Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord – known as the cauda equina – is damaged.
Signs and symptoms include low back pain, pain that radiates down the leg, numbness around the buttocks, anus and genitals, and loss of bowel and/or bladder control. Onset may be rapid or gradual. Sudden onset is classed as a medical/surgical emergency requiring surgical intervention. Early CES signs that allow diagnosis include changes in bowel and bladder function and loss of feeling in the groin. Changes in bladder function/sensation may be changes to stream or inability to fully empty the bladder, therefore bladder scanning can also be used to evaluate bladder dysfunction in suspected cases before MRI/CT scanning (Long et al, 2021).
What is cauda equina syndrome (CES)?
Cauda equina syndrome (CES) is taken from the Latin name meaning ‘horse's tail’, and describes the bundles of nerve roots that emerge from the end of the spinal cord. The nerve roots serve the bladder, bowels, sexual function and lower limbs. The syndrome occurs when the nerves are compressed causing a set of symptoms that are known as ‘red flags’. These red flag symptoms can include acute back pain, bilateral sciatica/leg weakness, numbness around the anus/saddle area, and loss of bowel or bladder control. Onset may be rapid or gradual (Long et al, 2020). In CES, patients may present with some or all of the following symptoms (National Institute for Health and Care Excellence (NICE), 2022):
- Saddle anaesthesia – reduced or loss of feelings around the buttocks, anus and genitals
- Pain – severe nerve pain in the back and/or down one or both legs
- Incontinence – bladder incontinence or inability/difficulty in passing urine and/or bowel incontinence/constipation
- Numbness – lack of or altered sensation, pain and/or weakness in the legs.
The cause is usually when there is a disc herniation in the lower part of the back, although other causes may include spinal stenosis, tumours, trauma, cysts/abscesses, herniated discs, inflammatory and infectious conditions or an accidental medical intervention (Kapetanakis et al, 2017).
Diagnosis is suspected based on presenting symptoms; however, this can only be confirmed following medical imaging such as an MRI or CT scan. CES is generally treated surgically via laminectomy/discectomy, and sudden onset is regarded as a medical emergency, and will require prompt surgical decompression. Potential delays to treatment can result in a permanent loss of bladder and bowel function, sexual dysfunction (Angus et al, 2019), and permanent pain and discomfort, resulting in reduced mobility, permanent numbness and even paralysis may occur (Kuris et al, 2021). Sciatica and CES can present with very similar symptoms, including unbearable pain and doctors sometimes mistake CES for sciatica, often leading to devastating long-term consequences for the patient. The symptoms of sciatica can vary from mildly irritating to completely debilitating, with the most common symptom being a sharp pain that starts in the lower back, which can then radiate down the leg (Cauda Equina UK, 2023).
Bladder function in cauda equina syndrome
There are many nerves involved in bladder and bowel control. Some of the main nerves responsible include:
- Spinal cord: this is the main pathway for nerve signals between the brain and the bladder and bowel. The spinal cord lies inside the bones of the spine (Bladder and Bowel Community, 2023)
- Cauda equina: this is a group of nerve roots at the lower end of the spinal cord. They provide sensation and control of movement to the lower part of the body, including the bladder and bowel
- Pudendal nerves: there are pudendal nerves on the left and right sides of the body within the pelvis; they affect both bowel and urinary control
- Pelvic parasympathetic nerves: these nerves begin at the sacral level of the spinal cord, which is the lowest part of the spine above the coccyx; they stimulate the bladder and relax the urethra
- Lumbar sympathetic nerves: these nerves of the lower region of the spine stimulate the base of the bladder and urethra.
The bladder symptoms associated with cauda equina syndrome include the following:
- Difficulty fully emptying the bladder, resulting in retention of urine
- The need to stand, strain or press on the bladder to urinate
- Poor urinary flow/stream
- Reduced sensation/numbness when passing urine
- Reduced sensation in the bladder, making it hard to tell when the bladder is full – this can result in overflow, ie, the bladder becomes so full that it cannot hold any more urine and the patient will become incontinent. This will be entirely painless.
The aim of this case study is to highlight the impact of CES on a patient's bladder function, and how support from a clinical nurse specialist can lead to effective management enabling improved quality of life.
Case study
When I first met Allison during a home visit, she was 12 months post surgery, and had been suffering with debilitating bladder and bowel issues and had also been left unable to walk or stand. Allison advised that she had not received any offers of help or support in the 12 months after her surgery, and only realised that she could seek help and support after she read an article online. Allison had never heard the term ‘cauda equina syndrome’ before her diagnosis and the emergency operation she had had on her spine in November 2014.
Allison disclosed that for several years before diagnosis/surgical intervention she had suffered with low back pain/pain radiating into her left leg, diagnosed by her GP as sciatica. Allison presented several times at her local emergency department at the suggestion of her GP surgery, each time displaying the red flag symptoms of CES, before she eventually had laminectomy and discectomy, which was a 7-hour surgical procedure, in November 2014 when a diagnosis of CES was confirmed.
