WHAT IS CAUDA EQUINA SYNDROME?
CAUDA EQUINA SYNDROME - A RARE DISORDER
Cauda Equina Syndrome (CES). The Cauda Equina is so named as the bundle of nerves resemble a horse’s tail
as shown in diagram below. It is hard to describe to the layperson other than it is a rare and serious injury of the
It causes the sufferer extreme pain and suffering, as well as embarrassment in certain circumstances
depending largely on the symptoms or should it be clarified the after effects of Cauda Equina Syndrome (CES).
This manual/book is not the complete guide to CES but hopefully will give people a better understanding of the
problems it can create within a person as well as those around him or her.
Other chapters you will be enlightened to what a sufferer of CES has to live with every day of their lives. CES is not
just any disease or syndrome, it is a disorder, caused by many factors as you read the information contained herein as
well as the personal stories of some of the sufferers.
It is a hideous disorder; in fact, it causes so many complications and variations as each sufferer are different.
With some who have the syndrome, the nerves affected may repair in 12 months, 2 years or even 5 or 10 years, then
there are those who are living with it every day, never to improve, although rare it may cause death. Further in the
book you will read how the disorder varies in differing ways for different people and how the medical profession or
should I say a large proportion of them have never heard of it, or some have heard but know nothing about it, as well
as those who just pass it off as a bad back.
Cauda Equina Syndrome causes the patient, in differing degrees, pain, stress, anxiety, depression and in some
cases even trying to take their own lives being the ultimate due to this hideous and incomparable disorder. Here I must
say that a lot of information out in the medical world believes to only affects a certain few, and mainly elderly is
a myth. This disorder can affect new-born babies upwards to any age. You will see from some of the graphs and
tables contained within this website and many more within the Book/Manual, results from surveys on the subject.
As a CES sufferer and finding it extremely hard to obtain any information about CES, it was evident that the information
obtained from most web sites was repeated many times, and it became frustrating to obtain facts to really get a grip on
the actual repercussions of what the disorder was. The pages following contains evidence of the disorder as well as
information from many sources around the world, who have kindly given permission for some of the material to be
repeated within these pages. This manual or book or medical journal whatever you may wish to call this item has all
available information possible.
It was gathered to aid not only the sufferers of CES, but to inform the carers and doctors of CES sufferers, and
the short- or long-term outlook and what is needed to make life just a little bit normal. The book is broken up
into Sections and within those Sections are separate chapters, each an individual piece of information about CES but
all intertwine with each other to a real and actual overall view. As mentioned, there is a section on the carers and what
they need to know, how doctors need to look for the RED FLAGS and realise that what the patient is describing is not
just sciatica, pulled muscle or strain, it could be life-threatening or even disabling the patient for life.
I can only hope that this book/manual/journal will be the first of many as the medical fraternity find few cures etc., like
any disease, disorder, syndrome or health issue there is always research being carried out for the future. Let us start by
giving you a heads up on what to expect within the following pages. Although leg pain is common and usually goes
away without surgery, CES, a rare disorder at the lower (lumbar) end of the spinal cord, and is a surgical emergency
once diagnosed. The longer the time from diagnosis to surgery can be a huge difference in the final outcome.
CES refers to a group of symptoms that occur when nerves in the Cauda Equina (a collection of nerve roots that
spread out from the bottom of the spinal cord) become compressed or damaged. Those nerve roots
connect the central nervous system and peripheral nervous system.
The Cauda Equina (Latin for Horse's Tail) is a tangle of
nerves as shown in picture below.
CES can lead to pain, numbness, and weakness in the lower back, pelvic area and legs; "foot drop";
problems with bowel or bladder control; sexual dysfunction; and even paralysis. CES has also been linked with CRPS
(Complex Regional Pain Syndrome) CES is considered a medical emergency and requires hospitalization. Therefore,
people with unexplained onset of symptoms should seek medical attention as soon as possible and consult with a
neurologist or neurosurgeon.
CES is most commonly caused by a herniated disk in the lumbar spine. Other causes of CES may include a
birth abnormality (such as spina bifida), spinal infection or tumour, trauma or injury to the lower back, spinal stenosis,
a spinal arteriovenous malformation, and complications after spinal surgery. There is a list on another page CES can
be difficult to diagnose since symptoms vary and they may mimic other conditions. Tests that may be used to diagnose
CES include MRI, CT scan, and a myelogram (a special type of X-ray of the spinal canal). Treatment usually targets
the underlying cause of CES (removing the cause of nerve pressure) and most often involves urgent surgery to prevent
permanent neurologic impairment. How well a person recovers from CES often depends on the underlying cause and
how promptly they are treated.
Symptoms are more likely to improve or go away if the cause is identified quickly and treatment begins right away.
Some people have significant improvement of symptoms and quality of life after treatment. However, others may have
a permanent neurologic impairment, chronic pain, and/or mental health problems due to the impact of symptoms on
social life and relationships. An extension of the brain, the nerve roots send and receive messages to and from the
pelvic organs and lower limbs.
The breakdown of the Spine showing the Lumbar and
Sacrum area where the Cauda Equina is Placed.
Cauda Equina Syndrome occurs when the nerve roots in the lumbar spine are compressed, cutting off
sensation and movement. Nerve roots that control the function of the bladder and bowel are especially
vulnerable to damage. If patients with Cauda Equina Syndrome do not seek immediate treatment to
relieve the pressure, it can result in permanent paralysis, impaired bladder and/or bowel control, loss of
sexual sensation, and other problems. Even with immediate treatment, some patient may not recover
What are the Causes
Cauda Equina Syndrome may be caused by a herniated disk, tumour, nfection, fracture, or narrowing of
the spinal canal see a full list below.
Diseases and Condition
Herniated Disk in the Lower Back or Fractures of the Thoracic and Lumbar Spine also, Lumbar Spinal Stenosis.
Although early treatment is required to prevent permanent problems, Cauda Equina Syndrome may be
difficult to diagnose. Symptoms vary in intensity and may evolve slowly over time. The following are
some of as mentioned the RED FLAGS your doctor should be looking for when you attend an
appointment with him complaining of a bad back that does not seem to resolve itself, and the
complications that come along with it.
