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Cauda Equina Syndrome
• Neurosurgical emergency due to compression of cauda equina nerve roots, usually from disc herniation, tumor, or trauma
Clinical Presentation
- Severe low back pain with bilateral leg radiation, saddle anesthesia, bowel/bladder dysfunction (urinary retention, overflow incontinence), decreased rectal tone, lower extremity weakness
Labs, Studies, and Physical Exam Findings
- Immediate MRI lumbar spine (gold standard) showing nerve root compression
- Rectal exam showing decreased sphincter tone
Treatment
- Emergent surgical decompression within 24-48 hours
- Supportive care: Pain management, bladder catheterization
Key Differentiators
- Rapid onset of bilateral symptoms with bowel/bladder dysfunction differentiates it from typical lumbar radiculopathy or sciatica
Epidural Abscess
• • Spinal epidural infection commonly caused by Staphylococcus aureus
- Risk factors: IV drug use, recent spinal procedures, immunosuppression
Clinical Presentation
- Classic triad: Fever, localized spinal tenderness, progressive neurological deficits
- Insidious onset of worsening back pain, fever, neurological symptoms over days to weeks
Labs, Studies, and Physical Exam Findings
- Elevated ESR, CRP, leukocytosis
- MRI with gadolinium (gold standard): Ring-enhancing lesion with surrounding inflammation
Treatment
- First-line: Immediate empiric IV antibiotics (Vancomycin + Ceftriaxone or Cefepime)
- Surgical drainage for progressive neurologic deficit, large abscess, or failed medical management
Key Differentiators
- Progressive fever and neurological deficits distinguish from mechanical back pain; confirmed by MRI and inflammatory markers
Spinal Cord Injuries
• • Traumatic injury causing varying neurological deficits based on level and completeness
Clinical Presentation
- Acute trauma history, spinal shock (temporary loss of reflexes, motor/sensory function)
- Neurological deficits depend on injury level:
- Cervical injuries: Tetraplegia/quadriplegia
- Thoracic/lumbar injuries: Paraplegia
- Neurogenic shock (hypotension, bradycardia) seen with injuries above T6 due to disrupted autonomic pathways
Labs, Studies, and Physical Exam Findings
- CT scan for initial assessment of bony injuries/fractures
- MRI to evaluate soft tissue and spinal cord involvement
Treatment
- Initial management: Spinal stabilization (cervical collar, spine immobilization), airway control, neurogenic shock treatment (IV fluids, vasopressors)
- Surgical decompression/stabilization for unstable injuries or ongoing compression
- High-dose corticosteroids controversial but considered if initiated within 8 hours post-injury
Key Differentiators
- Neurogenic shock (bradycardia + hypotension) distinguishes cervical spinal injuries from hemorrhagic shock (tachycardia + hypotension)
