Cauda Equina and Conus Medullaris Syndromes Medication

  • Author: Segun T Dawodu, MD, JD, MBA, LLM, FAAPMR, FAANEM; Chief Editor: Nicholas Lorenzo, MD   more...
 
Updated: Aug 24, 2011
 

Medication Summary

Appropriate analgesia should be provided for a patient with cauda equina syndrome. Anti-inflammatory medication may prevent worsening of injury. Anticoagulants provide prophylaxis against thrombotic complications. Use of antispasticity medications to reduce muscle tone is encouraged. Bisphosphonates may be beneficial in patients with bony lesions. Phosphodiesterase type 5 inhibitors treat erectile dysfunction (ED).

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Corticosteroids

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Methylprednisolone sodium succinate (A-Methapred, Depo-Medrol, Solu-Medrol)

 

This agent decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. This prevents further worsening of injury.

Treatment must be started within 8 h of injury; treatment apparently has no benefit if started later than 8 h after injury. Late treatment may have detrimental effects.

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Anticoagulants

Class Summary

These agents are taken as prophylaxis for deep venous thrombosis and/or pulmonary embolism.

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Heparin

 

Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse clot but is able to inhibit further thrombogenesis. It prevents re-accumulation of clot after spontaneous fibrinolysis. Administer low dose.

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Skeletal Muscle Relaxants

Class Summary

These agents are thought to work centrally by suppressing conduction at the spinal level.

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Baclofen (Lioresal, Gablofen)

 

Baclofen may induce hyperpolarization of afferent terminals and inhibit both monosynaptic and polysynaptic reflexes at the spinal level.

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Dantrolene (Dantrium, Revonto)

 

Dantrolene stimulates muscle relaxation by modulating skeletal muscle contractions at sites beyond the myoneural junction and acting directly on muscle itself. It prevents calcium release from sarcoplasmic reticulum.

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Benzodiazepines

Class Summary

These agents may act in the spinal cord to induce muscle relaxation.

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Diazepam (Diastat, Valium)

 

Diazepam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing activity of gamma-aminobutyric acid (GABA). Individualize dosage and increase cautiously to avoid adverse effects.

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Alpha 2-adrenergic Agonist Agents

Class Summary

These agents may reduce sympathetic outflow, which may produce a reduction in muscle tone.

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Clonidine (Catapres)

 

Clonidine stimulates alpha2-adrenoreceptors in the brain stem, activating an inhibitory neuron, which in turn results in reduced sympathetic outflow.

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Tizanidine (Zanaflex)

 

Tizanidine is a centrally acting muscle relaxant that is metabolized in the liver and excreted in urine and feces.

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Neuromuscular Blocker Agent, Toxin

Class Summary

These agents inhibit transmission of impulses in neuromuscular tissue.

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OnabotulinumtoxinA (BOTOX)

 

This agent binds to receptor sites on motor nerve terminals and inhibits release of acetylcholine, which in turn inhibits transmission of impulses in neuromuscular tissue.

It is most useful for treating spasticity in the gastrocnemius and soleus muscles; less effective in larger muscles such as quadriceps. Re-examine patients 7-14 d after initial dose, to assess for response. It may be repeated q3-4mo.

Also indicated for urinary incontinence in patients with neurologic conditions (eg, spinal cord injury, multiple sclerosis) in adults who have an inadequate response to or are intolerant of an anticholinergic medication. Intradetrusor injections are administered about every 9 months.

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Bisphosphonate Derivatives

Class Summary

These agents are analogs of pyrophosphate. They act by binding to hydroxyapatite in bone-matrix, thereby inhibiting the dissolution of crystals. They prevent osteoclast attachment to the bone matrix and osteoclast recruitment and viability.

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Etidronate disodium (Didronel)

 

Etidronate inhibits normal and abnormal bone resorption. It appears to inhibit bone resorption without inhibiting bone formation and mineralization.