See your doctor immediately if you have:
Bladder and/or bowel dysfunction, causing you to retain urine or be unable to hold it. Severe or
progressive problems in the lower extremities, including loss of oraltered sensation between the legs,
over the buttocks, the inner thighs and back of the legs (saddle area), and feet/heels.
To diagnose Cauda Equina Syndrome, your doctor will evaluate your medical history, give you a physical
examination and order multiple diagnostic imaging studies.
Describe your overall health, when the symptoms of Cauda Equina Syndrome began, and how they
impact your activities. Your doctor assesses stability, sensation, strength, reflexes, alignment, and motion. He or she
may ask you to stand, sit, walk on your heels and toes, bend forward, backward and to the sides, and lift your legs
while lying down. Your doctor might check the tone and numbness of anal muscles. You may need blood tests.
Your doctor may order x-rays, magnetic resonance imaging (MRI) scans and computed tomography (CT)
scans to help assess the problem.
The above chart shows the following:
13% Allow 6 weeks of normal activity with rest and analgesics for pain.
23% Surgery to relieve the disc and pressure on the spinal cord.
8% Trade-off between wait and see compared to surgery.
6% Manipulation and bed rest (The old remedy for back complaint).
4% Do nothing, likely to be ineffective or harmful.
46% Surgery unknown quantity.
86% of the time surgery is required as will be shown in other sections of this work.
If you have Cauda Equina Syndrome, you may need urgent surgery to remove the material that is
pressing on the nerves. The surgery may prevent pressure on the nerves from reaching the point at
which damage is irreversible.
Living with Cauda Equina Syndrome
Surgery may not repair permanent nerve damage. If this occurs as a result of Cauda Equina Syndrome,
you can learn how to improve your quality of life.
Managing Bladder and Bowel Function
Some bladder and bowel function are automatic, but the parts under voluntary control may be lost if you
have Cauda Equina Syndrome. This means you may not know when you need to urinate or move your
bowels, and/or you may not be able to eliminate waste normally.
Some general recommendations for managing bladder and Bowel dysfunction:
* Empty the bladder completely with a catheter 3 to 4 times each day.
* Drink plenty of fluids and practice regular personal hygiene to prevent urinary tract infection.
* Check for the presence of waste regularly and clear the bowels with gloved hands.
* You may want to use glycerine suppositories or enemas to help empty the bowels.
* Use protective pads and pants to prevent leaks.
In addition to medical personnel, you may want to get help from an occupational therapist, social worker,
continence advisor, or sex therapist. Involve your family in your care. To learn all you can about managing
the condition, you may want to join a CES support group. The reason this web site was created to support and
help. We have listed a series of world wide web sites at the rear of the book for you to view and join if you wish.
All have extremely good communication with CES sufferers, and this could be of great benefit to you. There are also
pages of acknowledgments for the people who help put this book together and their web sites are available to
view. The following are all connected in some way to the spine and the Cauda Equina or the (“Horses Tail”). Further on
we will show illustrations of the areas and sections of the back that causes extreme discomfort. As you may or may not
know each nerve in your entire body has a number as shown in the diagram further on. These, of course, are not
everyday diseases that everyone will suffer, but 1 in 1,324,879 people worldwide suffer from CES a very scary
This list has a medical explanation for the ease of understanding. Not all though lead to CES, it depends on the
severity of the named condition and position. We could have placed this in an annex page but believe should be here
as they will all be mentioned somewhere within other pages.
We will start with an overview of what to Expect.
A spinal cord injury or damage to any part of the spinal cord or nerves at the end of the spinal canal
(Cauda Equina) and often causes permanent changes in strength, sensation and other body functions
below the site of the injury. If you've recently experienced a spinal cord injury, it might seem like every
aspect of your life has been affected. You might feel the effects of your injury mentally, emotionally and socially.
Many scientists are optimistic that advances in research will someday make the repair of spinal cord injuries possible.
Research studies are ongoing around the world. In the meantime, treatments and rehabilitation allow
many people with spinal cord injuries to lead productive, independent lives.
Spinal Cord Injuries
Your ability to control your limbs after a spinal cord injury depends on two factors: the place of
the injury along your spinal cord and the severity of injury to the spinal cord. The lowest normal part of
your spinal cord is referred to as the neurological level of your injury.
The severity of the injury is often called "the completeness" and is classified as either of the following:
Complete - If all feeling (sensory) and all ability to control movement (motor function) are lost below
the spinal cord injury, your injury is called complete.
Incomplete - If you have some motor or sensory function below the affected area, your injury
is called incomplete. There are varying degrees of incomplete injury.
Additionally, paralysis from a spinal cord injury may be referred to as:
Also known as quadriplegia, this means your arms, hands, trunk, legs and pelvic organs are all
affected by your spinal cord injury.
This paralysis affects all or part of the trunk, legs and pelvic organs. Your health care team will perform a
series of tests to determine the neurological level and completeness of your injury.
Spinal cord injuries of any kind may result in one or more of the following signs
+ Loss of movement
+ Loss or altered sensation, including the ability to feel heat, cold or touch
+ Loss of bowel or bladder control
+ Exaggerated reflex activities spasms, or intense pain in certain areas, known as CRPS (Complex Reflex Pain
Syndrome) This Syndrome may other causes other than CES.
+ Changes in sexual function, sexual sensitivity and fertility
+ Pain or an intense stinging sensation caused by damage to the nerve fibres in your spinal cord
+ Difficulty breathing CES is known to cause COPD, Chronic Obstruction Pulmonary Disease
+ Coughing or clearing secretions from your lungs
Emergency Signs and Symptoms
Emergency signs and symptoms of a spinal cord injury after an
accident may include:
1. Extreme back pain or pressure in your neck, head or back.
2. Weakness, incoordination or paralysis in any part of your body.
3. Numbness, tingling or loss of sensation in your hands, fingers, feet or toes, Loss of bladder
or bowel control.
4. Extreme Pain in certain areas that persists, and fails to go away. This could be CRPS?
5. Difficulty with balance and walking.
6. Impaired breathing after injury.
7. An oddly positioned or twisted neck or back.
When to see a Doctor
Anyone who experiences significant trauma to his or her head or neck needs immediate medical evaluation for
the possibility of a spinal injury. In fact, it's safest to assume that trauma victims have a spinal injury until
proved otherwise because:
i: A serious spinal injury isn't always immediately obvious. If it isn't recognized, a more severe injury
ii: Numbness or paralysis may occur immediately or come on gradually as bleeding or swelling occurs
in or around the spinal cord.
iii: The time between injury and treatment can be critical in determining the extent and severity of
complications and the possible extent of expected recovery.
