In my twenty six months in residency I’ve been called perhaps a couple dozen times by staff in the emergency room for suspected cauda equina. The usual cabal of symptoms are:
- Back pain
- Possible bilateral lower extremity radiating pain
- Possible subjective weakness
- Bowel and/or bladder incontinence
It is the last one that usually gets those physicians and physician extenders who are triaging the patients in the emergency astiring.
The cauda equina are the nerves that continue, after the end of the spinal cord, down to the legs and the sacrum. They provide for movement of the legs, urination, defecation, feeling to the legs and the perineal and “saddle” regions. Compression of these nerves, the majority of the time by a centrally herniated disc, is a neurosurgical emergency and known as cauda equina syndrome. Symptoms of cauda equina syndrome include: numbness or tingling to the inner thighs and perineum thought of as the “saddle” region, weakness especially a foot drop, inability to urinate or deficate, the opposite to include bowel or bladder incontinence, back pain.
Now, I’m sure I don’t get consulted with the vast majority of individuals who come into the emergency room with back pain. Even those individuals who have pain radiating from their back into their legs. But as soon as someone complains that they’re involuntarily urinating that seems to almost guarantee me a call.
Often times it seems that those triaging these patients seem to believe that involuntary urination or defecation has some high sensitivity for identifying patients suffering from cauda equina syndrome when combined with other symptoms as described above.
It turns out however that very few of these individuals have true neurogenic bowel or bladders.
In the perhaps two dozen of these patients I’ve seen I think two or three of them have had true cuada equina.
The question is then, if there is not something organic making these individuals urinate or defecate involuntarily then what is going on with the majority of patients I see who complain of such?
As one paper describes it, I truly believe there is an association between low back pain and urinary incontinence,
A rare association between severe low back pain and urgency incontinence of urine, not explained on the basis of any conventional neurologic or genito-urinary pathology, should be recognized.
For an unexplained reason there is a described association between pain and involuntary urination and defecation. And indeed, in my limited experience the vast majority of patients with both back pain and either bowel or bladder incontinence do not have neurogenic bowels or bladders or cauda equina syndrome.
Indeed, amongst these cabal of symptoms, urinary retention is likely much more sensitive a symptom for cauda equina pathology. With all the back pain that must be seen i the emergency room it’s probably an important point for staff to realize.
I am in the same boat as you. I have seen exactly one case of true cauda equina syndrome (from a patient with known metastatic cancer) in the ER, but have been consulted at least 2 dozen times. Often times I believe the ER staff have never really examined the patient, but in a effort to improve turnover time, call with a hastily gathered story. This is a result of administrators who seem to care most about the tme a patient spends in the ER as opposed to the care they receive.
The true lack of understanding of spine issues by ER residents/staff is truly staggering. Cauda equina and central cord syndrome are very poorly understood by these groups. In addition, pseudosubluxation in neuro intact children is another common consult call.
While I am at it, let me add compartment syndrome to that list as well. Our ER has currently been on a binge of using a Stryker needle on every patient with a swollen, painful arm who had even minor trauma with no fractures. Nearly all of these patients are completely oriented, making this an extremely unnecessarily painful and quite dangerous procedure in the hands of someone with little knowledge of applied anatomy.
ER residents, as the future front line physicians/primary care providers, should be required to rotate on and obtain basic surgical/orthopedic/neurosurgical knowledge.
just get a postvoid residual.(or have the muffin down in the ED get it).
Defintley a PVR
That’s cleared my thoughts. Thanks for coigtiburnnt.
Back pain patients are frequently prescribed physical therapy for their spinal stenosis symptoms and, increasingly, the McKenzie Method for back pain is being recognized as particularly effective in correcting postural problems, easing chronic and acute back pain, and improving function. The McKenzie Method is also known as ‘mechanical diagnosis and therapy’ (MDT) and is a philosophy of active patient involvement and education whereby the patient learns to manage their pain themselves and to self-treat in some regards. Many physiotherapists use the McKenzie Method in their care of spinal stenosis patients as it can be helpful not only for back pain but also for neck and extremity problems caused by spinal abnormalities.
