Nursing care of patient with cauda equina syndrome

Baby Blessy

Nursing Department, Kauvery Hospital, Salem, Tamil Nadu

Background

A 80 years old female presented with lower back pain and urinary incontinence. Patient was a known case of HCV positive, on antiviral and history of recent infective endocarditis/APLA.

On Examination

At admission patient was conscious and oriented, afebrile. Patient was unable to move the lower limbs, mild swelling and tenderness present in lower back.

GRBS: 129 mg/dl

MDCT Chest plain

  • Mild cardiomegaly with minimal pericardial effusion
  • Small air-filled cyst in left lingual superior and lateral basal segment of lower left lobe
  • No consolidation / ground glass opacities in bilateral lungs
  • Mildly dilated aortic root and ascending aorta.

MRI

  • Compression of Cauda equina

Cauda Equina

The cauda equina is a collection of spinal nerves that travel through the lumbar cistern as they leave the vertebral column. The spinal cord is shorter than the vertebral column, which causes nerves that innervate the lower limbs to bundle together as they travel down through the vertebral column to leave at the appropriate level. It is so named as it resemble a horse’s tail.

These nerves send and receive messages to and from the lower limbs and pelvic organs. Cauda equina syndrome (CES) occurs when there is dysfunction of multiple lumbar and sacral nerve roots of the cauda equina.

Cauda Equina Syndrome

Definition

A prolapsed disc occurs when the outer fibers of the intervertebral disc are injured, and the soft material known as the nucleus pulpous ruptures out of its enclosed space.

Causes

  • Herniated disc causes:
    • Age
    • Improper lifting
    • Whiplash-type injury
    • Repetitive activities that strain the spine
    • Sudden twisting or bending
  • Thoracic disc herniation:
    • Age
    • Degeneration
    • Trauma or injury to upper back
  • Lumbar disc herniation:
    • Disc degeneration
    • Repetitive mechanical stress
    • Obesity
    • Trauma or injury
    • Poor or heavy lifting
    • Connective tissue disorder
    • Congenital disorder

Symptoms

  • Cervical disc prolapse:
    • Weakness
    • Headache
    • Numbness or tingling
  • Thoracic herniated disc:
    • Upper back pain
    • Increased reflexes in legs
  • Lumbar herniated disc:
    • Lower back pain
    • Leg pain

Stages of Herniation

  1. Bulging
  2. Protrusion
  3. Extrusion
  4. Sequestration

Diagnostic Findings

  • History collection
  • Physical examination
  • Neurological check
  • Vital signs check
  • Weight monitoring
  • Lumbar spine area examination
  • X-Ray
  • CT Scan
  • MRI
  • Myelogram
  • EMG

Medical Management

  • Analgesic agents
  • Sedative agents
  • Muscle relaxants
  • Corticosteroids
  • Hot & moist compress
  • Non-steroidal anti-inflammatory drugs

Indications for Surgery

  1. Persistent pain & signs of sciatic tension after 2–3 weeks of conservative treatment
  2. Cauda equina compression syndrome – this is an emergency
  3. Neurological deterioration while under conservative treatment

Surgical Management

  • Intradiscal electrothermic therapy
  • Nucleoplasty
  • Discectomy / microdiscectomy
  • Chemonucleolysis
  • Laminectomy
  • Lumbar fusion
  • Disc arthroplasty

Nursing Diagnosis

  • Acute pain related to compression of nerve as evidenced by visual analogue scale
  • Risk of trauma related to temporary weakness of vertebral column and changes in muscle coordination as evidenced by balancing difficulty and weakness verbalized by the patient
  • Risk of constipation and urinary retention related to pain in lower back operated evidenced by redness & swelling on prolapsed site
  • Impaired physical mobility related to pain evidenced by severe pain during walking and standing, and inability to move independently
  • Disturbed sleep pattern related to pain and discomfort as evidenced by redness of eyes
  • Risk for pressure ulcer related to limited mobility as evidenced by bad positioning
  • Imbalanced nutritional status related to discomfort, pain as evidenced by weight loss
  • Self-care deficit related to immobility as evidenced by imbalance of muscle coordination
  • Anxiety related to ineffective individual coping as evidenced by tension and uncertainty
  • Knowledge deficit regarding disease condition related to lack of information as evidenced by questions, statement of misconception, request for information

Nursing Management

  • Bed rest
  • Cervical isometric exercises
  • Back care, pressure ulcer prevention
  • Ice application
  • Fall prevention
  • Anxiety & coping support
  • Sleep promotion
  • Diet and nutritional support
  • Range of motion exercise
  • Bladder training
  • Physical therapy – includes modalities to temporarily relieve pain (e.g. traction, electrical stimulation, massage)
  • Patient education on proper body mechanics
  • Weight control
  • Lumbosacral back support

Discharge Condition

On the day of discharge, her tenderness and back pain settled. There was a promotion of coping capabilities and self-confidence. She was discharged as per doctor’s advice.

Reference

  1. American Association of Neurological Surgeons (AANS)
  2. OrthoInfo – https://orthoinfo.aaos.org/diseases–conditions/cauda-equina

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