Case study 21 - Cauda Equina Syndrome from a large lumbar disc herniation - EXPLAINED by a surgeon

Case study 21 #backpain #neurosurgery #spinesurgery #chiropractor #caudaequinasyndrome #spineemergency
The collection of nerves at the end of the spinal cord is known as the cauda equina, due to its resemblance to a horse's tail. The spinal cord ends at the upper portion of the lumbar (lower back) spine. The individual nerve roots at the end of the spinal cord that provide motor and sensory function to the legs and the bladder continue along in the spinal canal. The cauda equina is the continuation of these nerve roots in the lumbar and sacral region. These nerves send and receive messages to and from the lower limbs and pelvic organs.
Cauda equina syndrome (CES) occurs when there is dysfunction of multiple lumbar and sacral nerve roots of the cauda equina.
CES is accompanied by a range of symptoms, the severity of which depend on the degree of compression and the precise nerve roots that are being compressed.
Patients with CES may experience some or all of these “red flag” symptoms.
Urinary retention: the most common symptom. The patient’s bladder fills with urine, but the patient does not experience the normal sensation or urge to urinate.
Urinary and/or fecal incontinence. The overfull bladder can result in incontinence of urine. Incontinence of stool can occur due to dysfunction of the anal sphincter.
“Saddle anethesia” sensory disturbance, which can involve the anus, genitals and buttock region.
Weakness or paralysis of usually more than one nerve root. The weakness can affect lower extremities.
Pain in the back and/or legs (also known as sciatica).
Sexual dysfunction.
If a patient is experiencing any of the “red flag” symptoms above, immediate medical attention is required to evaluate whether these symptoms represent CES.
Treatment
Once the diagnosis of CES is made and the etiology established, urgent/emergent surgery is usually the treatment of choice. The goal is to free up the compressed nerve roots and give them the best chance of recovery possible. Left untreated, CES can result in permanent paralysis and incontinence.
Those experiencing any of the red flag symptoms should be evaluated by a neurosurgeon or orthopedic spine surgeon as soon as possible. Prompt surgery is the best treatment for patients with CES. Treating patients within 48 hours after the onset of the syndrome provides a significant advantage in improving sensory and motor deficits as well as urinary and rectal function. Even patients who undergo surgery after the 48-hour ideal time frame may experience improvement.
Although short-term recovery of bladder function may lag behind reversal of lower extremity motor deficits, the function may continue to improve years after surgery. Following surgery, drug therapy coupled with intermittent self-catheterization can help lead to a slow, but steady, recovery of bladder and bowel function.
Coping with CES
Follow-up with the patient’s surgeon occurs a few weeks after surgery to check healing and progress. Many of these patients also require long term follow-up with rehabilitation medicine. Cauda Equina is a relatively rare condition and therefore data on long term outlook is limited.
CES can affect people both physically and emotionally, particularly if it is chronic. People with CES may no longer be able to work, either because of severe pain, socially unacceptable incontinence problems, motor weakness and sensory loss - or a combination of these problems.
Loss of bladder and bowel control can be extremely distressing and have a highly negative impact on social life, work and relationships. Patients with CES may develop frequent urinary infections. Sexual dysfunction can be devastating to the patient and his/her partner and may lead to relationship difficulties and depression.
Severe nerve-type (neurogenic) pain may require prescription pain medication with side effects that may cause further problems. If the pain is chronic, it may become "centralized" and radiate to other areas of the body. Neurogenic pain tends to be worse at night and may interfere with sleep. This type of pain tends to produce a burning feeling that can become constant and unbearable. Sensory loss may range from pins and needles to complete numbness, and may affect the bladder, bowel and genital areas. Weakness is usually in the legs and may contribute to problems walking.
It is essential that people with CES receive emotional support from a network of friends and family members, if possible. It is important to work closely with your physician on medication and pain management. There are several medications prescribed to address pain, bladder and bowel problems. In addition, some patients find that physical therapy and psychological counseling help them cope with CES.