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Alendronate (Fosamax)

 

Alendronate inhibits bone resorption via actions on osteoclasts or osteoclast precursors. It is used to treat osteoporosis in both men and women and it may reduce bone resorption and incidence of fracture at spine, hip, and wrist by approximately 50%. Alendronate should be taken with a large glass of water, at least 30 min before eating and drinking, to maximize absorption. Because of possible esophageal irritation, patients must remain upright after taking the medication. Since it is renally excreted, it is not recommended in patients with moderate-to-severe renal insufficiency (ie, CrCl < 30 mL/min or CrCl >3.0 mg/dL), thus its use in perirenal transplantation is limited.

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Ibandronate (Boniva)

 

Ibandronate inhibits osteoclast-mediated bone resorption. In postmenopausal women, it reduces bone turnover rate, leading to a net gain in bone mass.

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Phosphodiesterase (type 5) Enzyme Inhibitors

Class Summary

These agents increase the vasodilatory effects of nitric oxide by inhibiting the enzyme phosphodiesterase type 5, which in turn increases sensitivity for erections.

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Sildenafil (Viagra)

 

Sildenafil is a phosphodiesterase type 5 (PDE5) selective inhibitor. Inhibition of PDE5 increases the activity of cyclic guanosine monophosphate (cGMP), which increases the vasodilatory effects of nitric oxide. This agent is effective in men with mild-to-moderate ED.

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Vardenafil (Levitra)

 

Vardenafil is a PDE5 selective inhibitor. Inhibition of PDE5 increases cGMP activity, which increases the vasodilatory effects of nitric oxide. It is effective in men with mild-to-moderate ED.

Take on an empty stomach about 1 h before sexual activity. Sexual stimulation is necessary to activate response. Increased sensitivity for erections may last 24 h. Vardenafil is available as 2.5-mg, 5-mg, 10-mg, and 20-mg tabs.

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Tadalafil (Cialis)

 

Tadalafil is a PDE5 selective inhibitor. Inhibition of PDE5 increases cGMP activity, which increases the vasodilatory effects of nitric oxide. Sexual stimulation is necessary to activate response. Increased sensitivity for erections may last 36 h. Tadalafil is available as 5-mg, 10-mg, and 20-mg tabs.

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Contributor Information and Disclosures
Author

Segun T Dawodu, MD, JD, MBA, LLM, FAAPMR, FAANEM  Associate Professor of Rehabilitation Medicine and Interventional Pain Medicine, Albany Medical College

Segun T Dawodu, MD, JD, MBA, LLM, FAAPMR, FAANEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Coauthor(s)

Kirsten A Bechtel, MD  Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP  Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Scott D Hodges, DO  Consulting Surgeon, Department of Orthopedic Surgery, Center for Sports Medicine and Orthopedics

Scott D Hodges, DO is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Medical Association, American Osteopathic Association, American Spinal Injury Association, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association, and Tennessee Medical Association

Disclosure: Medtronic Royalty Consulting; Biomet Spine Royalty Consulting

S Craig Humphreys, MD  Orthopedic Spine Surgeon, Department of Orthopedic Surgery, Center for Sports Medicine and Orthopedics

S Craig Humphreys, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Spinal Injury Association, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association, and Tennessee Medical Association

Disclosure: Nothing to disclose.

James F Kellam, MD  Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center

James F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Milind J Kothari, DO  Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center

Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD  Consulting Staff, Neurology Specialists and Consultants

Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and American College of Physician Executives

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Jason C Eck, DO, MS,to the development and writing of a source article.

References

  1. Mauffrey C, Randhawa K, Lewis C, Brewster M, Dabke H. Cauda equina syndrome: an anatomically driven review. Br J Hosp Med (Lond). Jun 2008;69(6):344-7. [Medline].

  2. Olmarker K, Rydevik B, Hansson T, Holm S. Compression-induced changes of the nutritional supply to the porcine cauda equina. J Spinal Disord. Mar 1990;3(1):25-9. [Medline].

  3. Delamarter RB, Sherman JE, Carr JB. 1991 Volvo Award in experimental studies. Cauda equina syndrome: neurologic recovery following immediate, early, or late decompression. Spine (Phila Pa 1976). Sep 1991;16(9):1022-9. [Medline].

  4. Olmarker K, Rydevik B, Holm S. Edema formation in spinal nerve roots induced by experimental, graded compression. An experimental study on the pig cauda equina with special reference to differences in effects between rapid and slow onset of compression. Spine (Phila Pa 1976). Jun 1989;14(6):569-73. [Medline].

