Early Deficits in Cauda Equina Syndrome: A Case Study

The real red flags of cauda equina syndrome (CES) are the early neurological deficits patients experience, said Courtney Hart, PA-S, in a poster presentation at the American Academy of PAs 2021 (AAPA 2021) conference.

“Familiarity with uncharacteristic clinical presentations from CES, including unilateral numbness and lower extremity weakness, can help clinicians order prompt lumbar imaging and neurosurgical consultation,” said Hart, a student in the PA program at Quinnipiac University in Hamden . Connecticut (table).

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Table. Signs and Symptoms of Cauda Equina Syndrome

Early-stage CES signs / symptoms
Progressive neurological deficits in the lower extremities
Impaired bladder or urethral sensation, hesitation, poor water jet with maintained urination control
Late-stage CES signs / symptoms
Impaired perineal sensation
Reduced anal tone
Urinary retention or incontinence
Fecal incontinence
Perianal anesthesia

Ponytail Syndrome revealed

A 22 year old obese Hispanic male presented to the emergency room with atraumatic left calf pain radiating to the inner thigh that began 1 day earlier. Upon first introduction, he denies recent trauma, lumbar back pain, radiculopathy, and lower extremity weakness. His physical examination is normal for calf erythema, edema or sensitivity to palpation, and his neurological examination is normal and without sensory deficits. He is diagnosed with myalgia based on the clinical picture and, if necessary, discharged with a prescription for naproxen and cyclobenzaprine.

He returns to the emergency room for no use. On his third trip to the emergency room, the patient presents with progressive symptoms such as leg cramps and weakness on both sides, lower back pain, numbness, tingling, urinary incontinence and saddle anesthesia. Relevant findings on examination include tenderness of the lumbar paraspinal muscles, positive leg raises, inability to stand or walk, and perianal anesthesia on rectal examination.

“A simple review of the systems provided answers that I immediately realized that something more urgent was going on when, to my surprise, the patient revealed that he had had an episode of urinary incontinence and was feeling numb in his groin,” Hart said. Urinary retention was quickly confirmed by bladder ultrasound. His complete blood count and electrolytes were normal and the highly sensitive D-dimer test was negative.

Progressive symptoms increase concern

The progression of clinical symptoms with spinal cord compression was of concern and magnetic resonance imaging (MRI) of the lumbar spine was required. However, an on-site MRI was not available at the community hospital.

“The question that was raised was should we move the patient immediately to a higher-quality facility with MRI capabilities or have a lumbar computed tomography (CT) scan at the community hospital prior to the move?” Said Hart. Although symptoms such as urinary incontinence and perianal paresthesia supported a diagnosis of CES, it was decided that a confirmatory CT scan would be helpful for the transfer facility so that urgent neurosurgery can be performed on arrival. “My research has confirmed that lumbar spine CT has a role in screening for CES in public hospitals, as well as in excluding CES when clinical suspicion is low. The CT scan was ordered, ”Hart explained.

CT images showed a large central disc osteophyte protrusion with multifactorial degenerative changes and congenital short pedicles at L4-L5, which led to suspected severe central canal stenosis and compression of the CES nerve roots. The bladder and bilateral ureters were distended.

The patient was urgently transferred to the neurosurgical spine department of the university hospital for further clarification and treatment.

Practice Notes for ED Clinicians

“Looking back, I think that the patient’s first visit to the emergency room did not warrant further clarification based on the clinical picture and the corresponding negatives. However, when the patient returned 2 days later with the same symptoms progressing and bilateral involvement, further consideration of other possible diagnoses would have been useful. It was easy to tell that at the time it was simply an aggravated myalgia, and perhaps the patient’s young age did not raise any suspicion of anything more serious. With the CES diagnosis now known, this case highlights progressive signs and symptoms of the syndrome that started with only unilateral calf pain, ”Hart said.

Fast facts about CES

  • Cauda equina syndrome is a collection of symptoms that include sciatica, saddle anesthesia, urinary retention, and sphincter dysfunction. The diagnosis is made through physical examination and lumbar imaging.
  • The true red flags of CES are early neurological deficits. These warning signs should lead to a lumbar spine imaging and neurosurgical consultation.
  • Familiarity with uncharacteristic clinical presentations of CES, including unilateral numbness and lower extremity weakness with no sphincter involvement or saddle anesthesia, will help clinicians identify premonitory features of CES.
  • In public hospitals with no access to MRIs, a CT scan should be performed before the patient is transferred.
  • Consider CES if a patient presents with progressive neurological deficits in the lower extremities.


Hart C, Lavender Z. Cauda equina syndrome with unilateral calf myalgia in a 22-year-old man. Poster presented at: American Academy of PAs Conference 2021; 23-26 May 2021. Poster 222.

This article originally appeared on Clinical Advisor

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