If you suspect that someone has a back or neck injury:
a) Don't move the injured person — permanent paralysis and other serious complications may result
b) Call your local emergency medical assistance number
c) Keep the person still
d) Place heavy towels on both sides of the neck or hold the head and neck to prevent them from
moving until emergency care arrives
e) Provide basic first aid, such as stopping any bleeding and making the person comfortable, without
moving the head or neck
In the emergency room, a doctor may be able to rule out a spinal cord injury by careful inspection
and examination, testing for sensory function and movement, and by asking some questions about the
accident. But if the injured person complains of neck pain, isn't fully awake, or has obvious signs of
weakness or neurological injury, emergency diagnostic tests may be needed.
These tests may include:
Medical personnel typically order these tests on people who are suspected of having a spinal cord injury after
trauma. X-rays can reveal vertebral (spinal column) problems, tumours, fractures or degenerative changes in the spine.
Computerized Tomography (CT) Scan.
A "CT" scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to
form a series of cross-sectional images that can define bone, disk and other problems.
Magnetic Resonance Imaging (MRI).
MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is
very helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses
that may be compressing the spinal cord.
A few days after injury, when some of the swellings may have subsided, your doctor will conduct a more
comprehensive neurological exam to determine the level and completeness of your injury. This involves
testing your muscle strength and your ability to sense light touch and pinprick sensations.
Unfortunately, there's no way to reverse damage to the spinal cord. But researchers are continually working on
new treatments, including prostheses and medications that may promote nerve cell regeneration or improve the
function of the nerves that remain after a spinal cord injury. In the meantime, spinal cord injury treatment focuses on
preventing further injury and empowering people with a spinal cord injury to return to an active and productive life.
Urgent medical attention is critical to minimize the effects of any head or neck trauma. Therefore, treatment for a spinal
cord injury often begins at the scene of the accident. Emergency personnel typically immobilize the spine as gently and
quickly as possible using a rigid neck collar and a rigid carrying board, which they'll use to transport you to the hospital.
Early (acute) stages of Treatment
In the emergency room, doctors focus on:
A) Maintaining your ability to breathe
B) Preventing shock
C) Immobilizing your neck to prevent further spinal cord damage
D) Avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular
difficulty, and formation of deep vein blood clots in the extremities
If you do have a spinal cord injury, you'll usually be admitted to the intensive care unit for treatment.
You may even be transferred to a regional spine injury centre that has a team of neurosurgeons,
orthopaedic surgeons, spinal cord medicine specialists, psychologists, nurses, therapists and social
workers with expertise in spinal cord injury.
Intravenous (IV) methylprednisolone (A-Methapred, Solu-Medrol) has been used as a treatment option for an
acute spinal cord injury. But recent research has shown that the potential side effects, such as blood clots and
pneumonia, from using this medication outweigh the benefits. Because of this, methylprednisolone is no longer
recommended for routine use after a spinal cord injury. Most Opiates are now used either by Intravenous (IV) or orally.
We expand on this further in the Opiates and Drugs Section
You may need traction to stabilize your spine, to bring the spine into proper alignment or both. In some
cases, a rigid neck collar may work. A special bed also may help immobilize your body.
Often surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured
vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to
prevent future pain or deformity.
Scientists are trying to figure out ways to stop cell death, control inflammation and promote nerve
regeneration. For example, doctors may lower the body temperature significantly in a condition known
as hypothermia for 24 to 48 hours to help prevent damaging inflammation. Ask your doctor about the
availability of such treatments.
After the initial injury or the condition stabilizes, doctors turn their attention to preventing secondary
problems that may arise, such as deconditioning, muscle contractures, pressure ulcers, bowel and
bladder issues, respiratory infections, and blood clots. The length of your hospitalization depends on
your condition and the medical issues you're facing. Once you're well enough to participate in therapies
and treatment, you may transfer to a rehabilitation facility.
Rehabilitation team members will begin to work with you while you're in the early stages of recovery.
Your team may include a physical therapist, an occupational therapist, a rehabilitation nurse, a
rehabilitation psychologist, a social worker, a dietitian, a recreation therapist, and a doctor who
specializes in physical medicine (physiatrist) or spinal cord injuries. During the initial stages of
rehabilitation, therapists usually emphasize maintenance and strengthening of existing muscle function,
redeveloping fine motor skills and learning adaptive techniques to accomplish day-to-day
You'll be educated on the effects of a spinal cord injury and how to prevent complications, and you'll be
given advice on rebuilding your life and increasing your quality of life and independence. You'll be
taught many new skills, and you'll use equipment and technologies that can help you live on your own as
much as possible. You'll be encouraged to resume your favourite hobbies, participate in social and
fitness activities, and return to school or the workplace. This area is probably one of the most important
in your recovery and is often overlooked or not followed up on. It is essential that your rehabilitation is
Medications may be used to manage some of the effects of spinal cord injury. These include medications
to control pain and muscle spasticity, as well as medications that can improve bladder control, bowel
control and sexual functioning.
Inventive medical devices can help people with spinal cord injury become more independent and more
mobile. Some devices may also restore function.
Improved, lighter weight wheelchairs are making people with spinal cord injuries more mobile and more
comfortable. For some, an electric wheelchair may be needed. Some wheelchairs can even climb stairs,
travel over rough terrain and elevate a seated passenger to eye level to reach high places without help.
For someone who has limited hand function, computers can be very powerful tools, but they're difficult
to operate. Computer adaptations range from simple to complex, such as key guards or voice
Electronic Aids for Daily Living.
Essentially any device that uses electricity can be controlled with an electronic aid to daily living.
Devices can be turned on or off by a switch or voice-controlled and computer-based remotes.
Electrical Stimulation Devices.
These sophisticated devices use electrical stimulation to produce actions. They're often called functional
electrical stimulation systems, and they use electrical stimulators to control arm and leg muscles to
allow people with spinal cord injuries to stand, walk, reach and grip.
