Case Report

CAUDA EQUINA SYNDROM

IN HERNIA NUKLEUS
PULPOSUS
Presented by :
dr. Riski Amanda

Supervisors :
dr. H. M. Hasnawi Haddani, Sp.S (K)
dr. Andika Okparasta, Sp.S
dr. Hanna Marsinta Uli, Sp. RAD

Neurology Department
Sriwijaya University
Mohammad Hoesin General Hospital Palembang
INTRODUCTION
Low back pain (LBP) often found in daily
practice, usually considered a non-emergency case

noted that low back pain can be an emergency

case if you have signs of Red Flags.
INTRODUCTION
 Cauda Equina Syndrome collection of
symptoms disturbance of intradural nerve
root at the end of the spinal cord.
 The prevalence is estimated at 1: 33,000 to 1:
100,000 from the general population. The most
common disorder lumbar disc herniation,
which is 2-6% of all cases of Hernia Nucleus
Pulposus (HNP).
 Patient Identification

• Name : Ms. E
• Age : 31 tahun
• Adrress : Demang
• Religion : Moeslem
• Date of hospitalization : 27-10-2018 –
13-11-2018
Anamnesis
• Reason of admission: Weakness in
both legs.
• 3 days before admission  low back
pain that radiates to the left leg,
• pain felt like it was pierce by a
sharp
• moderate to severe pain intensity
• Pain felt worsed when coughing
and straining
Anamnesis
• 2 days before admission  the
patient had sudden weakness of both
limbs, weakness in both legs is felt
more severe in the left leg
Anamnesis
• 1 days before admission 
the patient complains of lost of
sensation in the buttocks, behind the
right and left thighs, and a feeling of
tingling is felt from both legs.
 • history of motorcycle accident (2013
Anamnesis and 2017)

• History of difficulty to walk for 6 months

after accident in 2017, then can walk
again after traditional treatment

• No History of fever

• History of tumor in uterus tract that

cause disturbed menstruation cycle
 PHYSICAL EXAMINATION
• General clinical examination
• GCS : E4M6V5
• Blood pressure :120/80
Weight : 55 kg
mmHg
Height : 150 cm
• Pulse : 95 x / minute Nutritional Status : normal

• Respiratory : 20 x / minute
• Temperature : 36,5º C
• NPRS :8
 Cranial Nerve
Examination
N. I normal
N. II normal

N. III normal
N. III, IV, normal
VI
N. VII normal

N. VIII normal
N. IX, X normal
N. XI normal
N. XII normal
Clinical Neurological
Examination MOTORIC FUNCTION

Right
Examination Left arm Right leg Left leg
arm
Movement C C K K

Strength 5 5 4+ 4
Tone normal normal decrease decrease
Clonus - -
Physiologic
al reflex
normal normal decrease decrease
Pathological
- - - -
reflex
 Clinical Neurological Examination

 Sensory function : saddle anesthesia

 Higher Cortical function : Normal
 Vegetative function : urinary incontinence, retention
of bowel
 Meningeal Sign : nuchal rigidity (-), kernig (-/+),
lasseque (-/+), neck sign (-),
 Abnormal movement : none
 Gait and balance : Not yet defined
 Clinical Neurological Examination

 Toe Flexion +/-

 Rectal Touche : no contraction

 DIAGNOSIS

 Clinical diagnosis :
 Paraparese inferior flaccid type
 Saddle anesthesia
 Radicular pain
 urinary incontinence, retention of bowel

 Topical diagnosis : Discus Intervertebralis levels L4-

L5 cauda equina

 Etiology diagnosis: Susp HNP lumbal

 DD : SOL
 TREATMENT
•IVFD NaCl 0,9% gtt 20/mnt
•Inj. Metilprednisolon 1x1gr IV
• Inj. Mecobalamin 3x500mg IV
•Inj. Ranitidin 2 x 50mg IV
•Inj. Ketorolac 3x30mg IV
•Inj. Gabapentin 2x300mg PO
•Laxadyn syr 3x10cc PO