  5. Olmarker K, Rydevik B, Holm S, Bagge U. Effects of experimental graded compression on blood flow in spinal nerve roots. A vital microscopic study on the porcine cauda equina. J Orthop Res. 1989;7(6):817-23. [Medline].

  6. Olmarker K, Holm S, Rydevik B. Importance of compression onset rate for the degree of impairment of impulse propagation in experimental compression injury of the porcine cauda equina. Spine (Phila Pa 1976). May 1990;15(5):416-9. [Medline].

  7. Olmarker K, Holm S, Rosenqvist AL, Rydevik B. Experimental nerve root compression. A model of acute, graded compression of the porcine cauda equina and an analysis of neural and vascular anatomy. Spine (Phila Pa 1976). Jan 1991;16(1):61-9. [Medline].

  8. Metser U, Lerman H, Blank A, Lievshitz G, Bokstein F, Even-Sapir E. Malignant involvement of the spine: assessment by 18F-FDG PET/CT. J Nucl Med. Feb 2004;45(2):279-84. [Medline].

  9. Takahashi K, Olmarker K, Holm S, Porter RW, Rydevik B. Double-level cauda equina compression: an experimental study with continuous monitoring of intraneural blood flow in the porcine cauda equina. J Orthop Res. Jan 1993;11(1):104-9. [Medline].

  10. Rydevik BL, Pedowitz RA, Hargens AR, Swenson MR, Myers RR, Garfin SR. Effects of acute, graded compression on spinal nerve root function and structure. An experimental study of the pig cauda equina. Spine (Phila Pa 1976). May 1991;16(5):487-93. [Medline].

  11. Rydevik B. Neurophysiology of cauda equina compression. Acta Orthop Scand Suppl. 1993;251:52-5. [Medline].

  12. Pedowitz RA, Garfin SR, Massie JB, Hargens AR, Swenson MR, Myers RR, et al. Effects of magnitude and duration of compression on spinal nerve root conduction. Spine (Phila Pa 1976). Feb 1992;17(2):194-9. [Medline].

  13. Todd NV. An algorithm for suspected cauda equina syndrome. Ann R Coll Surg Engl. May 2009;91(4):358-9; author reply 359-60. [Medline]. [Full Text].

  14. Olivero WC, Wang H, Hanigan WC, Henderson JP, Tracy PT, Elwood PW, et al. Cauda equina syndrome (CES) from lumbar disc herniations. J Spinal Disord Tech. May 2009;22(3):202-6. [Medline].

  15. Kingwell SP, Curt A, Dvorak MF. Factors affecting neurological outcome in traumatic conus medullaris and cauda equina injuries. Neurosurgical Focus. 2008;25(5):E7. [Medline].

  16. Fujisawa H, Igarashi S, Koyama T. Acute cauda equina syndrome secondary to lumbar disc herniation mimicking pure conus medullaris syndrome--case report. Neurol Med Chir (Tokyo). Jul 1998;38(7):429-31. [Medline].

  17. Raj D, Coleman N. Cauda equina syndrome secondary to lumbar disc herniation. Acta Orthop Belg. Aug 2008;74(4):522-7. [Medline].

  18. Gleave JR, MacFarlane R. Prognosis for recovery of bladder function following lumbar central disc prolapse. Br J Neurosurg. 1990;4(3):205-9. [Medline].

  19. Gellido CL, Onesti S, Llena J. Spinal schistosomiasis. Neurology. Jan 25 2000;54(2):527. [Medline].

  20. Waters JH, Watson TB, Ward MG. Conus medullaris injury following both tetracaine and lidocaine spinal anesthesia. J Clin Anesth. Dec 1996;8(8):656-8. [Medline].

  21. Kothbauer K, Seiler RW. [Tethered spinal cord syndrome in adults]. Nervenarzt. Apr 1997;68(4):285-91. [Medline].

  22. Widge AS, Tomycz ND, Kanter AS. Sacral preservation in cauda equina syndrome from inferior vena cava thrombosis. J Neurosurg Spine. Mar 2009;10(3):257-9. [Medline].

