Sometimes a patient walks into your clinic and it’s hard to decipher what’s going on with them.

It may be something we’ve never seen before, their signs and symptoms don’t add up, or their pain doesn’t seem to correlate to their description of the cause. When things don’t seem to add up, our clinical reasoning has to jump into full effect to figure out what’s going on.

Looking at the red flags of low back pain, one of the conditions that really stands out is Cauda Equina Syndrome.

While it is rarely seen in practice (I have yet to ever encounter a patient with it) it is something we should have a working knowledge of, so our clinical reasoning can jump into action.

Early recognition and referral to medical help can make a massive difference in its development and effect on a patient, so we have a responsibility to recognize and refer out when necessary, and in this case, it is!

Recognizing Cauda Equina

The Cauda Equina is a bundle of nerve roots that angle down in the vertebral canal from the end of the spinal cord, which looks like wisps of hair, giving it its name, meaning “horse’s tail”.

What causes Cauda Equina Syndrome is usually some sort of compression happening at the nerve roots around the lumbar to sacral area. The most common causes are:

• Lumbar disc herniation, prolapse, or sequestration (one systematic review showed 45% were disc related)
• Smaller prolapses due to spinal stenosis.

The less common causes are:

• Epidural Haematoma.
• Infection.
• Primary and metastatic neoplasms.
• Trauma.
• Post-surgical.
• Prolapse due to manipulation.
• Chemonucleolysis.
• After spinal anesthesia.
• Patients with Ankylosing Spondylitis.
• Gunshot wounds.
• Constipation.

All of these things are important to ask during a patient history if you suspect a possibility of Cauda Equina, but more important is their clinical presentation. It may present as: 

• Low back pain.
• Saddle anesthesia.
• Bilateral sciatica.
• Weakness of their lower extremities.
• Paraplegia.
• Bowel, bladder, or sexual dysfunction.

The most commonly seen are low back pain and radicular leg pain because of tissue irritation around the lumbar spine.

When it comes to assessing patients who could possibly be dealing with this, one review showed they can be placed into three groups: 

1. CESS (Cauda Equina Syndrome Suspicious or Suspected)
   • Bilateral radiculopathy.
   • Subjective sphincteric problems with no objective evidence of CES.
2. CESI
   • Subjective symptoms and objective signs, but voluntary control of urination.
3. CESR (Cauda Equina Syndrome Retention)
   • Neurogenic retention of urine with a paralyzed, insensate bladder along with urinary incontinence.

Now just as we see some “red flags” with low back pain, CES has also been divided into red flags and white flags and are divided into:

• Definite Red Flags
  • Bilateral Radiculopathy.
  • Progressive neurological deficit in the legs.
• Possible Red or White Flags
  • Impaired perineal sensation.
  • Impaired anal tone (not that I’m suggesting you should ever try to palpate this).
  • Urinary difficulties that are unspecified.
• Definite White Flags
  • Urinary retention or incontinence.
  • Fecal incontinence.
  • Perineal anesthesia.

With this outline, we define the “true red flags” as someone who has bilateral radiculopathy, difficulties with urinating, or changes in bladder function, along with the loss of perineal sensation. However, there is nothing that gives a clear diagnosis because so many of the symptoms are objective. It is recommended that MRI is important, not because it can diagnose, but rather it shows which people with red flag symptoms have significant compression of the nerve roots, which may result in treatment before the development of the white flags which are more severe.

White flags are a way of saying “defeat or surrender” as the signs are often seen too late and are irreversible. Therefore the review outlining these red and white flags makes the argument that white flags should be removed because treatment at this stage might be too late to recover and avoid long term harm.

Another review even pointed out these different subclasses were too ambiguous as far as signs any symptoms go, so they should be avoided as well.

Then the argument is made that CES diagnosis should revolve around one or more of the following being present:  bladder or bowel dysfunction, reduced sensation in the saddle area, and sexual dysfunction with possible lower limb neurologic deficits.

Clear Communication And Reassurance

As we have talked about before, when it comes to low back pain, patient reassurance is a crucial aspect of helping them deal with these issues.

Much of the evidence shows good outcomes occur when patients have decompressive surgery early before there are incomplete lesions on the nerve. However, it is unclear as to which exact surgery (there are a few different types) works the best and is another factor that could affect patient outcomes.

So the important thing is for us to recognize these symptoms, realize there is an issue, and have our patients get the appropriate help, (which is most likely a trip to the hospital), as early recognition and treatment is key.

We want to ensure when talking to our patients that we are using clear and easily understandable terms, as well as proper descriptive terms when referring to doctors as this is a rare condition and is estimated a doctor may only see this once in their career.

It is crucial that our communication with patients is centered on them, not only in the way we talk, but also in the way we listen, as it has been shown they use very explicit language in their description of symptoms. It is then important for us to use terms they understand. Much of the research uses terms like “micturition” and “incontinence” which came across as very vague and hard to understand for patients. Rather, using terms like “urinating”, or “difficulties using the restroom” would be more appropriate. One patient was told their issue was serious if they were incontinent, yet the patient would be able to “force” themselves to use the toilet, so didn’t understand this was an issue.

So, clear communication is key to the emphasis and seriousness of their condition, as well as the importance of getting to the hospital quickly (better outcomes within 48 hours of recognition and treatment). While these can be difficult conversations to have, they are crucial ones because if this isn’t recognized and dealt with, there can be long term and VERY undesirable consequences, which are quite simply life altering. We can play a major role in this for our patients. While it may be difficult to have conversations (and some would argue we shouldn’t) centered around sexual dysfunction and using the toilet, we owe it to our patients as healthcare professionals to not only be open to,  but willing to talk about this for their better outcome.