Robotic Gait Training.
This emerging technology is used for retraining walking ability after a spinal cord injury.
Prognosis and Recovery.
Your doctor may not be able to give you a prognosis right away. Recovery, if it occurs, typically starts a
week to six months after an injury. The fastest rate of recovery is often seen in the first six months, but
some people experience small improvements for up to one to two years. After about 18 months the
chances of full recovery are less than 20%.
Coping and Support.
An accident that results in paralysis is a life-changing event. Suddenly having a disability can be
frightening and confusing, and adapting is no easy task. You may wonder how your spinal cord injury
will affect your everyday activities, job, relationships and long-term happiness. Recovery from such an
event takes time, but many people who are paralyzed progress to lead productive and fulfilling lives.
It's essential to stay motivated and get the support you need.
If you're newly injured, you and your family will likely experience a period of mourning and grief.
Although the grieving process is different for everyone, it's common to experience denial or disbelief,
followed by sadness, anger, bargaining and, finally, acceptance. The grieving process is a common,
healthy part of your recovery. It's natural and important to grieve the loss of the way you were. But it's
also necessary to set new goals and find a way to move forward with your life.
You'll probably have concerns about how your injury will affect your lifestyle, your financial situation
and your relationships. Grieving and emotional stress is normal and common. However, if your grief
and sadness are affecting your care, causing you to isolate yourself from others, or prompting you to
abuse alcohol or other drugs, you may want to consider talking to a social worker, psychologist or
Or you might find a support group of people with spinal cord injuries helpful. Talking with others who
understand what you're going through can be encouraging, and members of the group may have good
advice on adapting areas of your home or work space to better accommodate your current needs. Ask
your doctor or rehabilitation specialist if there are any support groups in your area.
One of the best ways to regain control of your life is to educate yourself about your injury and your
options for reclaiming an independent life. A range of driving equipment and vehicle modifications is
The same is true of home modification products. Ramps, wider doors, special sinks, grab bars and easy-
to-turn doorknobs make it possible for you to live more autonomously. Because the costs of a spinal
cord injury can be overwhelming, you may want to find out if you're eligible for economic assistance or
support services from the state or government or from charitable organizations. Your rehabilitation
team can help you identify resources in your area.
Talking about your Disability
Your friends and family may respond to your disability in different ways. Some may be uncomfortable
and unsure if they're saying or doing the right thing. Being educated about your spinal cord injury and
willing to educate others is helpful. Children are naturally curious and sometimes adjust rather quickly if
their questions are answered in a clear, straightforward way.
Adults also can benefit from learning the facts. Explain the effects of your injury and what your family and
friends can do to help. At the same time, don't hesitate to tell friends and loved ones when they're helping too
much. Although it may be uncomfortable at first, talking about your injury often strengthens your
relationships with family and friends. There is an unfortunate side here, men as a whole do not like to talk
about such matters and tend to be guarded. This is where they need to change and open about their problem
as it comes into the equation again in the next section.
Dealing with Intimacy, Sexuality and Sexual Activity
Your spinal cord injury may affect your body's response to sexual stimuli. However, you're a sexual
being with sexual desires. A fulfilling emotional and physical relationship is possible but requires
communication, experimentation and patience. A professional counsellor can help you and your partner
communicate your needs and feelings. Your doctor can provide the medical information you need
regarding sexual health. As mentioned in the previous section, here is an unfortunate side here,
men as a whole do not like to talk about such matters and tend to be guarded. This is where they
need to change and open about their problem.
You can have a satisfying future complete with intimacy and sexual pleasure. During our Survey study
conducted 2017 - 2019 there were 19.4% of marriage break- downs due to this
area after counselling. Prior to Counselling help 25.6% of marriages were on the verge of failing. It
shows that not only the individual does it affect, but those around the person.
By nature, a spinal cord injury has a sudden impact on your life and the lives of those closest to you.
When you first hear your diagnosis, you may start making a mental list of all of the things you can't do
anymore. However, as you learn more about your injury and your treatment options, you may be
surprised by all you can do. Thanks to new technologies, treatments and devices, people with spinal cord
injuries play basketball and participate in track meets. They paint and take photographs. They get
married, have and raise children, and have rewarding jobs.
Today, advances in stem cell research and nerve cell regeneration give hope for a greater recovery for
people with spinal cord injuries. At the same time, new treatments are being investigated for people
with long-standing spinal cord injuries. No one knows when new treatments will be available, but you
can remain hopeful about the future of spinal cord research while living your life to the fullest today.
Preparing for your appointment.
Traumatic spinal cord injuries are emergencies, and the person who's injured may not be able to
participate in his or her care in the beginning. A number of specialists will be involved in stabilizing the
condition, including a doctor who specialises in nervous system disorders (neurologist) and a surgeon
who specialises in spinal cord injuries and other ervous system problems (neurosurgeon), among others.
A doctor who specializes in spinal cord injuries will lead your rehabilitation team, which will include a
variety of specialists. If you have a possible spinal cord injury or you accompany someone who's had a
spinal cord injury and can't provide the necessary information, here are some things you can do to
What you can do?
Be prepared to provide information about the circumstances of the event that caused the injury, including any that may
seem unrelated. Ask another family member or friend to join you when you're speaking with the doctors, if possible.
Sometimes it can be difficult to remember all the information provided. Someone who accompanies you may remember
the details and help you communicate them to the person with the injury at the appropriate time.
Write down questions to ask the Doctors.
1: For a spinal cord injury, some basic questions to ask the doctor include:
2: What's the prognosis?
3: What will happen in the short term?
4: What will happen over the long term? What treatments are available, and which do you recommend?
5: What types of side effects can be expected from treatment?
6: Could surgery help?What type of rehabilitation might help?
7: Are there any alternatives to the primary approach that you're suggesting?
8: What research is being done to help this condition?
9: Do you have brochures or other printed material? Are there websites you recommend?
Don't hesitate to ask any other questions you have.
What to Expect from the Doctor?
Your doctor is likely to ask questions, including:
A: What were the circumstances that led to your injury?
B: When did it occur?
C: What do you do for work and leisure?
D: With whom do you live?
E: Tell me about your housing situation (home, apartment, number of stairs)?
