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Cauda Equina Syndrome (CES)

Written by Chris Heywood - MSc BSc (Hons) MCSP HCPC reg
Physiotherapist

Cauda Equina Syndrome, or CES as it is sometimes abbreviated to, is a serious spinal pathology that affects just 6-10 people per million population. Although lasting symptoms are unusual, even when Cauda Equina Syndrome is diagnosed, it can in rare cases lead to personally devastating, and sometimes life-changing conditions. We have seen the impact a missed diagnosis can make to patients, more than once, so we feel it is something that everyone should be aware of, both for themselves, but also to pass on to other as well.

What is Cauda Equina Syndrome?

An image depicting a horse tail to help undestand the medical term Cauda Equina Syndrome

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.

These nerves are not responsible for the pains or symptoms often associated with back pains, such as sciatica. Instead, they provide you with important functions such as the ability to control your bowel and bladder function, the sensation around your anus/genitalia, and some of your sexual abilities. Having permanent changes, or damage to these can have a severe impact on someone's wellbeing and quality and life.

Most of our clients often look really quite surprised when we ask them if they have noticed any change to their toileting habits when they have come in for back pain. As those of you who have experienced acute back pain,  sexual activity is often the last thing on your mind so when we also enquire about this the eyebrows tend to raise even more so, until we explain why we are doing so - to rule out CES.

There are multiple reasons why CES can occur but the most common that we see is nerve compression and/or irritation, caused by a bulging (slipping, prolapsing) intervertebral disc (but it can be caused by anything that compresses the nerves, included fractures, spinal cysts, tumours etc). As we have highlighted in other articles, having bulging discs in the lower back is extremely common and in most cases, when you are over the age of 40 ish, it would be considered more normal to have them, than not. In fact, most of the time you will not even be aware they are there, unless we scan you, and they will produce no symptoms or problems for you. It is unfortunately just a confirmation that you are getting further away from the age of 21, mixed with a splash of the genetic lottery.

The symptoms of CES can vary and need to be interpreted as part of a wider presentation but there are some key points that you, the patient, should look out for (see video below). If you feel that you may have symptoms of CES, you must attend an emergency department, to be formally assessed as soon as possible. This would normally consist of a normal spinal examination, with the addition of a bladder scan, after urinating (possibly the best indicator of CES is not being able to fully empty 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 video 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, emergency surgery may be the only option available but even then, if caught very early, the outcome is still very favourable for a full recovery. The important take away message is that the longer it goes on (hour and days versus months), the more chance you have of long lasting symptoms.

Unfortunately, although CES is a very hot topic in the acute health care sector, a majority of patients will not be aware of CES, or of how to simply watch out for the symptoms. In an age where we find access to GP's and other front line healthcare challenging, to say the least, patient education is more important that ever.

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