  23. Rooney A, Statham PF, Stone J. Cauda equina syndrome with normal MR imaging. J Neurol. May 2009;256(5):721-5. [Medline].

  24. Harrop JS, Hunt GE Jr, Vaccaro AR. Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles. Neurosurg Focus. Jun 15 2004;16(6):e4. [Medline].

  25. Fisher RG. Sacral fracture with compression of cauda equina: surgical treatment. J Trauma. Dec 1988;28(12):1678-80. [Medline].

  26. Schizas C, Ballesteros C, Roy P. Cauda equina compression after trauma: an unusual presentation of spinal epidural lipoma. Spine (Phila Pa 1976). Apr 15 2003;28(8):E148-51. [Medline].

  27. Thongtrangan I, Le H, Park J, Kim DH. Cauda equina syndrome in patients with low lumbar fractures. Neurosurg Focus. Jun 15 2004;16(6):e6. [Medline].

  28. Haldeman S, Rubinstein SM. Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. Spine (Phila Pa 1976). Dec 1992;17(12):1469-73. [Medline].

  29. Muthukumar T, Butt SH, Cassar-Pullicino VN, McCall IW. Cauda equina syndrome presentation of sacral insufficiency fractures. Skeletal Radiol. Apr 2007;36(4):309-13. [Medline].

  30. Kebaish KM, Awad JN. Spinal epidural hematoma causing acute cauda equina syndrome. Neurosurg Focus. Jun 15 2004;16(6):e1. [Medline].

  31. Chen HJ, Liang CL, Lu K, Liliang PC, Tsai YD. Cauda equina syndrome caused by delayed traumatic spinal subdural haematoma. Injury. Jul 2001;32(6):505-7. [Medline].

  32. Zuccarello M, Powers G, Tobler WD, Sawaya R, Hakim SZ. Chronic posttraumatic lumbar intradural arachnoid cyst with cauda equina compression: case report. Neurosurgery. Apr 1987;20(4):636-8. [Medline].

  33. Raaf J. Removal of protruded lumbar intervertebral discs. J Neurosurg. May 1970;32(5):604-11. [Medline].

  34. Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. Mar 1986;68(3):386-91. [Medline].

  35. Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery. May 1993;32(5):743-6; discussion 746-7. [Medline].

  36. Shapiro S. Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine (Phila Pa 1976). Feb 1 2000;25(3):348-51; discussion 352. [Medline].

  37. Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine (Phila Pa 1976). Jun 15 2000;25(12):1515-22. [Medline].

  38. Scott PJ. Bladder paralysis in cauda equina lesions from disc prolapse. J Bone Joint Surg. 1965;47B:224-235.

  39. Dinning TA, Schaeffer HR. Discogenic compression of the cauda equina: a surgical emergency. Aust N Z J Surg. Dec 1993;63(12):927-34. [Medline].

  40. Shaw M, Birch N. Facet joint cysts causing cauda equina compression. J Spinal Disord Tech. Oct 2004;17(5):442-5. [Medline].

  41. Ahn NU, Ahn UM, Nallamshetty L, Springer BD, Buchowski JM, Funches L, et al. Cauda equina syndrome in ankylosing spondylitis (the CES-AS syndrome): meta-analysis of outcomes after medical and surgical treatments. J Spinal Disord. Oct 2001;14(5):427-33. [Medline].

  42. Tullous MW, Skerhut HE, Story JL, Brown WE Jr, Eidelberg E, Dadsetan MR, et al. Cauda equina syndrome of long-standing ankylosing spondylitis. Case report and review of the literature. J Neurosurg. Sep 1990;73(3):441-7. [Medline].

  43. Devlin GP, Sheppeard H. Cauda equina syndrome in ankylosing spondylitis diagnosed by computed tomography. N Z Med J. Oct 28 1987;100(834):651-2. [Medline].

  44. Rubenstein DJ, Ghelman B. Case report 477: Cauda equina syndrome (CES) complicating long-standing ankylosing spondylitis (AS). Skeletal Radiol. 1988;17(3):212-5. [Medline].

  45. Indrieri RJ. Lumbosacral stenosis and injury of the cauda equina. Vet Clin North Am Small Anim Pract. May 1988;18(3):697-710. [Medline].