F: Do you or anyone in your family have a history of blood clots?
G: Do you have any other medical conditions?
Central Nervous System
Spinal cord injuries may result from damage to the vertebrae, ligaments or disks of the spinal column or
to the spinal cord itself. A traumatic spinal cord injury may stem from a sudden, traumatic blow to your
spine that fractures, dislocates, crushes or compresses one or more of your vertebrae. It also may result
from a gunshot or knife wound that penetrates and cuts your spinal cord. Additional damage usually
occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and
around your spinal cord. A nontraumatic spinal cord injury may be caused by arthritis, cancer,
inflammation, infections or disk degeneration of the spine.
Your Brain and Central Nervous System
The central nervous system comprises the brain and spinal cord. The spinal cord, made of soft tissue
and surrounded by bones (vertebrae), extends downward from the base of your brain and is made up of
nerve cells and groups of nerves called tracts, which go to different parts of your body. The lower end of
your spinal cord stops a little above your waist in the region called the conus medullaris. Below this
region is a group of nerve roots called the Cauda Equina.
Tracts in your spinal cord carry messages between the brain and the rest of the body. Motor tracts carry
signals from the brain to control muscle movement. Sensory tracts carry signals from body parts to the
brain relating to heat, cold, pressure, pain and the position of your limbs. With this in mind there is also another
thing to think of and that is CRPS, as this can cause extreme and constant pain in one or more areas as
well as contributing to the complexities of CES.
Damage to Nerve Fibres
Whether the cause is traumatic or nontraumatic, the damage affects the nerve fibres passing through
the injured area and may impair part or all of your corresponding muscles and nerves below the injury
site. A chest (thoracic) or lower back (lumbar) injury can affect your torso, legs, bowel and bladder
control, and sexual function. A neck (cervical) injury affects the same areas in addition to affecting
movements of your arms and, possibly, your ability to breathe.
Common Causes of Spinal Cord Injuries
The most common causes of spinal cord injuries in the Developed Western World are:
Motor Vehicle Accidents
Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for almost 56%
of the new spinal cord injuries each year.
A spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause more than 15%
of spinal cord injuries.
Acts of Violence.
Around 12 % of spinal cord injuries results from violent encounters, often involving gunshot and
Sports and Recreation Injuries.
Athletic activities, such as impact sports and diving in shallow water, cause about 10% cent of spinal
cord injuries. Especially Rugby, Rugby League, Grid Iron (American Football), Soccer, Australian Rules
Football, and Ice Hockey just to name a few. Of course there are many more.
Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.
We have included a list of some these disorders further on in the website.
Although a spinal cord injury is usually the result of an accident and can happen to anyone, certain
factors may predispose you to a higher risk of sustaining a spinal cord injury, including:
Spinal cord injuries affect a disproportionate amount of men. In fact, females account for only about
27% per cent of traumatic spinal cord injuries Globally as at June 2019.
Being between the ages of 16 and 45.
You're most likely to suffer a traumatic spinal cord injury if you're between the ages of 16 and 45.
The reason being these are the most active years for sport etc.
Being Older Than 60.
Falls cause most injuries in older adults.
Engaging in Risky Behaviour.
Diving into too-shallow water or playing sports without wearing the proper safety gear or taking proper
precautions can lead to spinal cord injuries. Motor vehicle crashes are the leading cause of spinal cord
injuries for people under 65.
Having a Bone or Joint Disorder.
A relatively minor injury can cause a spinal cord injury if you have another disorder that affects your
bones or joints, such as arthritis or osteoporosis, increases your chances of a spinal injury by 63%.
At first, changes in the way your body functions may be overwhelming. However, your rehabilitation
team will help you develop the tools you need to address the changes caused by the spinal cord injury, in
addition to recommending equipment and resources to promote quality of life and independence.
Areas Often Affected Include:
Your bladder will continue to store urine from your kidneys. However, your brain may not be able to
control your bladder as well because the message carrier (the spinal cord) has been injured.
The changes in bladder control increase your risk of urinary tract infections. The changes also may cause
kidney infections and kidney or bladder stones. During rehabilitation, you'll learn new techniques to help
empty your bladder.
Although your stomach and intestines work much as they did before your injury, control of your bowel
movements is often altered. A high-fibre diet may help regulate your bowels, and you'll learn techniques
to optimize your bowel function during rehabilitation.
Below the neurological level of your injury, you may have lost part of or all skin sensations. You could even suffer from
severe pain in certain areas but not in others this is described as Complex Regional Pain Syndrome a severe and
thoroughly painful side effect of CES. Therefore, your skin can't send a message to your brain when it's injured by
certain things such as prolonged pressure, heat or cold. This can make you more susceptible to pressure sores, but
changing positions frequently — with help, if needed — can help prevent these sores. You'll learn proper skin care
during rehabilitation, which can help you avoid these problems.
A spinal cord injury may cause circulatory problems ranging from low blood pressure when you rise
(orthostatic hypotension) to swelling of your extremities. These circulation changes may also increase
your risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus. Another
problem with circulatory control is a potentially life-threatening rise in blood pressure
(autonomic hyperreflexia). Your rehabilitation team will teach you how to address these problems if
they affect you.
Your injury may make it more difficult to breathe and cough if your abdominal and chest muscles are
affected. These include the diaphragm and the muscles in your chest wall and abdomen. Chronic
Obstructive Pulmonary Disease can be a common side effect from a spinal injury.
Although more related to Cervical and Thoracic, it is not unusual for anyone with a Lumber or Sacrum
injury to have COPD (Chronic Obstructive Pulmonary Disease), experts have noted in research that
approximately 43.7% of CES patients end up with COPD over a two year period 2015-2016, in a
***Government funded study by the German Research Institute into respiritory disorders and their
affiliation to spinal injuries. The research was a combined study of 1200 CES sufferers in association
with French and British Research Centres respectively over a 24 month period.) *** It must also be noted that CES is
commonly associated as stated with Lumbar and Sacrum, but the Thoracic is vunerabul, CRPS (Complex Regional
Pain Syndrome) can also be caused by CES or associated with CES due to the nerves that are affected.
