Elsevier

Progress in Neurobiology

Volume 64, Issue 6, August 2001, Pages 613-637
Progress in Neurobiology

Cauda equina syndrome

https://doi.org/10.1016/S0301-0082(00)00065-4Get rights and content

Abstract

Single or double-level compression of the lumbosacral nerve roots located in the dural sac results in a polyradicular symptomatology clinically diagnosed as cauda equina syndrome. The cauda equina nerve roots provide the sensory and motor innervation of most of the lower extremities, the pelvic floor and the sphincters. Therefore, in a fully developed cauda equina syndrome, multiple signs of sensory disorders may appear. These disorders include low-back pain, saddle anesthesia, bilateral sciatica, then motor weakness of the lower extremities or chronic paraplegia and, bladder dysfunction. Multiple etiologies can cause the cauda equina syndrome. Among them, non-neoplastic compressive etiologies such as herniated lumbosacral discs and spinal stenosis and spinal neoplasms play a significant role in the development of the cauda equina syndrome. Non-compressive etiologies of the cauda equina syndrome include ischemic insults, inflammatory conditions, spinal arachnoiditis and other infectious etiologies. The use of canine, porcine and rat models mimicking the cauda equina syndrome enabled discovery of the effects of the compression on nerve root neural and vascular anatomy, the impairment of impulse propagation and the changes of the neurotransmitters in the spinal cord after compression of cauda equina. The involvement of intrinsic spinal cord neurons in the compression-induced cauda equina syndrome includes anterograde, retrograde and transneuronal degeneration in the lumbosacral segments. Prominent changes of NADPH diaphorase exhibiting, Fos-like immunoreactive and heat shock protein HSP72 were detected in the lumbosacral segments in a short-and long-lasting compression of the cauda equina in the dog. Developments in the diagnosis and treatment of patients with back pain, sciatica and with a herniated lumbar disc are mentioned, including many treatment options available.

Introduction

A simultaneous compression of several, eventually all lumbosacral spinal nerve roots may lead to the development of a complex clinical entity called cauda equina syndrome (CES) (Aho et al., 1969, Jaradeh, 1993). Clinical signs accompanying CES may differ in each individual patient but the fully developed syndrome is characterized by low-back pain, bilateral sciatica, saddle hypaesthesia or anaesthesia, motor weakness of the lower extremities, impairment of anal, bulbocavernous, medioplantar, and Achilles’ tendon reflexes bilaterally, rectal and bladder sphincter's dysfunction as well as sexual impotence (Aho et al., 1969, Floman et al., 1980, Rhein et al., 1985, Kostuik et al., 1986, Humphrey, 1990, Byrne, 1993, Jaradeh, 1993, Shapiro, 1993, Leroi et al., 1994, Drábek, 1995). The clinical picture resembles that observed after an injury of conus medullaris, however, with the exception that symptoms may be asymmetric (Aho et al., 1969, Jaradeh, 1993).

Section snippets

Ontogeny of the spinal cord and cauda equina

The pairs of the dorsal (sensory) and ventral (motor) roots occurring caudally to the level of termination of the spinal cord form the cauda equina that is located in the dural sac filled with cerebrospinal fluid in the subarachnoid space. Laterally, the pairs of nerve roots, including the dorsal root ganglia, pass out from the spinal canal through the nerve root canal (Rydevik et al., 1984, Cohen et al., 1989, Rydevik, 1993).

The development of the cauda equina begins in the human embryo soon

Symptomatology

Polyradicular symptomatology of the CES results from a dysfunction of sensory, motor and autonomic components of the lumbosacral nerve roots and is often diagnosed as low-back pain, saddle anaesthesia, bilateral sciatica, motor weakness of the lower extremities or chronic paraplegia and bladder dysfunction (Byrne, 1993). In order to identify the signs resulting after different nerve root involvement, four distinct forms of the cauda equina compression can be described; upper (L2-L4 nerve

Herniated lumbosacral discs

Partial or total paralysis in both legs, with impaired sensitivity, urodynamics and micturition and sphincter dysfunction may develop acutely or subacutely, when the cauda equina is compressed by a massive protrusion of a disc or a sequestration. An extreme variability of the symptoms and signs, their development, course, nature and severity occurring in the cauda syndrome is caused by various factors such as localization, size and extent of the disc disorder. Six different types can be

Dog models of the cauda equina compression

Several animal models mimicking the cauda equina syndrome have been used to study and explain the pathophysiology of the polyradicular symptomatology of the syndrome. Among them porcine and canine models clearly predominate.

A model of lumbar spinal stenosis in dogs was developed consisting of the entire cauda equina constriction at the seventh lumbar level with a nylon electrical-cable tie, 2.8 mm wide, placed circumferentially around the dura (Delamarter et al., 1990) and, after a laminectomy

The diagnosis of the cauda equina syndrome

The correct diagnosis of the cauda equina syndrome accompanied by back pain, sciatica and bladder dysfunction is usually based on detailed history and clinical picture (Kerr et al., 1988; Jaradeh, 1993) and supported by basic blood tests, chemistry with fasting glycemia, sedimentation rate, syphilis, and lyme serologies. There are multiple imaging modalities available for localizing and evaluating the causes of the cauda equina compression. However, there is no single imaging modality which

Acknowledgements

The authors thank to D. Krokavec, M. Syneková, M. Špontáková, M. Tkačiová, M. Vargová and I. Vrábelová for their excellent technical assistance. The experimental work was supported by the VEGA Grant No. 2/7222/20 from the SAS and by NIH grant NS 32794 to M.M.

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