  46. Baba H, Maezawa Y, Furusawa N, Imura S, Tomita K. The role of calcium deposition in the ligamentum flavum causing a cauda equina syndrome and lumbar radiculopathy. Paraplegia. Apr 1995;33(4):219-23. [Medline].

  47. Schweitzer JS, Batzdorf U. Ependymoma of the cauda equina region: diagnosis, treatment, and outcome in 15 patients. Neurosurgery. Feb 1992;30(2):202-7. [Medline].

  48. Anderson JR, Gullan RW. Paraganglioma of the cauda equina: a case report. J Neurol Neurosurg Psychiatry. Jan 1987;50(1):100-3. [Medline]. [Full Text].

  49. Kagaya H, Abe E, Sato K, Shimada Y, Kimura A. Giant cauda equina schwannoma. A case report. Spine (Phila Pa 1976). Jan 15 2000;25(2):268-72. [Medline].

  50. Bagley CA, Gokaslan ZL. Cauda equina syndrome caused by primary and metastatic neoplasms. Neurosurg Focus. Jun 15 2004;16(6):e3. [Medline].

  51. Ampil FL, Mills GM, Burton GV. A retrospective study of metastatic lung cancer compression of the cauda equina. Chest. Nov 2001;120(5):1754-5. [Medline].

  52. Saad F, Clarke N, Colombel M. Natural history and treatment of bone complications in prostate cancer. Eur Urol. Mar 2006;49(3):429-40. [Medline].

  53. Natale M, Spennato P, Savarese L, Bocchetti A, Esposito S, Barbato R. Anaplastic oligodendroglioma presenting with drop metastases in the cauda equina. Clin Neurol Neurosurg. Aug 2005;107(5):417-20. [Medline].

  54. den Boon J, Avezaat CJ, van der Gaast A, Koops W, Huikeshoven FJ. Conus-cauda syndrome as a presenting symptom of endodermal sinus tumor of the ovary. Gynecol Oncol. Apr 1995;57(1):121-5. [Medline].

  55. Bourezgui M, Rafai MA, El Moutawakkil B, Boulaajaj FZ, Sibai M, Lezar S, et al. [Cauda equina syndrome revealing neuroblastoma]. Rev Neurol (Paris). Dec 2008;164(12):1048-51. [Medline].

  56. Lenehan B, Sullivan P, Street J, Dudeney S. Epidural abscess causing cauda equina syndrome. Ir J Med Sci. Jul-Sep 2005;174(3):88-91. [Medline].

  57. Kapoor SK, Garg V, Dhaon BK, Jindal M. Tuberculosis of the posterior vertebral elements: a rare cause of compression of the cauda equina. A case report. J Bone Joint Surg Am. Feb 2005;87(2):391-4. [Medline].

  58. Faraj A, Krishna M, Mehdian SM. Cauda equina syndrome secondary to lumbar spondylodiscitis caused by Streptococcus milleri. Eur Spine J. 1996;5(2):134-6. [Medline].

  59. Brecker SJ, Pugey CD. Nocardia asteroides infection of the cauda equina. J Neurol Neurosurg Psychiatry. Feb 1988;51(2):309-11. [Medline]. [Full Text].

  60. Donovan DJ, Polly DW Jr, Ondra SL. The removal of a transdural pedicle screw placed for thoracolumbar spine fracture. Spine (Phila Pa 1976). Nov 1 1996;21(21):2495-8; discussion 2499. [Medline].

  61. Rittmeister M, Leyendecker K, Kurth A, Schmitt E. Cauda equina compression due to a laminar hook: A late complication of posterior instrumentation in scoliosis surgery. Eur Spine J. 1999;8(5):417-20. [Medline].

  62. Mineiro J, Weinstein SL. Delayed postoperative paraparesis in scoliosis surgery. A case report. Spine (Phila Pa 1976). Jul 15 1997;22(14):1668-72. [Medline].

  63. Ilias WK, Klimscha W, Skrbensky G, Weinstabl R, Widhalm A. Continuous microspinal anaesthesia: another perspective on mechanisms inducing cauda equina syndrome. Anaesthesia. Jul 1998;53(7):618-23. [Medline].

