Given the suspected diagnosis, what does theevidence suggest needs to be performed onexamination?

There is no evidence regarding the predictive value of physical examination in working up malignant spinal cord compression. Although equivocal, there is evidence for the predictive value of history and physical examination in cauda equina syndrome (CES).

CES is a surgical emergency, classically described as a combination of low back pain, unilateral or bilateral sciatica, weakness in the lower extremities, saddle sensory loss, and/or urinary retention with overflow incontinence.7 Although the spinal cord ends at L1-2 in most adults, compression of the cauda equina is often grouped with spinal cord compression because some etiologies are similar which include abscess, epidural hematoma, and malignancy.8 Others are lumbar disc herniation, spinal anesthesia, ankylosing spondylosis, inferior vena cava thrombosis, and sarcoidosis.8-9

Balasubramanian et al. studied the reliability of clinical assessment in diagnosing CES in 80 patients. Fifteen of these patients had confirmed CES. Only saddle sensory deficit significantly associated with magnetic resonance imaging (MRI) confirmed CES. Association of other symptoms and signs, namely back pain, unilateral and bilateral leg pain, bladder retention, bladder incontinence, previous lumbar surgery, and decreased sphincter tone was not statistically significant.7

In 2009, Domen et al. published the results of a retrospective review investigating the predictive value of clinical examination in patients suspected to have CES. Out of 58 patients, 8 patients had cauda equina compression confirmed on MRI. Six of these patients underwent a bladder scan and all were found to have urinary retention. The clinical picture of urinary retention is greater than 500 ml and at least 2 of the following—bilateral sciatica, patient perception of urinary retention, or bowel incontinence—was associated with MRI-positive CES with an odds ratio of 48, 95% CI (3.30-697.21), (P = .04).10

Jalloh and Minhas identified 32 patients with CES who were transferred to a London neurosurgical center. Only 19% presented with the cluster of symptoms representing the characteristic of CES, namely lower back pain, bilateral sciatica, motor loss, sacral sensory loss, and sphincter disturbance. The strongest predictive features were lower back pain, sacral sensory loss, and urinary symptoms.11

Bottom line: Given the importance of prompt diagnosis and management, CES should immediately be suspected in a patient with back pain and urinary retention or saddle sensory loss.

  • Contact
  • Category: Heart and vessels