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Cauda Equina Syndrome (CES)

Written by Chris Heywood
Cons Physiotherapist

Cauda Equina Syndrome, or CES as it is sometimes abbreviated, is a serious spinal pathology that affects just 6-10 people per million population. This can mean however that the identification of key symptoms that can help to identify its presence are not always picked up on by the patient, or sometimes by the clinician. Although lasting symptoms are unusual, even when Cauda Equina is clinically, or radiologically, diagnosed, it can occasionally lead to personally devastating, and sometimes life-changing conditions.

CES occurs when the collection of nerves at the base of the spine, the Cauda equina (named as they look like the vertically descending hairs in a horses tail) are compressed or irritated. There are multiple reasons why this can ultimately occur but the most common that we see is caused by the bulging (bulging, slipping, prolapsing) of an intertervertebral disc.

Having a bulging disc in the lower back is extremely common and in many cases, people will be completely unaware as they do not always cause symptoms. It is only when an intervertebral disc reaches certain anatomical thresholds, that are different in all of us, that the brain may create pain as a result.

Due to anatomical nuances, disc bulges normally occur in a direction that is ultimately backward and diagonal so they tend to affect either the left or right nerve roots as they leave the spinal cord. In certain circumstances however these can occur more centrally, and it is largely in these situations where the Cauda Equina is ultimately more at risk. Again, this is different in all of us however and if someone has a large spinal canal, they may be able to tolerate a large bulge without any symptoms at all, in other however, it may take a lot less.

The symptoms of CES can vary and need to be interpreted as part of a wider presentation, however there are some key points that you, the patient, should look out for. If you feel that you may have symptoms of CES, you must attend an emergency department, to be formally assessed. This should consist of a normal spinal workup with the addition of a bladder scan, after urinating (possibly the best indicator of CES is not being able to fully void your bladder). Sometimes they will also include a sphincter strength test but this is less common nowadays. If you are suspected of CES, an MRI should be undertaken as soon as possible

The Chartered Society of Physiotherapy created a very good patient-focused video on CES several years ago but it is still very relevant today. Rather than simply creating a duplicate for the sake of it, we would advise all acute back pain patients to watch this to educate themselves and be advocates of the knowledge for others, going forward.

Remember, if you are in any doubt at all and have the symptoms of CES, you MUST attend an urgent care centre or A/E for immediate assessment. 

In many cases, even if you test positive for CES, processes to reduce acute inflammation such as steroids can be used orally, or sometimes by direct injection, to treat the condition. In cases where there is a significant compromise to the nerve however, decompressive emergency surgery is normally the gold standard care.

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