  64. Wera GD, Dean CL, Nho S, Ahn UM, Cassinelli EH, Liu RW, et al. Cauda equina syndrome resulting from treatment of dural ectasia with fibrin glue injection. J Spinal Disord Tech. Apr 2006;19(2):148-50. [Medline].

  65. Imran Y, Halim Y. Acute cauda equina syndrome secondary to free fat graft following spinal decompression. Singapore Med J. Jan 2005;46(1):25-7. [Medline].

  66. Johnson ME. Potential neurotoxicity of spinal anesthesia with lidocaine. Mayo Clin Proc. Sep 2000;75(9):921-32. [Medline].

  67. Loo CC, Irestedt L. Cauda equina syndrome after spinal anaesthesia with hyperbaric 5% lignocaine: a review of six cases of cauda equina syndrome reported to the Swedish Pharmaceutical Insurance 1993-1997. Acta Anaesthesiol Scand. Apr 1999;43(4):371-9. [Medline].

  68. Liu YC, Wu RS, Wong CS. Unexpected complication of attempted epidural anaesthesia: cauda equina syndrome. Anaesth Intensive Care. Aug 2003;31(4):461-4. [Medline].

  69. Pouchot J, Si-Hassen C, Damade R, Bayeux MC, Mathieu A, Vinceneux P. Cauda equina compression by epidural lipomatosis in obesity. Effectiveness of weight reduction. J Rheumatol. Sep 1995;22(9):1771-5. [Medline].

  70. Diaz JH. Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache. Anesthesiology. Jun 2002;96(6):1515-7. [Medline].

  71. Prusick VR, Lint DS, Bruder WJ. Cauda equina syndrome as a complication of free epidural fat-grafting. A report of two cases and a review of the literature. J Bone Joint Surg Am. Sep 1988;70(8):1256-8. [Medline].

  72. Lambert DH. Bupivacaine spinal block cauda equina syndrome: why did it happen?. Anesthesiology. Jun 2005;102(6):1285-6; author reply 1287-8. [Medline].

  73. Shaw A, Anwar H, Targett J, Lafferty K. Cauda equina syndrome versus saddle embolism. Ann R Coll Surg Engl. Sep 2008;90(6):W6-8. [Medline]. [Full Text].

  74. O'Laughlin SJ, Kokosinski E. Cauda equina syndrome in a pregnant woman referred to physical therapy for low back pain. J Orthop Sports Phys Ther. Nov 2008;38(11):721. [Medline].

  75. Bell DA, Collie D, Statham PF. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning?. Br J Neurosurg. Apr 2007;21(2):201-3. [Medline].

  76. Ma B, Wu H, Jia LS, Yuan W, Shi GD, Shi JG. Cauda equina syndrome: a review of clinical progress. Chin Med J (Engl). May 20 2009;122(10):1214-22. [Medline].

  77. Balzer JR, Rose RD, Welch WC, Sclabassi RJ. Simultaneous somatosensory evoked potential and electromyographic recordings during lumbosacral decompression and instrumentation. Neurosurgery. Jun 1998;42(6):1318-24; discussion 1324-5. [Medline].

  78. Mathew P, Todd NV. Diagnosis of intradural conus and cauda equina tumours. Br J Hosp Med. Aug 18-31 1993;50(4):169-70, 172-4. [Medline].

  79. Bell DA, Collie D, Statham PF. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning?. Br J Neurosurg. Apr 2007;21(2):201-3. [Medline].

  80. Coscia M, Leipzig T, Cooper D. Acute cauda equina syndrome. Diagnostic advantage of MRI. Spine. Feb 15 1994;19(4):475-8. [Medline].

  81. Mailleux R, Redant C, Milbouw G. MR diagnosis of transdural disc herniation causing cauda equine syndrome. JBR-BTR. Nov-Dec 2006;89(6):303-5. [Medline].

  82. Kikuchi M, Nagao K, Muraosa Y, Ohnuma S, Hoshino H. Cauda equina syndrome complicating pneumococcal meningitis. Pediatr Neurol. Feb 1999;20(2):152-4. [Medline].

