One of the most common consults we see in neurosurgery is the 'cauda equina syndrome (CES) rule-out.' CES can be diagnostically challenging & panic-inducing due to its highly variable presentation & grave consequences if missed.
How to evaluate suspected CES: a thread 🧵
(1/9)
How to evaluate suspected CES: a thread 🧵
(1/9)
(2/9) When cauda equina syndrome is suspected, investigate the following:
•History (always)
•Bladder function (PVR)
•Rectal exam (3 parts: perianal sensation, voluntary contraction, wink reflex)
•Neuro exam (sensorimotor, reflexes)
•Imaging (MRI)
Let’s dive in 👇
•History (always)
•Bladder function (PVR)
•Rectal exam (3 parts: perianal sensation, voluntary contraction, wink reflex)
•Neuro exam (sensorimotor, reflexes)
•Imaging (MRI)
Let’s dive in 👇
(3/9) We all learned:
bladder/bowel dysfunction + saddle anesthesia + severe leg/low back pain = slam-dunk diagnosis
...but the presentation is not always this clear.
Fortunately, cauda equina syndrome is RARE - annual incidence is approx. 5-10 cases per 1,000,000.
bladder/bowel dysfunction + saddle anesthesia + severe leg/low back pain = slam-dunk diagnosis
...but the presentation is not always this clear.
Fortunately, cauda equina syndrome is RARE - annual incidence is approx. 5-10 cases per 1,000,000.
(4/9) HISTORY.
Listening to the patient is, & always will be, the first step. No skipping.
Ask:
❓onset, progression, severity, &c
❓NEW bladder/bowel dysfunction (retention, incontinence)
❓pain in low back or leg(s)
❓saddle anes.
❓PMH (blood thinners, infxn, cancer, &c)
Listening to the patient is, & always will be, the first step. No skipping.
Ask:
❓onset, progression, severity, &c
❓NEW bladder/bowel dysfunction (retention, incontinence)
❓pain in low back or leg(s)
❓saddle anes.
❓PMH (blood thinners, infxn, cancer, &c)
(5/9) BLADDER DYSFUNCTION.
Not always present, but concerning when it is.
Impaired sensation of bladder filling, impaired micturition ➡️ retention ➡️ overflow incontinence.
Get PVR. Normal <50-100 cc. <200 cc has 97% neg pred value for CES.
🔴 PVR > 300 cc is concerning.
Not always present, but concerning when it is.
Impaired sensation of bladder filling, impaired micturition ➡️ retention ➡️ overflow incontinence.
Get PVR. Normal <50-100 cc. <200 cc has 97% neg pred value for CES.
🔴 PVR > 300 cc is concerning.
(6/9) RECTAL EXAM.
"Tone” is highly subjective & is NOT enough. The adequate rectal exam for CES has 3 components:
-perianal sensation
-wink reflex
-voluntary contraction
🔴 If any of the above are diminished/absent, that is concerning.
"Tone” is highly subjective & is NOT enough. The adequate rectal exam for CES has 3 components:
-perianal sensation
-wink reflex
-voluntary contraction
🔴 If any of the above are diminished/absent, that is concerning.
(7/9) NEURO EXAM.
CES affects lumbosacral nerve *roots* (*lower* motor neuron signs).
•Motor: weakness or ⬇️ tone in myotomes supplied by lumbosacral nerve roots
•Sensory: diminished/absent in lumbosacral dermatomes
•Reflexes: diminished
🔴 Any of these = concerning.
CES affects lumbosacral nerve *roots* (*lower* motor neuron signs).
•Motor: weakness or ⬇️ tone in myotomes supplied by lumbosacral nerve roots
•Sensory: diminished/absent in lumbosacral dermatomes
•Reflexes: diminished
🔴 Any of these = concerning.
(8/9) IMAGING.
MRI w/wo contrast is first-line. If the patient can't tolerate being supine due to pain, sagittal & axial T2 sequences are the bare minimum.
If MRI unavailable or pt has contraindications (e.g., pacemaker), can do CT or CT myelogram.
MRI w/wo contrast is first-line. If the patient can't tolerate being supine due to pain, sagittal & axial T2 sequences are the bare minimum.
If MRI unavailable or pt has contraindications (e.g., pacemaker), can do CT or CT myelogram.
(9/9) Summary:
•CES is a common consult but an uncommon condition
•H&P is your first step, always
•Diagnostic eval is incomplete without PVR, rectal exam, neuro exam, & imaging
•Back pain or bilateral leg pain is not reliably present
•Breathe - you got this :)
•CES is a common consult but an uncommon condition
•H&P is your first step, always
•Diagnostic eval is incomplete without PVR, rectal exam, neuro exam, & imaging
•Back pain or bilateral leg pain is not reliably present
•Breathe - you got this :)
• • •
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