[@brendananderson9732]

I was misdiagnosed Jan 2019 with bulging discs in my L4 L5 in excruciating pain I got by as a scaffolder popping Lyrica like smarties. Until I couldnt urinate properly and began having hot baths so I could pee September 2019 I went to the hospital they done an MRI and confirmed there was a tumour size of a golf ball growing on the base of my spinal cord putting pressure on my bladder preventing me from weeing I was flown to Townsville Hospital and was lucky to have found a Neurosurgeon that was able to fix me… God bless you Dear Sir I am forever grateful Dr Norwitski

[@MissCookie8260]

I went to the ER and they sent me home with Ibupropfen. Now I can't feel my leg and I pis$ed on my couch. Headed to a differant ER.

[@Stavrosg76]

im happy she recovered

[@angelalarkin9619]

I developed this almost 10 years ago and live wirh chronic pain everyday 2 surgeries since. Currently nursing a kidney infection due to bladder retention I hate this condition so so much 😪 it's ruined my life

[@marion1517]

I was diagnosed with caudia equina and believe me it's brutal before and after surgery trying to recover and live a normal life without pain

[@littlelegs880]

Sending love, I’m also 7 months post op’ it’s a tough road but we battle on 💪

[@AbdombnaExtra]

What were your symptoms that made you get checked out?

[@drewthompson7457]

My back has been bad for 30 years. Then 1 morning I couldn't pee. The 1st doctor thought I'm just an old man with a prostate problem. I got a catheter and a future appointment with a urologist. I did tell them of my very sore back. About 2 weeks later, a doctor friend suggested CES, I went to Emergency. The doctor did an MRI, and I got surgery a couple of days later. Now, 2 months later, my back pain is almost gone, the tingling in my 1 leg is gone. I have control over my bowels and bladder, not 100%, but good. I have some weird sensations in the saddle area, but I can live with this. And, I still may improve. Overall, a great result. I had a laminectomy L4-L5 and discectomy.

[@littlelegs880]

Thank you so much for this explanation, I had emergency surgery for CES in April of this year, 7 months post op’ now, this is just about exactly what my MRI looked like, I was being treated for sciatica by my GP and in horrific pain for 11 days prior to surgery, the worst 11 days of pain I’ve ever felt, it wasn’t until I realised I couldn’t pee, was constipated and had numbness I felt something wasn’t right, thankfully the last GP I spoke with picked up on me saying this and sent me to A&E department, I’m slowly trying to adjust to the way my body works now, I’m grateful I can walk to a degree, still having bladder and bowel problems but I’m here and not paralysed thankfully 🙏

[@redo90]

Same here had surgery in November and am walking now no pain. Still having issues with going to the bathroom, but am hopeful function will return... How are you this far?

[@lunebeau5641]

Same situation here had horrible back pain and was delaying visit to doctor until I lost ability to pee and feeling my bladder then had urgent surgery I feel like my back is recovering really well but still have numbness and my senses with ability to go toilet didn’t come back yet

[@redo90]

@@lunebeau5641 you have saddle anesthesia as well? How long ago did you have the surgery? I have been taking vitamin B supplements I heard they might help with nerve damage.

[@lunebeau5641]

@@redo90 yes saddle anaesthesia, I had surgery 25 days ago now almost a month . My neurosurgeon told me it might take weeks or months to come back or not come back ever it’s so different for each person..reading a lot of comments and stories I’m afraid as I saw people still having bladder issues for 1.5 year even after surgery..yes I also take supplements B but not sure if it’s actually helpful or not. How about you? How long ago did you have surgery ?

[@redo90]

@@lunebeau5641 I had a microdisckectomy and a laminectomy on the L5-l4 on November 2023. I am walking now and making great progress, the only issues are bladder problems 😕 one thing I wouldn't recommend now is sex as it is more likely you will develop a UTI 😮‍💨 as a male this sucks. Have you gotten Physical therapy yet?

[@MzClementine]

Oh wow very obvious. Bless her heart. And here you are, to save the day..

[@dominicdigginnursingstuden7833]

Caudia Equina syndrome treatment is emergent decompression in the OR

[@claman61]

Hello! I love what you share! Thank you so much.Very clear and interesting!! Love the unusual cases. I think that it so important what you share! I am a Dr of physio 30 years treating ortho cases. I would like to hear what surgical options you have for severe stenosis cervical and/or lumbar and when surgical intervention is needed.

