Ponytail syndrome

Among the serious pathological conditions of a neurological nature, acute vertebrogenic pain syndrome in the area of the lumbar plexus of the nerve roots of the spinal canal is distinguished - cauda equina syndrome (code G83.4 according to ICD-10).

What is the cauda equina? The spinal cord is shorter than the spine, and doctors call the cauda equina the nerve roots that come out from the lower end of the spinal cord - lumbar (LI-LV) and sacral (SI-SV). The nerve roots of the lumbar plexus, diverging in a cone, provide innervation of the lower limbs and pelvic organs.

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Epidemiology

Those most at risk for disc herniation (and, accordingly, for the development of acute bilateral radicular syndrome) are people aged 40–50 years; it occurs slightly more often in men than in women. It is estimated that 10–25% of spinal fractures result in spinal cord injury and acute pain syndromes.

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Causes cauda equina syndrome

Being a complex of a number of symptoms, cauda equina syndrome (which can be called caudal syndrome or acute bilateral radicular syndrome) has various etiologies.

Neurologists, vertebrologists and spinal surgeons name the following possible causes of cauda equina syndrome:

• medial prolapse (herniation) of the intervertebral disc in the lumbar region (usually at the level of LIII-LV);
• traumatic spinal cord injuries located below the lumbar region;
• displacement of the vertebrae (spondylolisthesis) caused by osteochondrosis of the intervertebral discs or spondyloarthrosis (deforming arthrosis of the facet joints that connect the vertebrae);
• spinal cord neoplasms (sarcoma, schwannoma) or metastases of malignant tumors of various localizations to the vertebrae;
• stenosis (narrowing) of the spinal canal (spinal stenosis), developing as a result of degenerative-dystrophic changes in the spine;
• inflammation of the spinal cord (Paget's disease, Bechterew's disease, spondylodiscitis, neurosarcoidosis, chronic inflammatory demyelinating polyneuropathies);
• demyelination of nerve endings in progressive multiple sclerosis;
• complications of neurosurgical operations on the lumbar spine;
• consequences of regional epidural anesthesia or iatrogenic lumbar punctures.

As experts note, most often, cauda equina syndrome occurs when the nerve plexuses are compressed due to the displacement of intervertebral discs, which results from their prolapse.

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Pathogenesis

The pathogenesis of caudal syndrome is associated with compression (severe squeezing or pinching) of the dorsal and ventral roots of the spinal cord in the lumbar plexus area and damage to motor and sensory spinal neurons and their processes. In this case, the following roots are affected: LI-SII, innervating the lower limbs; SI-SIII roots, innervating the urinary bladder; SII-SV roots of the sacral region, which transmit nerve impulses to the perineum and anus.

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

The seriousness of this pain syndrome is that compression of the nerve roots of the equine tail and their damage can have irreversible consequences and complications: paresis or paralysis of the lower limbs, urinary and fecal incontinence, erectile dysfunction. Hyperactivity of the detrusor (smooth muscles of the bladder wall) can cause reflux of urine into the kidneys, which is fraught with their damage. In particularly severe cases, it may be necessary to use crutches or a wheelchair.

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Symptoms cauda equina syndrome

The first signs of this syndrome are sudden intense pain in the legs (especially in the thighs) and lower back, radiating to the buttocks and perineum.

And against the background of increasing pain, such characteristic clinical symptoms of cauda equina syndrome are noted as:

• loss of muscle strength in the legs (one or both);
• tingling (pasthesia) or numbness (hypesthesia) in the perineum and on the inner surfaces of the thighs and shins due to a disturbance of the superficial sensitivity of the skin;
• periodic involuntary contractions of individual muscle fibers (fasciculations);
• weakening or absence of reflexes - biceps femoris, patellar (knee), Achilles tendon and perineal muscles (anal and bulbocavernous);
• impairment or loss of function of the legs and pelvic organs (paraplegia);
• problems with urination (urinary retention or incontinence);
• loss of control over the process of defecation (dysfunction of the sphincters of the rectum and associated fecal incontinence);
• sexual dysfunction.

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Diagnostics cauda equina syndrome

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

Diagnosis of cauda equina syndrome begins with studying the anamnesis and clinical manifestations. For an objective assessment of the damage to the nerves of the lumbosacral plexus, sensitivity is checked at control points in areas innervated by the processes of each nerve root (on the anterior and inner surface of the thigh, under the knee joints, on the ankle and dorsum of the foot, on the Achilles plexus, etc.). The absence of sensitivity in these areas is a sure diagnostic sign of damage to the lumbar and sacral roots of the equine tail.

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

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Differential diagnosis

In case of cauda equina syndrome, differential diagnostics is especially important in order to distinguish this pain symptom complex 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 osteoarthrosis, etc.

Treatment cauda equina syndrome

Cauda equina syndrome is considered a medical emergency that requires immediate medical attention to prevent irreversible nerve damage and paralysis.

Therefore, today, treatment of cauda equina syndrome caused by a herniated disc is carried out by early surgical decompression (the need for which must be confirmed by making an appropriate diagnosis). In such cases, surgical treatment within 6-48 hours from the onset of symptoms makes it possible to eliminate pressure on the nerve roots using laminectomy or discectomy. According to spinal surgeons, surgical treatment of cauda equina syndrome within the specified time frame significantly increases the chance of avoiding persistent neurological disorders.

In addition, surgery may be required to remove spinal tumors, and when this is not possible, radiation therapy or chemotherapy is used. If the syndrome is caused by an inflammatory process, such as ankylosing spondylitis, anti-inflammatory drugs are used, including steroids (intravenous methylprednisolone).

Chronic cauda equina syndrome is much more difficult to treat. Strong painkillers are required to relieve pain, and doctors recommend using non-steroidal anti-inflammatory drugs (NSAIDs) for this purpose, for example, Lornoxicam (Xefocam) - 4-8 mg (1-2 tablets) two or three times a day. In case of very severe pain and injuries, the drug is administered parenterally; the maximum permissible daily dose is 16 mg. Contraindications for Lornoxicam include allergy to NSAIDs, bronchial asthma, poor blood clotting, ulcerative gastrointestinal pathologies, liver and kidney failure. And possible side effects of the drug include allergic reactions, headache, sleep disorders, decreased hearing and vision, increased blood pressure and pulse, shortness of breath, abdominal pain, dry mouth, etc.

The use of anticonvulsant drugs with gamma-aminobutyric acid (neurotransmitter GABA) is indicated. Such drugs include Gabapentin (Gabagama, Gabantin, Lamitril, Neurontin, etc.), which is recommended to be taken one capsule (300 mg) twice a day. The drug can cause side effects: headache, tachycardia, increased blood pressure, increased fatigue, nausea, vomiting, etc. This drug is contraindicated in liver diseases and diabetes.

If it is impossible to empty the bladder, catheterization is used, and anticholinergic drugs such as Oxybutynin (Sibutin) are needed to control 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 drug is not used in patients with ulcerative colitis, intestinal obstruction and Crohn's disease. Taking Oxybutynin can cause dry mouth, constipation or diarrhea, as well as headache and nausea.

Vitamins of group B have a positive effect on hypoesthesia accompanying cauda equina syndrome.

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

Prevention

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

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Forecast

The prognosis for recovery will depend on the duration of the compression effect on the nerve roots and the degree of their damage. Thus, the longer the period before the compression causing the nerve damage is eliminated, the greater the damage and the longer the recovery process. And with inflammatory etiology or loss of myelin sheaths, cauda equina syndrome can be chronic and progressive.

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