  83. Spencer TS, Campellone JV, Maldonado I, et al. Clinical and magnetic resonance imaging manifestations of neurosarcoidosis. Semin Arthritis Rheum. 2005;34(4):649-661. [Medline].

  84. Podnar S. Electromyography of the anal sphincter: which muscle to examine?. Muscle Nerve. Sep 2003;28(3):377-9. [Medline].

  85. Gleave JR, Macfarlane R. Cauda equina syndrome: what is the relationship between timing of surgery and outcome?. Br J Neurosurg. Aug 2002;16(4):325-8. [Medline].

  86. Hussain SA, Gullan RW, Chitnavis BP. Cauda equina syndrome: outcome and implications for management. Br J Neurosurg. Apr 2003;17(2):164-7. [Medline].

  87. Institute for Clinical Systems Improvement (ICSI). Adult low back pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); Nov 2008:[Full Text].

  88. Michigan Quality Improvement Consortium. Management of acute low back pain. Southfield (MI): Michigan Quality Improvement Consortium; Mar 2008:[Full Text].

  89. Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther. Jan 2008;31(1):33-88. [Medline]. [Full Text].

  90. Herschorn S, Gajewski J, Ethans K, Corcos J, Carlson K, Bailly G, et al. Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial. J Urol. Jun 2011;185(6):2229-35. [Medline].

  91. Cruz F, Herschorn S, Aliotta P, Brin M, Thompson C, Lam W, et al. Efficacy and Safety of OnabotulinumtoxinA in Patients with Urinary Incontinence Due to Neurogenic Detrusor Overactivity: A Randomised, Double-Blind, Placebo-Controlled Trial. Eur Urol. Jul 13 2011;[Medline].

  92. Ginsberg D, et al. Phase 3 Efficacy and Safety Study of OnabotulinumtoxinA in Patients With Urinary Incontinence Due to Neurogenic Detrusor Overactivity. Presented at 107th Annual Meeting of the American Urological Association, Washington, DC. May, 2011.

  93. McCarthy MJ, Aylott CE, Grevitt MP, Hegarty J. Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome. Spine (Phila Pa 1976). Jan 15 2007;32(2):207-16. [Medline].

  94. O'Laoire SA, Crockard HA, Thomas DG. Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disc prolapse. Br Med J (Clin Res Ed). Jun 6 1981;282(6279):1852-4. [Medline]. [Full Text].

  95. Weninger P, Schultz A, Hertz H. Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting. Arch Orthop Trauma Surg. Feb 2009;129(2):207-19. [Medline].

  96. Sayegh FE, Kapetanos GA, Symeonides PP, Anogiannakis G, Madentzidis M. Functional outcome after experimental cauda equina compression. J Bone Joint Surg Br. Jul 1997;79(4):670-4. [Medline].