Since her diagnosis, Allison's condition has changed and evolved. During a bladder and bowel assessment, she reported ongoing issues with the recurrent urinary tract infections, the feeling of incomplete bladder emptying, and urinary leakage associated with any type of movement, especially if she attempted to transfer from her wheelchair or leant forward. She also described a ‘fizzing’ sensation in her pubic area, which often meant she had already wet herself without realising this. This meant she was needing to wear continence containment pants in order to maintain some form of dignity.
She was also experiencing issues with chronic constipation, but had just been issued with a trans-anal irrigation system to try to resolve the constipation; she had been using this for the previous 2 weeks. She also reported some issues with symptoms associated with autonomic dysreflexia. Autonomic dysreflexia is the name given to a condition where there is a sudden and potential lethal rise in blood pressure. It is the body's way of responding to a problem and it is often triggered by acute pain or some other harmful stimulus within the body. Typical symptoms can include light-headedness, dizziness, fainting, fever, and heavy sweating. Autonomic dysreflexia can be triggered by stimuli such as bladder distention, urinary tract infections and faecal impaction (Yates, 2016).
Following a full in-depth holistic assessment of both bladder and bowels, and a discussion around past medical history, we had a discussion which included fluid intake, toileting regimen, and urinary flow rate; a pre/post bladder scan was offered. This demonstrated a pre-void scan of 575 ml and a post-void scan of 425 ml. Therefore, intermittent self-catheterisation (ISC) was discussed, and both written and verbal instruction provided.
Allison was happy to accept supervision on her first attempt at ISC. We discussed positioning, and the use of a mirror/touch technique to find her urethra. I demonstrated and offered a selection of catheters and provided samples of the ones chosen by Allison to trial over the next few days. Allison was happy to continue to monitor all input/output and record her post-void residual volumes.
We agreed a plan of frequency of using the catheters for ISC, and a date/time for a telephone review later in the week was scheduled; however, all contact details for myself were provided, in case Allison had issues or concerns on the days in-between. I rang Allison as agreed, and found she was using the catheters as suggested, every 3–4 hours and draining volumes of between 300 ml and 400 ml. Allison advised the leakage on movement had stopped, and she had also forgotten about the ‘fizzing’ sensation, because this had also stopped.
Allison decided that she would like to continue on this regimen for a further 2 weeks, just to make sure she was happy with her technique and the volumes being drained, and she could continue to manage her bladder and bowels independently. After a further 2 weeks, she continued to manage independently with both her bladder and bowels. She continued ISC every 3–4 hours and again thought she could manage independently and also reported no further issues with leaks.
With regards to her bowels, she was using the trans-anal irrigation daily and again was achieving a good bowel movement each time. Allison is now 8 years post diagnosis, and feels she is living her best life, and feels she knows how to manage this condition in order to fit in and live her life to the full.
Allison and her husband Nigel run the cauda equina spinal cord injury support group (www.cesci.org; and also on social media: Facebook cauda equina spinal cord injury) and hold meetings up and down the country. They have pages on social media with over 650 members. As a clinical nurse specialist, with a special interest in spinal cord injury, I will often attend the support group meetings to offer specialist bladder and bowel care advice to members of this group.
Conclusion
Early diagnosis of CES can allow for preventive treatment. Signs that allow early diagnosis include changes in bowel and bladder function. Changes in bladder function/sensation may be changes to stream, or inability to fully empty the bladder, therefore bladder scanning can also be used to evaluate bladder dysfunction in suspected cases of cauda equina syndrome before MRI scanning (Long, 2020). Essential to my specialist nurse role is having the ability to improve patient outcomes, as I have done with Allison in providing ongoing support to enable her to manage her bladder function with ISC, which gives her control and improves her quality of life.
Resources
Bladder and Bowel Community – www.bladderandbowel.org
Cauda Equina Champions Charity – www.championscharity.org.uk
Cauda Equina Foundation – www.ceslife.org
Cauda Equina Spinal Cord Injury – www.cesci.org
Cauda Equina UK – www.caudaequinauk.org.uk
Spinal Injuries Association – www.spinal.co.uk
KEY POINTS
- Cauda equina syndrome (CES) is taken from the Latin name meaning ‘horse's tail’, and describes the bundles of nerve roots that emerge from the end of the spinal cord. The nerve roots serve the bladder, bowels, sexual function and lower limbs
- The syndrome occurs when the nerves are compressed causing a set of symptoms that are known as ‘red flags’
- These red flag symptoms can include acute back pain, bilateral sciatica/leg weakness, numbness around the anus/saddle area, and loss of bowel or bladder control
- Diagnosis is suspected based on presenting symptoms; however, this can only be confirmed following medical imaging such as an MRI or CT scan
CPD reflective questions
- Can you identify what cauda equina syndrome is and how this occurs?
- Are you able to identify the early warning signs/red flag symptoms of cauda equina syndrome?
- Do you feel better prepared in providing support/advice to these clients with cauda equina syndrome and bladder issues?