenfeld AJ, Bader JO (2012). "Cauda equina syndrome: an analysis of incidence rates and risk factors among a closed North American military population". Clin Neurol Neurosurg. 114 (7): 947–50. doi:10.1016/j.clineuro.2012.02.012. PMID 22402198.
  21. Radcliff KE, Kepler CK, Delasotta LA, Rihn JA, Harrop JS, Hilibrand AS; et al. (2011). "Current management review of thoracolumbar cord syndromes". Spine J. 11 (9): 884–92. doi:10.1016/j.spinee.2011.07.022. PMID 21889419.
  22. Small SA, Perron AD, Brady WJ (2005). "Orthopedic pitfalls: cauda equina syndrome". Am J Emerg Med. 23 (2): 159–63. doi:10.1016/j.ajem.2004.03.006. PMID 15765336.
  23. Kapetanakis S, Chaniotakis C, Kazakos C, Papathanasiou JV (2017). "Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature". Folia Med (Plovdiv). 59 (4): 377–386. doi:10.1515/folmed-2017-0038. PMID 29341941.
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  25. Cushnie D, Urquhart JC, Gurr KR, Siddiqi F, Bailey CS (2018). "Obesity and spinal epidural lipomatosis in cauda equina syndrome". Spine J. 18 (3): 407–413. doi:10.1016/j.spinee.2017.07.177. PMID 28756300.
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  27. Korse NS, Pijpers JA, van Zwet E, Elzevier HW, Vleggeert-Lankamp CLA (2017). "Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction". Eur Spine J. 26 (3): 894–904. doi:10.1007/s00586-017-4943-8. PMID 28102451.
  28. Gardner A, Gardner E, Morley T (2011). "Cauda equina syndrome: a review of the current clinical and medico-legal position". Eur Spine J. 20 (5): 690–7. doi:10.1007/s00586-010-1668-3. PMC 3082683. PMID 21193933.
  29. Hazelwood JE, Hoeritzauer I, Pronin S, Demetriades AK (2019). "An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome". Acta Neurochir (Wien). 161 (9): 1887–1894. doi:10.1007/s00701-019-03973-7. PMC 6704093 Check |pmc= value (help). PMID 31263950.
  30. 30.0 30.1 Peacock, J.G.; Timpone, V.M. (2017). "Doing More with Less: Diagnostic Accuracy of CT in Suspected Cauda Equina Syndrome". American Journal of Neuroradiology. 38 (2): 391–397. doi:10.3174/ajnr.A4974. ISSN 0195-6108.
  31. . doi:10.1302/0301-620X. Missing or empty |title= (help)
  32. . doi:10.1302/0301-620X. Missing or empty |title= (help)
  33. Venkatesan M, Nasto L, Tsegaye M, Grevitt M (2019). "Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome". Spine (Phila Pa 1976). 44 (18): 1303–1308. doi:10.1097/BRS.0000000000003152. PMID 31479434.
  34. Hogan WB, Kuris EO, Durand WM, Eltorai AEM, Daniels AH (2019). "Timing of Surgical Decompression for Cauda Equina Syndrome". World Neurosurg. 132: e732–e738. doi:10.1016/j.wneu.2019.08.030. PMID 31415897.

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