 
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Muscle groups, surface anatomy, peripheral sensory innervation, and dermatomes of the anterior lower limb. This image should be correlated with Tables 1 and 2 in the text. Image courtesy of Nicholas Y. Lorenzo, MD.
Muscle groups, surface anatomy, peripheral sensory innervation, and dermatomes of the posterior lower limb. This image should be correlated with Tables 1 and 2 in the text. Image courtesy of Nicholas Y. Lorenzo, MD.
Conus/epiconus infarction in the setting of sickle cell crisis. Image courtesy of Matthew J. Baker, MD.
Conus/epiconus infarction in the setting of sickle cell crisis in the same patient shown in the above image. Image courtesy of Matthew J. Baker, MD.
Conus/epiconus infarction in the setting of sickle cell crisis in the same patient shown in the images above. Image courtesy of Matthew J. Baker, MD.
Illustration demonstrating the relevant anatomy of the cauda equina region
Illustration demonstrating an example of cauda equina syndrome secondary to a spinal neoplasm
Sagittal MRI of a patient with cauda equina syndrome secondary to a large lumbar disk herniation
Epidural abscess with effacement of thecal sac in a 56-year-old man.
Table 1. Symptoms and Signs of Conus Medullaris and Cauda Equina Syndromes
Conus Medullaris Syndrome Cauda Equina Syndrome
PresentationSudden and bilateralGradual and unilateral
ReflexesKnee jerks preserved but ankle jerks affectedBoth ankle and knee jerks affected
Radicular painLess severeMore severe
Low back painMoreLess
Sensory symptoms and signsNumbness tends to be more localized to perianal area; symmetrical and bilateral; sensory dissociation occursNumbness tends to be more localized to saddle area; asymmetrical, may be unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris
Motor strengthTypically symmetric, hyperreflexic distal paresis of lower limbs that is less marked; fasciculations may be presentAsymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common
ImpotenceFrequentLess frequent; erectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate
Sphincter dysfunctionUrinary retention and atonic anal sphincter cause overflow urinary incontinence and fecal incontinence; tend to present early in course of disease Urinary retention; tends to present late in course of disease
Table 2. Pain and Deficits Associated with Specific Nerve Roots
Nerve RootPainSensory DeficitMotor DeficitReflex Deficit
L2Anterior medial thighUpper thighSlight quadriceps weakness; hip flexion; thigh adductionSlightly diminished suprapatellar
L3Anterior lateral thighLower thighQuadriceps weakness; knee extension; thigh adductionPatellar or suprapatellar
L4Posterolateral thigh, anterior tibiaMedial legKnee and foot extensionPatellar
L5Dorsum of footDorsum of footDorsiflexion of foot and toesHamstrings
S1-2Lateral footLateral footPlantar flexion of foot and toesAchilles
S3-5PerineumSaddleSphinctersBulbocavernosus; anal
Table 3. Root and Peripheral Nerve Innervation of the Lumbosacral Plexus
MuscleNerveRoot
IliopsoasFemoralL2, 3, 4
Adductor longusObturatorL2, 3, 4
GracilisObturatorL2, 3, 4
Quadriceps femorisFemoralL2, 3, 4
Anterior tibialDeep peronealL4, 5
Extensor hallucis longusDeep peronealL4, 5
Extensor digitorum longusDeep peronealL4,5
Extensor digitorum brevisDeep peronealL4, 5, S1
Peroneus longusSuperficial peronealL5, S1
Internal hamstringsSciaticL4, 5, S1
External hamstringsSciaticL5, S1
Gluteus mediusSuperior glutealL4, 5, S1
Gluteus maximusInferior glutealL5, S1, 2
Posterior tibialTibialL5, S1
Flexor digitorum longusTibialL5, S1
Abductor hallucis brevisTibial (medial plantar)L5, S1, 2
Abductor digiti quinti pedisTibial (lateral plantar)S1, 2
Gastrocnemius lateralTibialL5, S1, 2
Gastrocnemius medialTibialS1, 2
SoleusTibialS1, 2
Table 4. Cauda Equina Versus Conus Medullaris Syndrome
FeaturesCauda Equina SyndromeConus Medullaris
Vertebral levelL2-sacrumL1-L2
Spinal levelInjury to the lumbosacral nerve rootsInjury of the sacral cord segment (conus and epiconus) and roots
Severity of symptoms and signsUsually severeUsually not severe
Symmetry of symptoms and signsUsually asymmetricUsually symmetric
PainProminent, asymmetric, and radicularUsually bilateral and in the perineal area
MotorWeakness to flaccid paralysisNormal motor function to mild or moderate weakness
SensorySaddle anesthesia, may be asymmetricSymmetric saddle distribution, sensory loss of pin prick, and temperature sensations (Tactile sensation is spared.)
ReflexesAreflexic lower extremities; bulbocavernosus reflex is absent in low CE (sacral) lesionsAreflexic lower extremities



(If the epiconus is involved, patellar reflex may be absent, whereas bulbocavernosus reflex may be spared.)



Sphincter and sexual function Usually late and of lesser magnitude;



lower sacral roots involvement can cause bladder, bowel, and sexual dysfunction



Early and severe bowel, bladder, and sexual dysfunction that results in a reflexic bowel and bladder with impaired erection in males
EMGMultiple root level involvement; sphincters may also be involvedMostly normal lower extremity with external anal sphincter involvement
OutcomeMay be favorable compared with conus medullaris syndromeThe outcome may be less favorable than in patients with CES
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