As a 36 year old female misdiagnosed with Cauda Equina Sydrome,I beg each of you to take CES seriously. It is one of the most horrible syndromes a person could ever experience. I am a nurse and I told the MD I thought I had CES- he ignored the RED FLAGS and did not do a CT or MRI. I am now left with permanent problems that are very personal. I beg each of you to take seriously saddle numbness and radiating back pain with leg weakness. One MRI could save a LIFETIME of hurt. ]
Thanks
I am a registered nurse retired due to a head injury in a bad MVA as a VN//I have 2 ruptired cervical disc in my neck and 1 bulging around C4//also have 2 in my back…I was offered chronic pain med in 2004 but have a high pain threshold and refused . However when the disc in my back ruptured and the spinal process went into the spinal canal the pain was unbearable/ Most recently Oct1 st of this year with head flex as a passenger we were rear ended and car was totaled and had concussion head and back injury..since then I am continuously incomtinent of urine around the clock and saturate multiple maxi pads yet in between I do void..i have no sensation of urine flowing out and now starting to have som bowel incontinence////I feel I need a neurological consult and repeat MRIs of neck and bacck..my first referral is to a neuropsychologist for head injury and an oB GYN urologist. During this process they checked me for a UTI..it showed large leukocytes after 5 days on Cupro UTI symptoms have not changed what soever////worried and often forgetfutl and wonder if I am not getting treated aggressively enough…lucille laroche
I actually have Cauda Equina and you are definitely right. I actually had a L4/L5 disc rupture in which I went to the ER right after and basically explained something felt like it snapped when I leaned down to pick up my toddler. I could still walk at that time but it felt weird. I also was starting to feel burning in my left foot going up my leg. I also told them I was constipated but had been for awhile and my doctors were saying it was from pain medication they had me on for the back pain which prior was less severe then it was that night. I explained I had degeneration in that area and had a neurologist I was seeing but I felt like it was difficult to walk. I also explained I had been having difficulty initiating urinating and was already in the week previous to a urologist who wanted me to keep my urine for a sample test. I had noticed I was urinating less frequently and had actually had couple nurses who thought I was refusing to give them a urine sample. I just couldn’t urinate as much or as easily. I definitely was having troubles initiating urine and voiding my whole bladder prior to the disc rupture. In my first visit they refused to run an MRI and did not admit me. They diagnosed me as sciatica. But I was still ambulatory that night. The next morning I finally heard from my family doctor who advised I go back to the ER but said I needed to go to the ER that was in network instead. I told her it was getting harder and harder to walk and basically was thinking I needed an MRI asap. She said she couldn’t order I have an MRI without seeing me but felt if my case was as I explained they should run an MRI. By this time I could only walk into the ER by having my mother walk holding her with my arm around her. The pain in my left foot and going up my leg was by then feeling as though it was on fire it burnt terrible. I exclaimed bladder and bowel symptoms, burning sensation, lower back pain which initially felt “as something snapped” upon lifting my toddler, inability to walk without holding on to my mother, actually having to crawl on my hands and knees otherwise now. I had also told that to my family doctor. Explained previous days trip to another ER where they thought it was sciatica but I had that when pregnant with my daughter and this didn’t feel the same. I explained the terrible burning sensation and said I had talked over the phone to my pain doctor who was the only doctor to call me back the night I felt the snap in my back. He had told me to take some pain medication I already had. I explained I wasn’t there to get pain relief but I thought it was ER urgent to get an MRI. I also explained I had a neurologist and had previous NEEd that showed degeneration in that area of my back. I explained the burning in my leg was worse than the pain in my back. I explained it hurt more than going into labor as it now felt like my leg was on fire. During my time in this ER I slowly couldn’t now walk even along another help hold me up. Basically the doctor was working on my Neurological exam and wanted me to stand on one leg. I tried and I couldn’t. I told him I can’t and the burning is too painful to even touch the floor. Explained all I could do was crawl to get myself around. The ER doctor then became angry with me saying I needed to attempt standing on one foot. I explained I couldn’t even stand up and tried over and over. I then became frustrated and scared and began crying. The doctor then left angrily saying I wasn’t trying. He then ordered a xray. They didn’t see anything abnormal. Then he had a group of nurses come in to try and lift me up to standing. I couldn’t stand up because by then my legs were so week I could only stand when they held all my weight up. The burning sensation was so extreme I couldn’t stop crying. And now basically they were lifting me up but then I would start to fall again and they would catch me. They then gave me pain medication and that was fine with me by then because my pain was so extreme. I just was trying to avoid it because I didn’t want the doctors thinking I was there for pills as I assume the previous ER thought. And actually they had mentioned my pain med usage and addiction due to being on the medication for such a long time. But anyone who ia prescribed such medications will develop tolerance and their bodies become addicted after taking pain meds over a long period of time. Then the next thing I know their trying to discharge me from the ER. I then said this makes no sense now I can’t walk even. Why am I being sent home when I can’t walk or stand up and feel like my legs on fire and my low back still hurts. It was then the doctor said it’s a muscular thing. We’re prescribing you another pain med that you don’t have tolerance too and also prescribing a steroid that will help you. I said okay but how am I to even