Horse tail syndrome

Among the serious pathological conditions of the neurological nature, acute vertebrogenic pain syndrome in the lumbar plexus of the nerve root of the vertebral canal is distinguished - horse tail syndrome (code G83.4 for ICD-10).

What is the ponytail? The spinal cord is shorter than the spine, and the doctors call the nerve roots out of the lower end of the spinal cord - lumbar (LI-LV) and sacral (SI-SV) nerves. Nerve roots of the lumbar plexus, divergent cone, provide innervation of the lower extremities and pelvic organs.

[1], [2], [3]

Epidemiology

The most vulnerable to the hernia of the disc (and, correspondingly, the development of acute bilateral radicular syndrome) are people 40-50 years old; in men it occurs a little more often than in women. It is estimated that 10 to 25% of vertebral fractures lead to spinal cord injuries and acute pain syndromes.

[4], [5], [6], [7]

Causes of the horse tail syndrome

Being a complex of a number of symptoms, horse tail syndrome (which can be called caudal syndrome or acute bilateral radicular syndrome) has a different etiology.

Neuropathologists, vertebrologists and spinal surgeons call the following possible causes of horse tail syndrome:

• medial prolapse (hernia) of the intervertebral disc in the lumbar region (more often at the level of LIII-LV);
• traumatic spinal cord injuries localized below the lumbar region;
• displacement of the vertebrae (spondylolisthesis) caused by osteochondrosis of the intervertebral discs or spondylarthrosis (deforming arthrosis of the articulating vertebrae of the articular joints);
• neoplasms of the spinal cord (sarcoma, schwannoma) or metastasis of malignant tumors of various locations in the vertebrae;
• stenosis (constriction) of the spinal canal (spinal stenosis), which develops due to degenerative-dystrophic changes in the spine;
• inflammation of the spinal cord (Paget's disease, Bechterew's disease, spondylodysitis, neurosarcoidosis, chronic inflammatory demyelinating polyneuropathies);
• demyelination of the nerve processes with progressive multiple sclerosis;
• complications of neurosurgical operations on the lumbar spine;
• consequences of carrying out regional epidural anesthesia or iatrogenic lumbar punctures.

As experts note, most often the syndrome of the horse's tail occurs when the nerve plexus is squeezed due to the displacement of intervertebral discs, to which their prolapse leads.

[8], [9]

Pathogenesis

The pathogenesis of caudal syndrome is associated with compression (strong compression or pinching) of the dorsal and ventral roots of the spinal cord in the lumbar plexus and damage to motor and sensory spinal neurons and their processes. This affects the roots of LI-SII, innervating the lower limbs; innervating the bladder roots SI-SIII; roots of the sacral department SII-SV, which carry the transmission of nerve impulses to the perineum and anus.

The main risk factors for the development of horse tail syndrome are spinal injuries, excessive mechanical or prolonged orthostatic loads on the vertebrae, age-related dystrophic changes in the structures of the spinal canal, as well as oncological diseases in the stage of metastasis.

The severity of this pain syndrome lies in the fact that compression of the nerve roots of the horse tail and their damage can have irreversible consequences and complications: paresis or paralysis of the lower extremities, incontinence of urine and feces, erectile dysfunction. Hyperactivity detrusor (smooth muscles of the bladder wall) can cause urine reflux into the kidneys, which is fraught with their damage. In particularly severe cases, you may need to use crutches or a wheelchair.

[10], [11], [12]

Symptoms of the horse tail syndrome

The first signs of this syndrome are manifested by sudden intense pain in the legs (especially in the hips) and the waist, giving back to the buttocks and perineum.

And against the backdrop of increasing pain, such characteristic clinical signs of horse tail syndrome are noted, as:

• loss of muscle strength in the legs (one or both);
• tingling (pastesia) or numbness (hypesthesia) in the perineal region and on the inner surfaces of the thighs and lower legs due to a violation of the skin's surface sensitivity;
• periodic involuntary contractions of individual muscle fibers (fasciculation);
• weakness or absence of reflexes - biceps femoris, patellar (knee), Achilles tendon and perineal muscles (anal and bulbocavernous);
• violation or loss of leg and pelvic organs (paraplegia);
• problems with urination (delay or incontinence);
• loss of control over the process of defecation (violation of the functions of the sphincter of the rectum and the associated stool incontinence);
• sexual dysfunction.

[13], [14], [15]

Diagnostics of the horse tail syndrome

The fact that caudal syndrome can manifest not only in acute, but also in a gradually increasing form, leads to some difficulties in diagnosing.

