CAUDA EQUinA – BACkgROUnD
identifiable reference points with as suggested by Rydevik et al 12 hours, 24 hours or 48 hours or
some relevance to the timing of 1984,54 Garfin et al 199155 and some other arbitrary number, and
surgery and clinical outcome. Olmarker et al 1993.56 Involved from which point does the clock
nerve roots are sometimes noted start ticking? Is it from the onset of
As mentioned above cauda equina to be grossly swollen and inflamed CES symptoms or from the loss of
syndrome may develop relatively at surgery. It may be that observed bladder control or from the time of
acutely, usually with severe low nerve recovery, sometimes after admission to hospital or surgical
back pain and complete anal and three days or more have passed unit? Also, what symptomatic
bladder motor and sensory loss and before surgical decompression, characteristics if any are good
usually but not always, with motor may at least be partly explained by indicators of prognosis? Is it the
and sensory deficits in the lower resolution of this chemical effect. presence or absence of perineal
limbs all within 24 hours (CES-R This could perhaps be mitigated by sensory loss or unilateral or bilateral
or Tandon and Sankaran Group 1). an early caudal epidural injection sciatica or motor weakness in the
At the other end of the spectrum, of steroid. In other situations lower limbs, or the presence or
low back pain may be mild with such as the use or miss-use of absence of bladder and/or anal
gradually developing or intermittent a tourniquet, the effect of nerve motor or sensory function?
sciatica over weeks or months in compression for more than four to
one or both legs and incomplete or six hours is usually considered to Finally, from a medico-legal
intermittent deficits of bowel and be irreversible. On the other hand angle, at what stage, if at all,
bladder function (CES-I or T and S it may be that the clinical diagnosis was the situation retrievable by
Group 3); there may be a relatively of CES-R with its less favourable surgical decompression? If there
modest central disc prolapse prognosis, often on the basis of was demonstrable delay what
causing compression because scanty information, may be overly difference did this make and what
of the coexistence of a degree of pessimistic in some cases when would have been the outcome if
stenosis of the spinal canal. they are in fact still CES-I at the that delay had not occurred? The
time of surgery. lawyers do ask difficult questions
The questions arise as to what and as involved clinicians or
extent these variations in time The traditional view articulated expert witnesses we have not only
and severity of compression are by Shephard (1959) was that to admit our uncertainty where
of prognostic significance. First, “early operation is an essential necessary, but also we must
for the delicate unmyelinated prerequisite for an improved be careful not to stray from the
preganglionic fibres of the cauda prognosis.”19 This seems validated behaviour patterns of this
equina in or near the midline logical and intuitive if somewhat complex and variable condition.
accompanied by the pudendal simplistic, as a discriminating look
nerves, and secondly, for the more at the available evidence provides References from this article can be
robust sciatic nerve roots laterally inconsistent support for this point found at www.backcare.org.uk at
at the exit foramina in which the of view. It begs the questions: the end of the full article headed:
sensory nerves are smaller and how early is early? Is it 6 hours, “Cauda Equina Syndrome.”
more sensitive to compression
than the motor nerves.14 The
answer is inevitably unclear,
with conflicting conclusions in Alan gardner M.B.B.S.(Lond.),F.R.C.S.(Eng.), is an Hon. Consultant
the literature, and especially Orthopaedic Surgeon South Essex University Hospitals and the Essex
in individual cases when vital Spine Centre, Brentwood.
reference data may be missing
from the record. Edward gardner B.M., M.R.C.S.(Ed.) is the Specialist Orthopaedic
Registrar, Southampton general Hospital, Wessex Orthopaedic
A further factor may be at work Rotation.
apart from mechanical and time
factors, and that is the possibility tim Morley M.A., M.B., F.R.C.S. (Eng.) is the Emeritus Consultant
of chemical interference with Orthopaedic Surgeon, Royal national Orthopaedic Hospital, Stanmore.
the function of nerves in contact
with the irritating components Enquiries to Alan gardner, 1 Hyde Lane, Danbury, Essex, CM3 4QX
in prolapsed nuclear material email adhg@btopenworld.com
34 The Backcare Journal
backcare Winter 2009/10.indd 34 8/1/10 11:20:14
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