THE TALE OF THE HORSE'S TAIL:

CAUDA EQUINA SYNDROME

By Dr. Sarah Smith

INTRODUCTION:

For those who suffer from Cauda Equina Syndrome (CES), there is usually a blank look from family, friends, acquaintances (and even doctors) when they mention their condition.

CES is not a "back problem" in the way that people generally think of "back trouble", although it may well have happened because of spinal problems such as a slipped disc.

Both public and medical awareness of CES needs to be improved to avoid those cases that can be avoided by prompt treatment, as well as to help those who suffer from the chronic form by recognizing their condition and helping them with appropriate measures to cope with the numerous problems it causes.

3 IMPORTANT FACTS ABOUT CES:

  1. CES is a neurological (nerve) condition. It may be regarded as a form of spinal cord injury (SCI).

  2. CES is seen more commonly as a medical emergency and may also be a chronic condition.

  3. CES is a descriptive diagnosis which pertains to a pattern of symptoms and signs, but can have various causes.

WHAT IS THE HORSE'S TAIL?

There are detailed anatomical descriptions available elsewhere, but in brief:

The cauda equina (horse’s tail) is so-called because of its appearance.

It is found at the lower end of the spinal cord. The spinal cord is shorter than the spinal (vertebral) canal in which it runs, ending at the approximate level of the first or second lumbar vertebra (this may vary in different people). The cauda equina contains the nerve roots from L1-5 and S1-5. Note that nerve roots L4-S4 join in the sacral plexus which gives rise to the largest nerve in the body, the sciatic nerve. The sacral plexus is also involved in sensory and motor nerves to and from the anal and genital regions. The nerve roots emerge in pairs from the relevant vertebral foramen (hole) e.g. L3 spinal nerve exits at the L3/4 space (see Image 6).

 

WHAT IS CES?

The syndrome arises through nerve damage to the cauda equina.

There is a specific pattern:

  • Severe pain in radicular (nerve root) pattern: back, buttocks, perineum(saddle area), genitalia, thighs, legs.

  • Loss of sensation: often tingling or numbness in the saddle area.

  • Weakness: in legs, often asymmetric

  • Bladder/bowel/sexual dysfunction: incontinence / retention of urine; incontinence of feces; impotence/loss of ejaculation or orgasm

  • Loss of reflexes: knee/ankle reflexes may be diminished, as may anal and bulbocavernosus. (a muscle of the perineum, the area between the anus and the genitals)

NOTE: This combination of symptoms arising suddenly is regarded as a medical emergency and requires immediate medical attention to avoid permanent nerve damage.

However, CES may also be a chronic condition as a result of belated treatment of the acute syndrome or as part of an ongoing illness such as Multiple Sclerosis. If it arises gradually, the major warning symptom may be urinary retention (inability to pass urine) which necessitates urgent medical attention.

CAUSES:

Damage to the nerve roots in the cauda equina may be due to:

  1. Compression: by prolapsed disc most commonly; but also by any other lesion, including spinal injury (fracture) and chronic compression such as in arachnoiditis.

  2. Stretching: e.g. by spondylolisthesis (slippage of one vertebra on another)

  3. Inflammation: in conditions such as arachnoiditis.

  4. Demyelination: loss of the myelin sheath, essential in nerve signal transmission, in conditions such as Multiple Sclerosis.

  5. Toxic damage: (rare)due to spinal anaesthetics.

CES due to compression/ distortion may respond well to speedy removal of the cause, but recovery will depend on the duration of the injury and the degree of damage sustained. However, in inflammatory or demyelinating conditions, CES may be chronic and progressive.

HOW CES AFFECTS PEOPLE:

CES is a devastating condition which can damage many aspects of life.

Often, the sufferer can no longer continue to work, either from severe pain, or because of loss of muscle power, or due to socially unacceptable continence problems, or indeed a combination of these problems.

It causes symptoms which may be invisible, and also about which the sufferer may feel unable to speak, as they relate to highly personal bodily functions.

Loss of bladder and bowel control can be extremely distressing and have a highly negative impact on social life, work and relationships. There may be frequent urinary infections.

Loss of sexual function can be devastating to the sufferer and his/her partner and may lead to relationship difficulties and depression.

Severe nerve-type (neurogenic) pain may be resistant to treatment and require strong painkillers whose side-effects may cause further problems. If the pain is chronic, it may become "centralized" and affect other parts of the body and involve strange pains such as electric shock type pain or pain from non-painful stimulus such as light touch. This can lead to the sufferer being viewed as neurotic or worse if it is not recognized. It is also very difficult to treat and alarming for the sufferer who either begins to question his/her sanity or fears the pain indicates some terrible underlying undiagnosed disease such as cancer.

Neurogenic pain tends to be worse at night, which can interfere with sleep and thus exacerbate the general debility it causes. Another feature of this type of pain, and a diagnostic one at that, is pain felt in numb areas, which appears to be a contradiction in terms. This tends to be of a burning nature and may be both constant and unbearable.

Sensory loss may range from pins and needles to complete numbness, and may affect the bladder, bowel and genitalia (and therefore exacerbate the problems with these organs).

Weakness is usually in the legs and may make walking difficult. There may be "foot drop" where the foot drags and causes trips and falls. In some cases it may be necessary to use walking aids or a wheelchair.

Bearing in mind these problems, it is unsurprising that sufferers may become depressed; they endure many losses: loss of health, loss of job and social standing, loss of relationships, loss of sexuality, loss of self-esteem. It is entirely appropriate that the sufferer and his/her loved ones may grieve over these losses and they may need considerable support to prevent the most serious loss of all: hope.

TREATING CES:

Acute CES requires urgent surgical treatment if there is a compressive injury.