get back home if I can’t walk or stand? I then starting more crying and basically was panicking as this made no sense. The doctor left and sent a nurse in with discharge info and medications. I explained I can’t walk I need a wheel chair I guess to take home because I can’t walk. The nurse said well then maybe you should call the police to help you. Finally a nurse brought in a wheelchair but said I could only use it to be taken to the car but then I was on my own. The doctor wouldn’t prescribe me a needed wheelchair. Upon getting home my mother had to find a neighbor and they worked together and lifted me out of the car onto a computer chair. Then pushed me down the sidewalk. Once in both lifted me up my stairway entry. I had told the ER staff I lived upstairs but waa basically advised if I truly needed help to call the police. Once in the medications and steroids were starting to alleviate the pain. He had also prescribed a muscle relaxant, since he believed it was muscular in nature. My mother had to lift me into my bed. By now she was staying with us due to all this as it was only my daughter and I, as I’m a single parent. My mom actually slept with me that night so she could help as needed. Upon waking up in the morning I excitedly noticed the pain and burning were gone. I then went to try and sit up and noticed I couldn’t feel anything from the waist down. I then felt like I really needed to urinate so Mom lifted me onto the computer chair and rolled me to the bathroom. I then found I couldn’t push out the urine at all. By then my feet were dropped already basically I was paralyzed and couldn’t use anything from the waist down. We called 911 for an ambulance. By then I had told my mom to basically stay with my daughter at the apartment as I had no clue what would happen this time since the doctor and nurses were so angry the day prior. After arriving I was told that I was taken into the exam room where the doctor accused me of lying. He said that I had walked to the bathroom by myself the previous day at the beginning of the exam. I told him no I hadn’t as the I hadn’t even been able to urinate as I’d mentioned was decreasing and was supposed to collect a sample for the urologist I’d mentioned. He basically then said something is wrong you don’t make any sense. I told him I now needed to urinate but couldn’t get it to come out when I’d tried. I asked if they could use a catheter and if I could please just get an MRI as something is seriously wrong. He finally said well I’ll have you take a Psych exam but your lying you can walk because you did walk yesterday by yourself upon first coming into the exam room. He then said if your not honest I’ll have to let them admit you into the Psych ward if you can’t pass the evaluation. I then called my mom telling her the situation and she said she had walked into the bathroom when we first were taken to the ER exam room. She then rushed to the ER and found someone to watch my daughter during all this. She was only 18 momtgs old then only weighed around twenty pounds or under. As when, I went to lift her it’s not like she was heavy, just fyi. But basically my mom told the doctor she had walked to the bathroom the previous day but I hadn’t. The Psych staff came I explained everything, which I passed theit eval. Finally the doctor ordered an MRI. They found my disc had ruptured and was causing nerve injury/impairment that was in need of urgent neurosurgery. They then had to have me transferred by ambulance to another hospital that its part of their same organization. I did get them to give me a catheter after the psych exam. Anyway once the surgery was complete. I still had no feeling or ability to move anything. The surgeon told me that basically if they would have listened to me and he could have done the surgery earlier I would have been able to walk after surgery and wouldn’t have been paralyzed. But yes I believe their is strong correlation to urinary problems. If you need any other info that might help you or others learn of the urgent care necessary in preventing cauda equina in disabling others or teaching staff of the signs and syndrome please email me back. Sorry it’s so long but I was making sure I explained things adequately.
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Re: Casey Baker…I am so very sorry that you had such idiots caring for you! And trust me, I’m a RN for 20 years and have seen quite a few uneducated/uncaring physicians/ nurses etc.
Are there people that abuse the system? YES. Is everyone? NO!
Trust me…I also feel for you as a fellow back patient on several medications…no matter who/what: people look at you differently when you start listing your meds/surgeries/ procedures/etc. (And yes, even to a fellow nurse…sometimes we get worse criticism at times)!
All I can say to patients/physicians/ nurses/aides/EMTs/etc….give each person a chance!!! IF after all the tests/exams/labs…and you find there is a DOCUMENTED history from hopping from one MD/ER/Pharmacy for the same meds etc…THEN you can start delving into it more with skepticism!
NOT ALL PEOPLE ARE BAD & NOT ALL PEOPLE ARE GOOD!
It’s our job/decree/reason for being the ones that people turn to for help!
And sorry to say, ER staff tend to get hardened faster than most! Not something to be proud of…or excuse; but as staff, we have to remember WHY we went in to do the job we signed up for….to help our fellow people!!
I am currently having these symptoms that Casey is explaining (but thank goodness not to such degree…yet). But I guarantee I won’t take No for an answer if I get blown off! If that person won’t help me, then there is always someone further up the food chain!
It’s sad we live in a society that you would have to do this to possibly get a positive reaction: but a letter to the CEO/President/Lawyer AND Board of Directors works wonders! And never forget to post your Positive and Negative outcomes on Health-grades/ internet/and complete the patient surveys!! It goes a long way… especially in today’s world because the patient (“customer”) is able to “shop around”/etc!!! And if the prospective customer/patient reads anything like this…I guarantee the next poor soul may think twice!
I’m sorry you had such a horrible outcome from such a horrible situation! God Bless you & your daughter…and your Mom!
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What a pleasure to find someone who idtieifnes the issues so clearly