The most common first symptom – 95% of patients will present initially with pain. May be present for up to two months before signs appear. May be localised in/around spinal column, or may be radicular (unilateral or bilateral) or both. Note that radicular pain from lower thoracic/upper lumbar spine may be interpreted as abdominal pain.
Features to look out for:
- Worsening over time
- Disturbing sleep
- Worse on straining at stool, coughing, or lying down, due to epidural plexus distension.
- May prevent sleep.
- May be associated with localised tenderness
Second most common symptom – 60 – 85% patients affected by time of diagnosis. May present as:
- Unsteady gait
- Rapid onset of difficulty in walking/standing/transferring – progresses over days or a few weeks
- Sudden deterioration in function noted by carers (in frail patients with advanced disease who may not be aware of the weakness)
Less common. Sensory symptoms may precede signs and may extend 1 – 5 dermatomes below the level of cord compression. May include:
- Decreased sensation
- Numbness of toes and fingers
Often a late consequence. Symptoms:
- Urinary retention
- Urinary or faecal incontinence
Cauda equina syndrome – differences in presentation
In CES, decreased awareness of passing urine/opening bowels is often a presenting symptom and can occur without a motor deficit and sometimes without pain. Urinary retention with overflow incontinence has a sensitivity of 90% and a specificity of 95%
Main clinical signs of CES are:
- Saddle anaesthesia (decreased sensation over buttocks/posterosuperior thighs/perineal region)
- Decreased anal sphincter tone
Recommended investigation is MRI of the whole spine (30 – 50% of people affected will have lesions in more than one area of the spine).
If only presenting symptom is pain with suspicious features, aim to speak to the designated MSCC co-ordinator within 24 hours (or the relevant team, if there isn’t an MSCC co-ordinator) and to arrange the scan within 7 days. If presents with pain + neurology, speak to co-ordinator or team immediately and aim for scan within 24 hours. Patients should be treated with a stat dose of 16 mg dexamethasone oral or subcut, followed by a short course of 8 mg bd, unless lymphoma is the suspected cause in which case steroids may impair diagnosis and are contraindicated.
If paralysis has been well established for more than a week, baseline performance status is poor, or patient is clearly at end of life, then it may be appropriate to treat palliatively rather than investigate/treat. In this case, consider steroids as above, but aim to wean off them within 14 days as no evidence of benefit from longer courses and they do have SEs.
(BMJ 2016; 353: i2539)