Plan for MRI Lumbosacral with contrast

 LABORATORIUM RESULTS

NORMAL RESULT
 Radiographic finding

 Ro Thoracolumbar AP/L
Date Anamnesis and physical examination Diagnosa Treatment

28-10- Kel: Kelemahan tungkai bawah, nyeri pada pinggang dan Diagnosa klinik : Paraparese Medikamentosa
2018 kedua tungkai terutama kiri Inferior tipe - IVFD NaCl 0,9% gtt 20/mnt
s/d 31- St. Generalis: flaksid - Inj. Metilprednisolon 1x1gr
10- Sens : E4M6V5 Nyeri radikuler IV (tapering off)
2018 TD: 120/80 mmHg RR: 20 x/mnt Saddle hipestesi - Inj. Mecobalamin 3x500mg
(07.00 Nadi : 94 x/mnt T: 36.2°C NPRS: 5 Inkontinensia IV
WIB) St. Neurologis: urin - Inj. Ranitidin 2 x 50mg IV
Nn. Craniales: dalam batas normal Retensio alvi - Inj. Tramadol 3x1amp IV
Fs. Motorik: l.ka l.ki t.ka t.ki Diagnosa topik : Discus - Gabapentin 2x300mg PO
Gerakan c c k k Intervertebralis - Amitriptilin 1x25mg PO
Kekuatan 5 5 4 4 L4-L5 + cauda - Laxadyn syr 3x10cc PO
Tonus n n ↓ ↓ equina Non Medikamentosa
Klonus - - Diagnosa etiologi :: - Diet Nasi Biasa 1800 kkal
Rf.Fisiologis n n ↓ ↓ Susp HNP lumbal - Rencana : MRI Lumbosacral
Rf. Patologis - - - - dengan kontras (1/1/2018)
DD : SOL
Fungsi sensorik : saddle hipestesi
Fungsi luhur : tak
Fungsi vegetatif : Inkontinensia urin
Retensio alvi
GRM : tidak ada
Gerakan abnormal : tidak ada
Gait dan keseimbangan : belum dapat dinilai
Date Anamnesis and physical examination Diagnosa Treatment

01-10- Kel: Kelemahan tungkai bawah, nyeri pada pinggang dan Diagnosa klinik : Paraparese Medikamentosa
2018 kedua tungkai terutama kiri Inferior tipe - IVFD NaCl 0,9% gtt 20/mnt
s/d 03- St. Generalis: flaksid - Inj. Mecobalamin 3x500mg
10- Sens : E4M6V5 Nyeri radikuler IV
2018 TD: 120/80 mmHg RR: 20 x/mnt Saddle hipestesi - Inj. Ranitidin 2 x 50mg IV
(07.00 Nadi : 94 x/mnt T: 36.2°C NPRS: 3 Inkontinensia - Inj. Tramadol 3x1amp IV
WIB) St. Neurologis: urin - Gabapentin 2x300mg PO
Nn. Craniales: dalam batas normal Retensio alvi - Amitriptilin 1x25mg PO
Fs. Motorik: l.ka l.ki t.ka t.ki Diagnosa topik : Discus - Laxadyn syr 3x10cc PO
Gerakan c c k k Intervertebralis Non Medikamentosa
Kekuatan 5 5 4 4 L4-L5 + cauda - Diet Nasi Biasa 1800 kkal
Tonus n n ↓ ↓ equina - Follow up MRI Lumbosacral
Klonus - - Diagnosa etiologi : dengan kontras
Rf.Fisiologis n n ↓ ↓ HNP lumbal - Konsul bedah Orthopedi
Rf. Patologis - - - - - Konsul Departemen Obgyn
Fungsi sensorik : saddle hipestesi kesan : Penebalan
Fungsi luhur : tak endometrium, tidak ada
Fungsi vegetatif : Inkontinensia urin kelainan
Retensio alvi
GRM : tidak ada
Gerakan abnormal : tidak ada
Gait dan keseimbangan : belum dapat dinilai
Date Anamnesis and physical examination Diagnosa Treatment

04-11- Kel: Kelemahan tungkai bawah, nyeri pada pinggang dan Diagnosa klinik : Paraparese Medikamentosa
18 s.d kedua tungkai terutama kiri Inferior tipe - IVFD NaCl 0,9% gtt 20/mnt
06-11- St. Generalis: flaksid - Mecobalamin 3x500mg PO
18 Sens : E4M6V5 Nyeri radikuler - Inj. Ranitidin 2 x 50mg IV
07.00 TD: 120/80 mmHg RR: 20 x/mnt Saddle hipestesi - Paracetamol 3x1000mg PO
Nadi : 94 x/mnt T: 36.2°C NPRS: 3 Inkontinensia - Gabapentin 2x300mg PO
St. Neurologis: urin - Amitriptilin 1x25mg PO
Nn. Craniales: dalam batas normal Retensio alvi - Laxadyn syr 3x10cc PO
Fs. Motorik: l.ka l.ki t.ka t.ki Diagnosa topik : Discus Non Medikamentosa
Gerakan c c k k Intervertebralis - Diet Nasi Biasa 1800 kkal
Kekuatan 5 5 4 4 L4-L5 + cauda - Hasil MRI Lumbosacral dengan
Tonus n n ↓ ↓ equina kontras terlampir
Klonus - - Diagnosa etiologi :: Jawaban konsul bedah
Rf.Fisiologis n n ↓ ↓ HNP lumbal orthopedi : Penjadwalan
Rf. Patologis - - - - dilakukan operasi dekompresi
Fungsi sensorik : saddle hipestesi via poliklinik.
Fungsi luhur : tak
Fungsi vegetatif : Inkontinensia urin
Retensio alvi
GRM : tidak ada
Gerakan abnormal : tidak ada
Gait dan keseimbangan : belum dapat dinilai
Date Anamnesis and physical examination Diagnosa Treatment