There may be residual problems after the surgery and these may take some months to resolve. Extensive rehabilitation using physiotherapy and methods such as bladder re-training may be required.

Chronic CES is much harder to treat.

  • Pain: usually requires strong painkillers such as narcotics (morphine/related drugs): note that the risk of addiction is very small (around 0.1%) although the body will become accustomed to the drugs and withdrawal symptoms may be experienced on stopping. Adjuvant medication such as low dose an antidepressants (e.g. amitriptyline);. anticonvulsants ,.(e.g. Tegretol; (carbamazepine) neurontin(Gabapentin) are often helpful. Side-effects should tend to subside after the initial couple of weeks, constipation being the most persistent side-effect of opiates and weight gain being common with the adjuvant medication. The sedative effects of some medication may be beneficial if given at night as they may aid restful sleep. However, antidepressants may adversely affect bladder and sexual function and contribute to the problems experienced. It may be a delicate balancing act to achieve good pain relief with the minimum of adverse effects.

  • Bladder Control: depending on the exact nature of the problem, a neurogenic bladder will need to be treated with drugs such as Oxybutynin if it is hyper-reflexive, or intermittent self-catheterization if the bladder is unable to empty. The latter may give rise to a residual volume of urine in the bladder after voiding and this causes susceptibility to urinary infections that may require antibiotic treatment. An overactive bladder muscle(detrusor) may cause high bladder pressures and a reflux of urine up towards the kidneys, so regular checks may be needed to exclude any kidney damage. Use of measures such as cranberry juice and maintaining good fluid intake may reduce the risk of infection. Often pads may need to be worn in the underwear to protect against leakage of urine. This of course, may be distressing and embarrassing for the sufferer.

  • Bowel control: not only loss of control of feces may be a problem, but also of flatus and the inappropriate, uncontrollable passage of gas at inconvenient occasions may be a source of considerable embarrassment to the sufferer. Fecal incontinence of loose stools may in fact be helped, coincidentally, by use of painkillers such as codeine or morphine as they tend to be constipating. However, extreme constipation causing impaction of feces can lead to overflow of diarrhea around the impacted fecal mass. Most commonly in CES, it is difficult to empty the bowel, sensation in the rectum being diminished and propulsive action reduced. It is often necessary to assist the bowel to empty and there are a variety of methods available. Eating a high fiber diet and maintaining good fluid intake are useful general measures and using a stimulant laxative on a regular basis can facilitate matters.

  • Weakness: physiotherapy may be helpful provided that there is no inflammatory component, as in arachnoiditis, where exercise may exacerbate the condition and cause a "flare-up."

  • Sexual dysfunction: very difficult for people to discuss. It may be best to seek advice from specialists in this medical field; if no physical treatment is feasible for improvement of function, then the sufferer (and his/her sexual partner if appropriate) should be offered counseling, which may help lessen the impact this disability could have on the sufferer both as an individual and as part of a couple.

  • Sensory loss: there is little conventional treatment but in conditions such as MS, use of vitamin B complex is considered to have possible beneficial effects.

  • Sore feet: loss of muscle tone and control over movement of the foot may lead to pain in the foot. If foot drop is a significant problem, a brace to hold it in position may be helpful. However, it is important to try to maintain as much muscle tone as possible and range of movement (ROM) exercises may assist in this.

  • Poor circulation: this is quite a common problem: the feet may be cold and may turn white, then red when rewarmed(Raynaud's syndrome) as well as chilblains: there are some medications that can be taken, but it is probably best to use general measures such as avoiding getting cold feet (thick socks etc.) and also foot massage with warm oil may help improve circulation. Avoid very hot baths after the feet have been cold as this is more likely to cause chilblains.

  • Depression: this being an understandable and normal reaction to a debilitating illness, antidepressant medication should be reserved for severe depression, the preferred management being counselling and support. The sense of isolation may best be addressed by contact with support groups such as the online Cauda Equina Syndrome Support Group,(CESSG). These groups perform a vital role in allowing free and frank discussion: ‘mentioning the unmentionable’. Shared experiences can help sufferers to come to terms with the disabilities CES causes them.

General measures include reducing/stopping smoking: which may help to improve local blood flow in the affected spinal region as well as in the lower limbs. Exercise may be beneficial within the limits of pain as loss of mobility can lead to further problems such as osteoporosis (thinning of the bones).

One of the most important issues that needs to be tackled is that of a lack of information about CES available to sufferers and their families.

Medical and public awareness of CES needs to be significantly raised to achieve this.

Written on behalf of the Cauda Equina Syndrome Support Group.
Dr. Sarah Smith (nee Andreae-Jones) MB BS
 Patron of the Arachnoiditis Trust
August 2000.


Definitive links added by CESSG

Dr. Sarah Smith is well known in the world of arachnoiditis patients. She freely gives her time and expertise to all of us that suffer from arachnoiditis and now cauda equina syndrome as well. She has no idea how important the work she does on behalf of all of us means, to us as well as the medical community. A simple thank you doesn’t seem enough, but I will say thank you none the less. Your words and your knowledge will live on. Sadly every day someone that has just discovered these rare and baffling conditions will search the Internet and find YOUR words there to help them understand what is happening to them.

Many thanks to The Doe Report (www.doereport.com) for allowing CESSG to use this and all other illustrations used on this Web site.

We also urge you to take the time to explore all the information on the sites we used for our definitive links.

 

 

 

 


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  The information in Cauda Equina Syndrome Resource Center is not intended to substitute for medical professional advice but is to be used only as an aid in understanding this condition. This site is not maintained by physicians. No medical decision should be made based on information in this site. A physician should always be consulted for any health problem or medical condition. This site is a compilation of CES patients’ thoughts, ideas and discussions, which we hope you will find useful, but it is not medical advice.  
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