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)