07-11- Kel: Kelemahan tungkai bawah, nyeri pada pinggang dan Diagnosa klinik : Paraparese Medikamentosa
2018 kedua tungkai terutama kiri Inferior tipe - IVFD NaCl 0,9% gtt 20/mnt
s/d 09- St. Generalis: flaksid - Mecobalamin 3x500mg PO
11-18 Sens : E4M6V5 Nyeri radikuler - Inj. Ranitidin 2 x 50mg IV
07.00 TD: 120/80 mmHg RR: 20 x/mnt Saddle hipestesi - Paracetamol 3x1gr PO
Nadi : 94 x/mnt T: 36.2°C NPRS: 3 Inkontinensia - Gabapentin 2x300mg PO
St. Neurologis: urin - Amitriptilin 1x25mg PO
Nn. Craniales: dalam batas normal Retensio alvi - Laxadyn syr 3x10cc PO
Fs. Motorik: l.ka l.ki t.ka t.ki Diagnosa topik : Discus Non Medikamentosa
Gerakan c c k k Intervertebralis - Diet Nasi Biasa 1800 kkal
Kekuatan 5 5 4 4 L4-L5 + cauda - rencana pemeriksaan enmg
Tonus n n ↓ ↓ equina
Klonus - - Diagnosa etiologi :
Rf.Fisiologis n n ↓ ↓ HNP lumbal
Rf. Patologis - - - -
Fungsi sensorik : saddle hipestesi
Fungsi luhur : tak
Fungsi vegetatif : Inkontinensia urin
Retensio alvi
GRM : tidak ada
Gerakan abnormal : tidak ada
Gait dan keseimbangan : belum dapat dinilai
Date Anamnesis and physical examination Diagnosa Treatment

10-11- Kel: Kelemahan tungkai bawah, nyeri pada pinggang dan Diagnosa klinik : Paraparese Medikamentosa
2018 kedua tungkai terutama kiri Inferior tipe - IVFD NaCl 0,9% gtt 20/mnt
s.d 13- St. Generalis: flaksid - Mecobalamin 3x500mg PO
11-18 Sens : E4M6V5 Nyeri radikuler - Ranitidin 2 x 150mg PO
07.00 TD: 120/80 mmHg RR: 20 x/mnt Saddle hipestesi - Paracetamol 3x1gr PO
Nadi : 94 x/mnt T: 36.2°C NPRS: 3 Inkontinensia - Gabapentin 2x300mg PO
St. Neurologis: urin - Amitriptilin 1x25mg PO
Nn. Craniales: dalam batas normal Retensio alvi - Laxadyn syr 3x10cc PO
Fs. Motorik: l.ka l.ki t.ka t.ki Diagnosa topik : Discus Non Medikamentosa
Gerakan c c k k Intervertebralis - Rawat jalan
Kekuatan 5 5 4 4 L4-L5 + cauda - inform consent pasien dan
Tonus n n ↓ ↓ equina keluarga
Klonus - - Diagnosa etiologi :
Rf.Fisiologis n n ↓ ↓ HNP lumbal
Rf. Patologis - - - -
Hasil pemeriksaan ENMG : Sesuai
Fungsi sensorik : saddle hipestesi
gambaran
Fungsi luhur : tak
kompresi
Fungsi vegetatif : Inkontinensia urin
radiks L3-L4,
Retensio alvi
L4-L5, L5-S1
GRM : tidak ada
Gerakan abnormal : tidak ada
Gait dan keseimbangan : belum dapat dinilai
MRI
MRI
MRI
 Impression:
sequester discus intervertebralis L4-L5 which migrates to inferior to constrict right
neural foramen severe degree and push the right root which constrict left neural
foramen at middle degree.

Bulging at L3-L4 of intravertebral disc which constrict bilateral neural foramen at mild
degree

Bulging at L5-S1 of intravertebral disc which constrict right neural foramen at mild
degree
 Literature Review

• The term cauda equina, Latin for

“horse’s tail,” refers to the terminal
portion of the spinal cord and roots
of the spinal nerves beginning at
the first lumbar nerve root.
 Epidemiology

 Rarely happens, whether traumatic or non-traumatic etiology.

