2012 Annual Conference

Herman, Germaine

Harris County Hospital District, Houston, TX

Total versus partial loss of bowel and bladder control in cauda equina syndrome (CES) may be an indicator of spinal nerve compression severity in persons with CES[1]. Through a detailed history-taking,  physical therapists should distinguish between a patient’s loss of executive control of bowel and bladder versus isolated difficulties with urinary function such as decreased urinary sensation, a loss of desire to void, need to strain when urinating and decreased urinary stream2. Early surgical intervention for CES leads to improved return of bowel and bladder3.  Physical therapists play an important role in early detection of CES for appropriate operative referral, thereby leading to optimal post-operative prognosis.

1. Gleave JR, Macfarlane R. Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Br J Neurosurg. 2002;16(4):325–328.

2. Hindmarsh D, Davenport J, Selvaratnam V, Ampat G. How well are the urinary symptoms of cauda equina syndrome (CES) recognised by multidisciplinary health care professionals? Eur Orthop Traumatol. 2011; 1:219-223.

3. DeLong WB, Polissar N, Neradilek B. Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies. J Neurosurg Spine. 2008;8(4):305–320

50-year-old male with a history of low back pain (LBP) with surgical repair of an L4-5 herniated disk in 2004 s/p MVA. The patient returned to work despite non-radiating episodic LBP managed with pain medication. In 08/2011 LBP became constant with sensory deficits to the right lower extremity with no change in symptom management. In 01/2012, sensory deficits worsened to include both lower extremities. In the following three months, the patient was treated five different times through triage and physician office visits for worsening symptoms, now including sensory and motor deficits, never noting generalized bowel or bladder dysfunction.  Patient management continued unchanged.  Additionally, the patient was referred to neurosurgery and physical therapy (PT). During PT evaluation, the patient complained of worsening LBP, gait with an assistive device, three recent falls, and initial denial of generalized bowel and bladder dysfunction as well as saddle anesthesia.  However, upon further inquiry, patient reported a reduction in urinary flow despite straining, difficulty sensing desire to void, and feeling like bladder had not been fully emptied. On examination, the patient presented with absent sensory, motor and reflex L5-S1 on the right, hyperreflexia L3-4 on the right, foot drop on the right during gait and impaired static and dynamic balance. Sensory, motor and reflexes were normal on the left with tingling and numbness along L5 distribution to the foot. No centralization of symptoms occurred with positional changes. The patient was immediately referred to the emergency center.

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A repeat MRI revealed a worsening L4-5 disc extrusion causing severe spinal stenosis with L4-5 nerve root and cauda equina impingement. Four days later, he underwent an L4-5 diskectomy. On post-operative PT evaluation, the patient stated a resolution of bladder symptoms, back pain with prolonged positioning and sensory deficits down the lateral aspect of the right lower extremity only. Examination revealed a resolution of all sensory deficits on the left, all motor deficits on the right, static and dynamic balance deficits with only mild sensory deficits to light touch and hyporeflexia along the L5 dermatome on the right

Physical therapists should be aware of total versus partial loss of bowel and bladder control in CES. By inquiring into the specifics of urinary function through a detailed history-taking, physical therapists can aid in early detection of CES for appropriate operative referral. These practices will provide best patient care and lead to optimal post-operative prognosis.