This is more
reason for emergency department doctors to be consistently aware of the RED FLAGS. The people were NON-
SMOKERS , who have never smoked in their whole life.Your neurological level of injury
will determine what kind of breathing problems you may have. If you have a cervical and thoracic spinal cord injury,
you may have an increased risk of pneumonia or other lung problems. Medications and therapy can help prevent
and treat these problems.
Some people with spinal cord injuries experience one of two types of muscle tone problems:
uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle
Fitness and Wellness.
Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility may lead
to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes. A
dietitian can help you eat a nutritious diet to sustain an adequate weight. Physical and occupational
therapists can help you develop a fitness and exercise program.
Sexuality, fertility and sexual function may be affected by a spinal cord injury. Men may notice changes
in erection and ejaculation; women may notice changes in lubrication. Physicians specializing in urology
or fertility can offer options for sexual functioning and fertility.
In 81% of our survey responses expressed concern on their chronic pain on a daily basis. Then 38% had
to be "Dried Out", as they had become addicted to Opiates and other forms of addictive painkillers. The
most surprising return answer for Marijuana or it's oil. In 33% of cases used it as a pain relief. There
people who experience pain, such as muscle or joint pain, from overuse of particular muscle groups.
Nerve pain can just movement can cause crippling pain.
What feels like "Electric Shocks" was also an answer that was put in the survey returns, with almost
56%, saying it felt like they were being shocked. The pain of a spinal injury in any form is severe pain
and can occur after a spinal cord injury, surgery or especially in someone with an incomplete injury or
undiagnosed serious problem.
In 87% of people living today from approx. age sixteen onwards, has in some way had or suffered from
Depression in some form. This may be in a mild form, reactive, moderate or severe. Having Cauda
Equina Syndrome, and coping with all the changes to their life, family, friends etc., a spinal cord injury
such as CES brings brings with it, and living with constant pain causes some people to experience
extremes of depression CES has been in some instances "The Mountain of Suicide Disorders". It has been
noted in reputable Medical Journals that having CES and the diagnosis of such; if the sufferer has had it for more than
two years, and it is permanent; with Bowel,Bladder, Sexual Dysfunction, Anxiety and Panic Attacks, due to the
uncertainty of his/her problem, or future, will suffer a severe form of depression or even PTSD (Post Traumatic Stress
Car crashes are one of the most common causes of spinal cord injuries. Wear a seat belt every time you
drive or ride in a car. Make sure that your children wear a seat belt or use an age- and weight-
appropriate child safety seat. To protect them from airbag injuries, children under age 12 should always
ride in the back seat.
Check water depth before Diving;
To make sure you don't dive into shallow water, don't dive into a pool unless it's 12 feet (about 3.7
meters) or deeper,don't dive into an aboveground pool, and don't dive into any water of which you don't
know the depth.
Use a step stool with a grab bar to reach objects in high places. Add handrails along stairways. Put
nonslip mats on tile floors and in the tub or shower. For young children, use safety gates to block stairs
and consider installing window guards.
Taking a history is the most important part of the clinical examination of a back-pain patient.
Data obtained from history can be classified as follows:
# Earlier low back pain (onset of symptoms, visits at a doctor, earlier investigations, treatments and sick
# Current low back pain (onset, nature and intensity of symptoms, pain and sensory disturbances in the
lower extremity, perceived disability in daily living, investigations, treatments and their effectiveness)
# Other illnesses (operations, traumas, other musculoskeletal disorders, other diseases such as diabetes
and arteriosclerosis in lower extremities, diseases of the urogenital system, allergies, current
# Social history (couple relationship, family, education)
# Lifestyle (physical exercise, leisure time activities, smoking, use of alcohol and drugs, diet)
In the physical examination, the emphasis is placed on the detection of possible serious disease and
signs of nerve root compression as well as on the assessment of functional capacity.
Inspection of the Spine
Flattening of lordosis or scoliosis due to acute pain.
Bending of the lumbar spine; painful restriction may indicate the degree of severity.
Examination of the Mobility of the Back
Restriction in bending forward, backward and sideways may give a picture of the severity of the
back pain. Mobility of the spine and disturbances in the rhythm of motion provide an understanding
of the functional capacity of the back, and measuring the mobility is of significance in the follow-up
of the condition. The adjusted Schober test has moderate repeatability in measuring mobility.
The rotational motion of the spine and the mobility of the thorax become early restricted in ankylosing spondylitis.
Assessment of Signs of Nerve Root Compression
Straight Leg raising (SLR) and Lasègue's test are sensitive but non-specific tests for verifying
nerve root compression at S1 and L5 level. The tests are interpreted as positive when they cause pain radiating
from the back to the lower limb. Back pain itself or tightness behind the knee are not positive signs. n nerve root
compression, passive dorsiflexion of the foot during the SLR test increases the pain radiating from the back to the limb.
Crossing pain: Intensified radiating pain when raising the contralateral limb is a specific sign of
nerve root compression.
Muscular Strength of the Lower Limbs
Knee extension (L4 and partially L3 nerve root)
Dorsiflexion of the ankle (L5, partially L4 nerve root),
Dorsiflexion of the big toe (L5 root) and
Plantar flexion of the ankle (S1 nerve root)
Walking on heels (L5, partially L4 nerve root) or
On toes (S1 root)
Patella (L4 nerve root)
Achilles (S1 nerve root)
Babinski (upper motor neuron)
Patients with lower limb symptoms are examined for a sense of touch on the lower medial side of
the knee (L4 nerve root), medial (L5 nerve root), dorsal (L5 nerve root) and lateral (S1 nerve root)
sides of the foot.
Decreased muscle strength of both legs (paraparesis), enhanced or multiple tendon reflexes, and a positive
Babinski's sign suggests a need for neurological or neurosurgical assessment. Paraparesis is an indication for
immediate referral to a hospital with a possibility to urgently carry out an MRI examination and to perform potential
surgery. Rectal touch (tonus of the sphincter) and the sense of touch of the perineum should be examined
when Cauda Equina Syndrome is suspected (immediate referral).
Palpation of the vertebrae, sciatic nerves and lower extremitie. Numerous tender points and associated
symptoms may suggest e.g. fibromyalgia. Palpation or Doppler ultrasonography, or both, of the arteries
in the lower extremities in patients over 50 years of age with intermittent claudication.