 There is no difference in sex,
 Can occur at any age.
 Occurs in 2% to 6% of cases of lumbar intervertebral disc
herniation.
 Incidence varies, depending on the etiology of the cause.
 The prevalence is estimated at 1 in 33,000 to 1 in 100,000
general population.
ANATOMY
 PATHOPHYSIOLOGY
• The cauda equina syndrome is caused by any
narrowing of the spinal canal which suppresses nerve
roots below the level of the spinal cord.

• Several causes of cauda equina syndrome have been

reported, including
• traumatic injuries,
• disc herniation,
• spinal stenosis,
• spinal neoplasms,
• inflammatory conditions,
• infectious conditions,
CLASSIFICATION
• Tandon and Sankaran also Tay and Chacha divided
three variations of Cauda Equida Syndrome based on
the onset as follows:
• Acute onset without previous history of low back pain
• Acute bladder dysfunction with a history of lower
back and sciatic pain Chronic lower back pain and,
• sciatica which develops into Cauda Equina Syndrome
accompanied by spinal canal stenosis
• Based on lower back pain complained by patients
Cauda Equina Syndrome is classified into three
types, namely:
• Type I: first / acute symptoms
• Type II: chronic lower back pain with or without
sciatica
• Type III: more chronic lower back pain that
slowly causes sensory disturbances and urination
Shepherd and Kostuik has been classified group into two types
secondary to central disc herniation

1. Type I is an acute type with severe clinical symptoms with a

worse prognosis, especially for the function of voiding (bladder)

2. Type II with slower progressiveness and tend to be gradual

• Gleave and Macfarlane classify based on voiding
functions and group them into:
1. Cauda Equina Syndrome with urine retention
and characterized by painless retention and
overflow type incontinence
2. Cauda Equina Syndrome incomplete with
difficulty in urination and weak urine output
• Based on clinical symptoms and electrophysiologist
Shi divides into:
• Stage I: laboratory stage, asymptomatic with changes
in electrophysiological examination
• Stage II: initial clinical phase, reduced sensation in
saddle and perianal areas
• Stage III: intermediate phase, with anal sphincter and
sexual dysfunction
• Stage IV: advanced / advanced phase, loss of sensory
function and impotence
 Diagnosis

 Radiography, X-ray photos must be done to find destructive
changes, narrowing of the disc space or loss of spinal
alignment.
 Lumbar myelography
 CT scan with or without contrast
 MRI, the most helpful modality for the diagnosis of spinal cord
disorders, is the chosen test to help doctors diagnose cauda
equina syndrome
 Conservative treatment

• Vasodilation therapy can be helpful in some

patients. The mean arterial blood pressure (MABP)
must be maintained above 90 mmHg to maximize
blood flow to the spinal cord and nerve roots.
• Anti-inflammatory drugs and steroids can be
effective in patients with inflammatory processes,
including ankylose spondylitis.
• Patients with infectious causes must receive
appropriate antibiotic therapy
 Surgical Therapy
Emergency decompression of the spinal canal is an
appropriate treatment option. The aim is to reduce the
pressure on the nerves in the cauda equina by removing
agents that compress and expand the spinal canal space.
Cauda equina syndrome has been thought of as a surgical
emergency with surgical decompression required within 48
hours after symptom onset.
 Surgical Therapy
• Patients with cauda equina syndrome with symptoms of
saddle anerthesia and / or bilateral weakness of the lower
extremities or loss of control for bowel movements and
urination must undergo initial medical therapy for no more
than 24 hours.
• If there is no improvement in symptoms during this period,
immediate surgical decompression is necessary to minimize
the chance of permanent nerve damage.
CONCLUSION
• Clinicians need to be aware of patients with low back
pain by raising a red flags symptoms.
• Cauda equina syndrome (CES) is a collection of
symptoms arising from suppression (compression of
the spinal nerve roots that form the cauda equina, and
includes red flag simptoms. simptoms red flag as
follows:
▫ 1. Severe back pain / LBP
▫ 2. Sciatica
▫ 3. Sensory disorders in the saddle area and / or in the
genital area.
▫ 4. Sexual dysfunction, bladder and bowel dysfuntion
CONCLUSION
• CES is an emergency surgical case so an MRI
emergency is needed to determine its etiology.
MRI is the main supporting modality to help find
CES etiology.
• The prognosis cases of cauda equina is
traditionally considered multifactorial, and
depends on the etiology, progression of clinical
onset, duration of compression, severity of
neurological deficits and clinical signs and
symptoms and spinal level involved.