[@spiritmediumclaytonsilva649]

The L4-L5 and L5-S1 looks like there’s a disc going right into the cauda equina I’m assuming a discectomy and fusion would be the best tx. I’m interested to see what you say.

[@spiritmediumclaytonsilva649]

I just finished the video. I was pretty close!! 🎉

[@gus2gizmo]

I’m postop 4 days after finally having CES surgery. My pain has changed and isn’t in both legs completely anymore. This all developed slowly over the months since April but quickly escalated in September. From what I read and your video they delayed this emergency surgery by 20 days. Could this be the reason for the continuing pain? I suffered so much waiting for my surgery.

[@DicentTuryamusiima]

My brother got caunda equina syndrome I also have duchenne muscular muscular dystrophy he didn't get surgery

[@MisterW0lf]

How reliable s a rectal examination to determine if the numbness in my legs, groin is CES?

[@drewthompson7457]

I had 2 doctors stick a finger up my butt. Both thought I didn't have CES. Luckily, the emergency doctor had 2nd thoughts, and I got an MRI. My symptoms were a bad back for 30 years, then 1 morning I couldn't pee. The 1st doctor thought AI was just an old man with a prostate problem. My emergency surgery happened 2 weeks after the problem. Luckily, I'm now functioning well, maybe I will improve some more, but I can live with what I got.

[@DanaGore-vr7vg]

Can an mri miss it

[@ilhommuminov708]

I would like you post the MRI right after surgery pls also as we know she is 24 well to young for surgery also she did chiropractor manipulation which is very popular all over the KZbin probl she thought she will get better after that I might think but during the inflammation you got be very patient and need some time for inflammation slow down and pains get a lit bit annoying then start to slowly exercise for healing proses on my experience I went through that but I didn’t do any surgery only painkiller for couple days and after other days it become to normal I hope she is ok after surgery peace ✌️

[@AlanQuisido]

Do you need to have a contrast injected MRI to truly determine if a patient has cauda equina syndrome? I had suffered from a L5-S1 herniated disc last year with B/L numbness and current pelvic floor weakness. Doctors ran an MRI and did not opt for surgery. I'm just confused as to the issues I'm having versus someone that's experiencing true cauda equina syndrome (i.e would the symptoms be more constant and eventually get worse over time?). Have spent a lot of money and seen several doctors and PT's without the answers I need to truly solve my bladder and LBP issues..Thought I would ask for an opinion. Thanks

[@Preeti-lw9jc]

How are you now?? Was it CES or something else

[@AlanQuisido]

@@Preeti-lw9jc thanks for reaching out! just had another MRI this past week actually. The only updated was mild degenerative changes of my L4-L5 segment. The Doc said structurally there's nothing remarkable that would lead it to being CES. Options for now are updated pain meds (meloxicam & lyrica), potential epidural, and/or pelvic floor PT. Hope this helps

[@Preeti-lw9jc]

@@AlanQuisido and what about your l5 s1 disc herniation?? Did it resolved?? And what are your symptoms right now??

[@jltt2203]

I just had CES surgery. How long did it take before your patients bladder and bowl function return to normal? Thanks!!

[@ceemarie3678]

How are you doing now?

[@jltt2203]

@Cee Marie I'm a lot better. Still have weakness in my left leg, but I'm back in the gym and can run again for short distances, something I thought I'd never do again. I no longer feel like I have to immediately go to the bathroom when I sit but its still uncomfortable to sit for long periods. Bowels are pretty much normal. Bladder still isn't right, still have to push. Dr. said it could take over a year for that to return if it heels. Fingers crossed crossed.

[@marion1517]

My bladder works 60percent and have to remove my feces on my own. Been over 8 yrs after my surgery. I'm just happy I'm able to walk. But was hard first year after surgery had to use Cath to pee.

[@jmardinly]

I had a surgeon tell me I needed full ALIF and laminectomy when i don't have leg pain or incontinence and my L4-L5 MRI showed just a small extrusion. I think this is nuts. Was he over reacting?

[@Gina-Montana]

I personally would not gamble with an extrusion. A very small protrusion, maybe I’d try PT for a couple of months and if not better, reassess. But an extrusion, I wouldn’t play with, considering my history of emergency surgeries because of them. I didn’t have leg or back pain either. It was like CES just appeared out of nowhere as the only problem. How are you doing so far?