Psychosocial Risk Factors
Psychosocial factors may impede recovery, prolong and complicate functional capacity problems and
alter pain behaviour. Factors suggesting an increased risk for chronicity ("yellow flags").
Classification of Diagnostic Urgency
Uncommon but serious causes of back pain should be recognized at an early stage.
Also, signs of the sciatic syndrome should be recognized.
Back symptoms can be divided into 3 categories on the basis of the history and the findings in clinical
1. Possible serious (tumour, infection, fracture, cauda equina syndrome) or specific disease
2. Symptoms in the lower limbs suggesting nerve root dysfunction (sciatic
syndrome, intermittent claudication)
3. Non-specific back pain: symptoms occurring mainly in the back without any suggestion of nerve root
involvement or serious disease.
Patients Cauda Equina
Syndrome Wrist Band
Dog with Cauda Equina Syndrome
Serious or Specific Diseases
Urination is not possible or there is faecal incontinence. The patient has excruciating pain and a fresh
paresis of some muscle group,laboratory tests. Laboratory tests are usually not needed. If there are
signs of a serious or specific disease, the basic laboratory tests usually needed include at least ESR, CRP,
basic blood count with platelets and basic chemical Urinalysis.
Normal finding in radiography does not exclude a serious condition. In primary health care, one should
refrain from ordering lumbar x-ray examinations in patients with acute or subacute non-specific low
back pain if there are no symptoms suggesting serious back disorder. If special diagnostic examinations
are needed, MRI is the first-line imaging investigation. CT is a substitute investigation when planning
for an emergency operation if MRI is not available is contraindicated (e.g. patient with a pacemaker).
ENMG may be useful in the situations listed below if about 4 weeks have elapsed since the onset of
nerve- based symptoms. Demonstration of nerve root injury in cases where the clinical picture is not
consistent with the evidence suggested by other investigation. The patient has neurological symptoms
and signs but imaging studies do not reveal nerve root compression. In chronic pain states the
investigation may be indicated as a part of the comprehensive assessment. The investigation is
sometimes useful in the prognostic assessment. In differential diagnostics, if entrapment or damage
of a nerve is suspected
The most common reason for an acute sciatic syndrome is intervertebral disc herniation.
If the indications for emergency investigations and surgery (see below) are not fulfilled,
conservative treatment of a patient with sciatica may be continued for 6 weeks before
consideration of surgery. Chronic sciatica is caused by spinal stenosis, i.e. narrowing of the
lumbar spinal canal or the intervertebral nerve root canals.
In sciatic syndrome caused by intervertebral disc herniation, the patient may move around and act
within the limits of pain. The motion may be recommended in order to maintain general vitality and
Sometimes severe sciatic pain necessitates bed rest; the so-called psoas position often relieves the
symptoms. Surgical discectomy provides faster pain relief than conservative management for carefully
selected patients with sciatica. There is no difference in the recovery of nerve root symptoms in patients
treated with microdiscectomy as compared to patients treated with conventional discectomy.
The active and intensive exercise started 4–6 weeks after disc surgery reduces pain, improves
functional status and speeds the patient's return to work without increasing the re-operation rate.
Indications for Emergency Investigations and Emergency Surgery
Cauda Equina Syndrome
Sensory disturbance of the perineal (saddle) area, tone and contraction of the anal sphincter
weakened Urinary retention, faecal incontinence
Progressive or sudden loss of strength in the extensor or flexor muscles of the ankle or in the thigh
muscle and, often, an associated sensory disturbance
Excruciating Pain and a Forced Body Position
A typical patient safety incident occurs if no adequate follow-up is organised and the progression of
symptoms is not taken into account quickly enough, in which case further investigations are delayed.
Acute low back pain (duration less than 6 weeks)
If the pain is tolerable, if there are no signs of neurological deficits and if, based on patient history
or findings, there is no reason to suspect a severe disease or a disease that requires specific treatment,
the treatment is carried out based on the patient history and clinical examination as symptomatic
therapy. The benign nature and the good spontaneous healing tendency of the condition are
emphasized to the patient. Sick leave is considered on an individual basis. Short sick leave is usually
sufficient. The aim is that thepatient returns back to work after the sick leave.
Avoidance of Bed Rest and Continuation of Regular Activities
The patient is advised to avoid bed rest. A short period of bed rest may be necessary due to intense back
pain but bed rest must not be considered as a treatment of back problems. The patient is encouraged to
continue ordinary daily activities or resume them as soon as possible. Pain allowing, the patient can use
his/her back within reasonable limits, and there is usually no need to restrictthe continuation of fairly
Due to its safety, paracetamol is the first-line analgesic, unless the patient has strong pain.
The patient should be instructed to take sufficiently large doses of paracetamol, but the daily dose
should not exceed 3000 mg. Two drugs I would not recommend because of the really adverse side
effects are Gabapentin (Lyrica), Pregabalin. Click here to go to our DRUG PAGES.
Nevertheless, paracetamol is not superior to placebo in alleviating low back pain or reducing the length of
pain NSAIDs, may be used to relieve acute back pain, if NSAIDs are used it should be noted as to
whether the patient has had or has stomach ulcers or problems associated with G.O.R.D.
(Gastro-oesophageal reflux disease or I.B.S ( Irritable Bowel Syndrome).
Their effectiveness in acute low back pain has been proved but it is not very high. Risk of intestinal,
cardiac and renal adverse effects is associated with the use of all NSAIDs;If paracetamol and an NSAID
are not sufficient, the effect of pain medication may be increased by adding an Opioid (codeine in a
combination product, Oral Morhine (Zeveradol),Tramadol, Oxycodon, Oxynorm).
Muscle relaxants are more effective than placebo, but they are no more effective than NSAIDs,
and the combination of muscle relaxants and NSAIDs brings no further benefit. Muscle relaxants cause
drowsiness or dizziness in almost one-third of the patients. A muscle relaxant is, however, an
alternative when NSAIDs are not suitable or cause adverse effects.
Physical Activity, Exercise Therapy and Supportive Corset
Light exercise that maintains fitness, such as walking, can be recommended.Active exercise therapy of
the back is not beneficial in the early stages of acute disease. Lumbar supports are probably not
effective in preventing the onset or recurrence of low back pain.
