Cauda Equina and Conus Medullaris Syndromes Workup

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

Approach Considerations

The diagnosis of cauda equina syndrome generally is possible on the basis of medical history and physical examination findings. Radiologic and laboratory studies are used to confirm the diagnosis and for localizing the site of the pathology and the underlying cause.

Myelography,[77] computed tomography,[78] and MRI are each used in specific cases with good degrees of accuracy. Each test can be used to determine the level of pathology and aid in the determination of the cause of the syndrome. Bone scan may detect malignant tumor or metastases and inflammatory conditions affecting the vertebrae.

Due to its ability to depict the soft tissues, MRI generally has been the favored imaging study for assisting the physician in the diagnosis of cauda equina syndrome.[79, 80, 81] Urgent MRI is recommended for all patients who have new-onset urinary symptoms with associated back pain or sciatica.

Nevertheless, the superiority of MRI over CT is only suggested by case reports. Early consultation with the appropriate subspecialty is encouraged to guide imaging studies.[23]

Depending on the findings from the history and physical examination, laboratory studies can include basic blood tests, chemistries, fasting blood sugar, sedimentation rate, and syphilis and Lyme serologies. CSF examination should also be included if signs of meningitis are present.[82]

Alteration in bladder function may be assessed empirically by obtaining urine via catheterization. A significant volume with little or no urge to void, or as a post-void residual, may indicate bladder dysfunction. Bedside ultrasonography may be also used to estimate or measure post-void residual bladder volume.

Urodynamic studies are useful to evaluate the degree and cause of sphincter dysfunction, as well as to monitor recovery of bladder function following decompression surgery. Intraoperative monitoring of somatosensory and motor evoked potentials allows for evaluation of radiculopathy and neuropathy.

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Blood Studies

The following studies may help to define possible causes and any associated pathology, especially other causes of lesions in the lower spinal cord or cauda equina:

  • CBC count, blood glucose, electrolytes, blood urea nitrogen (BUN), and creatinine - As part of the workup to rule out associated anemia, infection, and renal dysfunction, especially in associated retroperitoneal mass
  • Erythrocyte sedimentation rate (ESR) – Elevation may point to an inflammatory pathology
  • Syphilis serology to rule out meningovascular syphilis
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Radiography

Plain radiography is unlikely to be helpful in cauda equina syndrome but may be performed in cases of traumatic injury or in search of destructive changes, disk-space narrowing, or spondylolysis. For example, plain radiographs of the lumbosacral spine may depict early changes in vertebral erosions secondary to tumors and spina bifida.

Chest radiography is indicated to rule out a pulmonary source of pathology that could affect the lumbosacral spine (eg, malignant tumor, tuberculosis). Follow-up chest CT may be required.

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Magnetic Resonance Imaging

MRI with gadolinium contrast of the lumbosacral area is the diagnostic test of choice to define pathology in the areas of the conus medullaris and cauda equina (see the images below). It provides a more complete radiographic assessment of the spine than other tests; plain x-rays and CT scan may be normal.[83, 80] . Gadolinium contrast MRI also may be able to rule out abdominal aneurysm, which could be the source of emboli causing conus medullaris infarction. See the following images for representative MRIs.

Conus/epiconus infarction in the setting of sickleConus/epiconus infarction in the setting of sickle cell crisis. Image courtesy of Matthew J. Baker, MD. Conus/epiconus infarction in the setting of sickleConus/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 sickleConus/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.

Schwannomas are visible using myelography, but MRI is the criterion standard. Schwannomas are isointense on T1 images, hyperintense on T2 images, and enhanced with gadolinium contrast. With infectious conditions, MRI can display the abnormal appearance of the nerve roots being forced to one side of the dural sac.

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Other Tests and Procedures

Needle electromyography (EMG)[84] may show evidence of acute denervation, especially in cauda equina lesions and multilevel lumbar spinal stenosis. EMG studies also could help in predicting prognosis and monitoring recovery. Performing needle EMG of the bilateral external anal sphincter muscles is recommended.

Nerve conduction studies,[11] especially of the pudendal nerve, may rule out more distal peripheral nerve lesions.

Somatosensory evoked potentials (SSEPs)[11] could be done as part of the workup to rule out multiple sclerosis, which could present initially as a lower spinal cord syndrome.

Duplex ultrasound of peripheral vessels may rule out compromised vasculature as a possible cause of associated claudication.

Lumbar puncture should be performed to examine the CSF to rule out inflammatory disease of the meninges or spinal cord.

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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.

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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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