A 40 Year Old Man Presents With Sudden Severe Back Pain.

A 40 year old man who is otherwise healthy with no past medical problems presents to the emergency department with the complains of sudden onset of severe back pain, along with gait disturbance and feeling of pins and needle sensation in the groin area and the inner thighs. While in the emergency room he felt losing control over his bladder and had urinary incontinence.
The doctor on call suspected Cauda equina syndrome and ordered urgent MRI and referral to neurosurgery to prevent long term complications.
The typical MRI from a patient with Cauda Equina syndrome is shown below:

The arrow shows a ruptures disc in the lumbar area.

Case Discussion:

Cauda Equina Syndrome:

Refers to a characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbo sacral nerve roots below the level of conus medularis.

Causes:  Common causes include:

• -          Herniated disk in the lumbar area
• -          Narrowing of the spinal canal (spinal stenosis)
• -          A spinal lesion or malignant tumor
• -          Spinal infection, inflammation, or hemorrhage
• -          A spinal trauma including fractures

Clinical features:

1. -          Sudden onset of severe lower back pain
2. -          Unilateral or bilateral sciatica
3. -          Saddle and perineal hypoesthesia or anesthesia
4. -          Bladder dysfunction: urinary retention, difficulty initiating micturation, altered urethral sensation and later on overflow incontinence).
5. -          Bowel dysfunction: incontinence, constipation, altered anal tone and sensation.
6. -          Gait disturbance
7. -          Decrease muscle strength in lower extremities
8. -          Absent or diminished reflexes
9. -          Saddle anesthesia: anesthesia or parasthesia involving perineum, external genitalia and anus.

       Diagnosis: 

•       A medical history of sudden onset of back pain and an examination showing loss of sensation in the S3 to S5 dermatomes including the perineum, external genitalia and the anus points towards the diagnosis.
•       Diagnosis can be confirmed by MRI or CT scan.
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Management:

Cauda equine Syndrome is an acute medical condition that requires urgent referral to neurosurgery. Surgery is done to relieve pressure on the nerves and to prevent permanent damage. It is best if the surgery is done within 48 hrs of onset of symptoms. 

Depending on the cause of cauda equina syndrome some patients may need high doses of corticosteroids, to reduce swelling and inflammation.