The effectiveness of manipulative therapy in acute low back pain does not differ from
other recommended treatments or sham treatment. If manipulative therapy is anyhow provided, it
should be performed by a person with appropriate educationand training and the patient have a form
of pain relief on board before the manipulation takes place. The appropriate people are a physician with
manual therapy training, orthopaedic manipulative therapist, licensed chiropractor, osteopath or
naturopath. This is NOT a recommended form of therapy, and may do more harm to the spinal cord
Therapy may be provided without prior imaging if there is no reason to assume that the
patient has a contraindication, which includes processes that soften the spine (e.g. advanced
osteoporosis, tumour,infection),ankylosing spondylitis, nerve root symptoms and clinically established
neurological signs, severespondylolisthesis (degenerative or spondylitis), recent trauma and
haemorrhagic diathesis. Lumbar traction is not effective in the treatment of low back pain or sciatica.
Subacute low back pain (duration 6–12 weeks)
If back pain is prolonged, further investigations for the confirmation of diagnosis, for the appraisal
of treatment and, if needed, for the drawing up of a comprehensive rehabilitation plan should be
performed after 6 weeks from the onset of symptoms.
Consultation with a physiatrist, orthopaedist, rheumatologist or neurosurgeo is often needed to assess
the diagnosis (special examinations), treatment, functional and working capacity and need for
rehabilitation. It is worthwhile to assess the patient's illness behaviour, exhaustion and depression in an
interview and by pain drawings and questionnaires that the patient fills in his or her e.g. Own History.
Treatment and Rehabilitation
Treatment modalities that aim at active participation by the patient and at the restoration of functional
capacity are emphasized in relation to symptomatic treatment when the goal is to prevent chronicity of
Thorough clinical examination, assessment of the patient’s situation and detailed instructions
(brief intervention) decrease the number of sick leaves and the occurrence of impairing symptoms in
subacute low back pain. Comprehensive and, if needed, multidisciplinary assessment of working
capacity may reduce the need for sick leaves. Extended sick leaves increase the risk of long-term
The basic approach to drug therapy is the same as with acute low back pain.
The adverse effects of analgesics in prolonged use must be considered especially in the elderly
who are at risk of developing serious peptic ulcer perforations as a complication of NSAIDs.
All NSAIDs can cause cardiovascular complications. Antidepressants have so far not been shown to be
better than placebo in the treatment of low back pain, but antidepressants should be used if the patient
is clearly depressive. Benzodiazepines should be prescribed with caution and antipsychotics are NOT
recommended for back pain.
Superficial heat provides a short-term reduction in pain and disability for patients with subacute back
pain. The effectiveness of manipulative therapy previously mentioned for sub-acute low back pain does
NOT differ from other recommended treatments or sham treatment.
Chronic back pain (duration over 12 weeks)
In the treatment of back pain that has lasted for more than 3 months, the same guidelines apply as
in the subacute phase. If needed, diagnostic investigations are carried out and a comprehensive plan
concerning treatment and rehabilitation is drawn up anew in cooperation of physicians from different
Intensive physical training as a part of multidisciplinary rehabilitation is beneficial. Restoring of
the working capacity requires measures directed at the work itself. Analgesics are used periodically
according to the intensity and occurrence pattern of the pain. Paracetamol, NSAIDs or a combination of
an NSAID and a weak opioid may be used as analgesics.
Adverse effects of prolonged use of NSAIDs should be kept in mind. Opioids alleviate chronic low back
pain but they have only a minor effect on functional capacity. Transdermal buprenorphine probably
alleviates chronic low back pain. Use of a strong opioid is decided and a therapeutic trial is carried out at
a multidisciplinary pain clinic or supervised by a specialist in pain management.
Other treatment modalities are to be tried before starting the use of a strong opioid, and they are
continued along with the opioid treatment. Earlier or current addiction problem or misuse, chronic
constipation, sleep apnoea and COPD are in most cases contradictions for opioid use.
The aim of the treatment is pain relief and improvement of functional capacity. Duloxetine may alleviate
chronic low back pain better than placebo, and its efficacy in chronic low back pain is comparable to
NSAIDs and tramadol.
Other antidepressants probably do not alleviate pain nor improve functional capacity.
Evidence of effectiveness is based on clinical trials made with tricyclic antidepressants and
serotonin reuptake inhibitors. Gabapentin and Topiramate may alleviate neuropathic sciatic pain, but as
warned above be aware of Gabapentin.
The effectiveness of manipulative therapy in chronic back pain is similar to conventional therapy
provided by a general practitioner and to analgesics, physiotherapy, exercise or back school. Lumbar
traction is NOT effective in the treatment of chronic low back pain.Transcutaneous electrical nerve
stimulation (TENS) may alleviate low back pain to some extent for a short period only, maybe 1-2 hours
at most. Acupuncture alone or in addition to other treatments may somewhat relieve chronic back pain
andimprove function in the short-term. Low-level laser therapy has not any clinically significant
beneficial effect in prolonged or chronic back pain. In severe pain syndromes, the patient may also be
referred to a specialized pain clinic for assessment and treatment.
Rehabilitation to Improve Functional and Working Capacity
Physical training and exercises that improve physical capacity reduce the number of sick
leaves. Sufficiently intensive and long-term resistance training (weight training) and exercise improving
the general physical condition (endurance training) reduce chronic back pain and improve
Multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach
improves functional capacity, work participation and quality of life and reduces pain in patients with
chronic back pain.
The back massage, when combined with therapeutic exercise and education, may alleviate chronic back
pain and improve function. Rehabilitation provided in a specialized rehabilitation facility may to some
extent reduce the number of sick leaves and the use of analgesics in 3 years following the rehabilitation
period. Improvement of the working capacity of a person with chronic back problems requires also
measures directed to the work itself. An approving attitude by the superiors and fellow workers towards
functional impairment promotes the maintenance of the working capacity of a person with back
Patient Educational Material
Giving patients the correct information may reduce pain and promote returning to work. The undulating character of
low back pain should be emphasized to the patient, and no freedom from symptoms should be promised. Back pain
often recurs but the intensity is, however, usually the same.
Scale of How Rare Cauda Equina Syndrome
in the Rare Disorders Field.
Another view of the impact of Cauda Equina Syndrome
***Awaiting final papers on the research to be reviewed.