Presented an in-service on the pathophysiology and differential diagnosis of cauda equina syndrome to Arcadia University's 2nd year Doctor of Physical Therapy students.

1. Jeffrey Turner SPT, CSCS
Junsik Yoon SPT

2.  5th most common condition
 ~25% adults report LBP w/in past 3
months
 Prevalence of 70% over the course of
one’s life
 >85% cannot be reliably attributed to
a specific disease or abnormality
 Classified into 3 broad categories:
1. Nonspecific LBP
2. Nerve Root Syndrome (CES, etc.)
3. Serious Spinal Pathology
Images Courtesy of www.ericcressey.com

3.  Less common than nonspecific
 Potentially disabling condition
 Most often caused by acute lumbar
disc herniation
 Commonly between ages of 30 – 55
 Related to:
 Radiculopathy
 Spinal Stenosis
 Cauda Equina Syndrome
Images Courtesy of www.publichealthwatchdog.com

5.  Rare and devastating condition
 Prevalence of ~0.04% of all patients
presenting w/ LBP
 “True neurologic emergency”
 Rapid clinical progression
 For optimal prognosis:
 Early recognition/diagnosis
 Immediate surgical referral
 Recommended w/in 48 hours of Dx
Images Courtesy of www.publichealthwatchdog.com

7. 32 year old male presented to a PT at
a medical aid station in Iraq.
 Convoy machine gunner
 Prolonged periods of standing >8 hrs
 Wearing equipment up to ~80 lbs
 4 week history of insidious onset and
recent worsening of:
 Low back pain
 Left buttock pain
 Posterior left thigh pain
 Goal: Decrease pain during work
Images Courtesy of www.defense.gov

8.  Pain: 4/10 resting and 7/10 at worst
 Hx: 3-4 prior occurrences of LBP
 Physical Exam:
 Neurologically intact, and negative SLR
 Limited lumbar flexion AROM
 Reduction of Sx w/ lumbar extensions
 Findings consistent w/ nonspecific LBP
 No red flag signs or symptoms
 Treatment:
 Prescribed extension-oriented exercises
 Prescribed NSAIDs for pain
 Patient education

9.  New Symptoms:
 Saddle anesthesia, LE paresthesia
constipation, and urinary hesitancy.
 Physical Exam:
 Right plantar flexor weakness, absent
right ankle reflex, and decreased anal
sphincter tone.
 Findings consistent w/ CES
 Referral:
 Medically evacuated to neurosurgeon
 L4-5 Laminectomy/decompression w/in
48 hours of CES diagnosis

10. Returned to full military duty 18
weeks after surgery without back or
lower extremity symptoms or
neurological deficits.
 Demonstrates the importance of
medical screening.
 Demonstrates the importance of
immediate referral to surgical
specialties when CES is suspected.
 Rapid intervention offers the best
prognosis.
Images Courtesy of www.englishrussia.com

11.  Spinal cord ends between vertebrae L1 & L2
 Originates after Conus Medullaris
 L2 to S5 nerve roots looks like horse’s tail
 Includes motor nerves, sensory nerves and
parasympathetic innervation of the bladder
Images Courtesy of Clinically Oriented Anatomy

12.  Compressive causes
 Herniated lumbosacral disc
 Spinal stenosis
 Spinal neoplasm
 Fracture of vertebrae
 Non-compressive causes
 Ischemia
 Infection
 inflammation
Image Courtesy of www.publichealthwatchdog.com

13. Images Courtesy of www.publichealthwatchdog.com

14.  Making a thorough evaluation
 Continually monitoring patient’s status throughout the patient management
 Acting appropriately when conditions emerge that requires immediate referral
Image Courtesy of www.bu.edu

16.  Crowell MS, Gill NW. Medical Screening and Evacuation: Cauda Equina
Syndrome in a Combat Zone. J Orthop Sports Phys Ther. 2009; 39(7):541-549.
 Moore KL, Dalley AF, Agur AMR, et al. Clinically Oriented Anatomy 7th Edition.
Lippincott Williams & Wilkins; 2013.