Diagnosis of horse tail syndrome begins with the study of anamnesis and clinical manifestations. For an objective assessment of the lesion of the nerves of the lumbosacral plexus, a sensitivity test is performed at control points on sites that are innervated by the processes of each nerve root (on the anterior and inner thighs, under the knee joints, on the ankle and the back surface of the foot, on the Achilles plexus, etc.). . Lack of sensitivity in these areas is a true diagnostic sign of damage to the lumbar and sacral roots of the horse tail.

Mandatory blood tests - general and biochemical. And instrumental diagnostics of this syndrome includes roentgenography of the spine, contrast myelography, computed tomography (CT) and magnetic resonance imaging (MRI).

[16], [17], [18]

Differential diagnosis

In case of horse tail syndrome, differential diagnosis is particularly important in order to distinguish this painful symptom of compression etiology from reflex pain syndrome associated with irritation of nerve trunks in such diseases of the spine as lumbar osteochondrosis, spondyloarthrosis, primary deforming osteoarthritis, etc.

Treatment of the horse tail syndrome

The cauda equina syndrome is an urgent condition requiring urgent medical attention aimed at preventing irreversible nerve damage and developing paralysis.

Therefore, to date, the treatment of horse tail syndrome, caused by a herniated intervertebral disc, is carried out by early surgical decompression (the need for which must be confirmed by the appropriate diagnosis). In such cases, operative treatment within 6-48 hours after the onset of symptoms makes it possible to eliminate pressure on the nerve roots by means of laminectomy or discectomy. In the opinion of spinal surgeons, surgical treatment of horse tail syndrome in the specified time significantly increases the chance to avoid persistent neurological disorders.

In addition, surgical treatment may be required to remove spinal tumors, and when this is not possible, radiotherapy or chemotherapy is used. If the syndrome is caused by an inflammatory process, for example, ankylosing spondylitis, anti-inflammatory drugs, including steroids (intravenous Methylprednisolone), are used.

Chronic horse tail syndrome is much more difficult to treat. To get rid of pain, strong painkillers are needed, and doctors recommend using non-steroidal anti-inflammatory drugs (NSAIDs) for this purpose, for example, Lornoxicam (Xefokam) - 4-8 mg (1-2 tablets) two or three times a day. With very severe pain and trauma, the drug is administered parenterally; the maximum permissible daily dose is 16 mg. Contra-indications of Lornoxicam include allergy to NSAIDs, bronchial asthma, poor blood coagulation, peptic ulcers of the gastrointestinal tract, hepatic and renal insufficiency. And the possible side effects of the drug include allergic reactions, headache, sleep disorders, decreased hearing and visual acuity, increased blood pressure and pulse, shortness of breath, abdominal pain, dry mouth, etc.

The use of anti-convulsants with gamma-aminobutyric acid (neurotransmitter GABA) is shown. These medicines include Gabapentin (Gabagama, Gabantin, Lamitril, Neurontin, etc.), which is recommended to take one capsule (300 mg) twice a day. The drug can cause side effects: headache, tachycardia, increased blood pressure, fatigue, nausea, vomiting, etc. With liver diseases and diabetes it is contraindicated.

When it is impossible to empty the bladder, its catheterization is used, and anticholinergic drugs, such as Oxibutinin (Sibutin), are needed to control the functioning of the bladder in conditions of its neurogenic dysfunction. The drug reduces the number of urges to urinate and is prescribed to adults one tablet (5 mg) up to three times a day. The agent is not used if patients have ulcerative colitis, intestinal obstruction and Crohn's disease. Taking Oxibutinin can cause dryness in the mouth, constipation or diarrhea, as well as headache and nausea.

A positive effect with hypoesthesia accompanying horse tail syndrome, give vitamins of group B.

Physiotherapeutic treatment for acute manifestation of the syndrome is simply impossible, and in chronic cases it can be useful provided that there is no inflammatory component. For example, to increase muscle tone there are sessions of hardware electrical stimulation. Physiotherapy is also used to restore the patient after surgery.

Prevention

Experts believe that the prevention of the development of this syndrome consists in the early diagnosis of diseases and pathologies of the spine and their timely treatment.

[19]

Forecast

The recovery prognosis will depend on the duration of the compression action on the nerve roots and the degree of their damage. So, the longer the period before the elimination of compression causing nerve damage, the greater the damage and the longer the recovery process. And with inflammatory etiology or loss of myelin sheaths, the horse tail syndrome can be chronic and progressive.

[20], [21]