Quelltext der Seite Benutzer:Seb12345678/Cauda equina syndrome Arbeitskopie

{{Importartikel}}
{{Infobox medical condition (new)
| name            = Cauda equina syndrome
| synonyms        =
| image           = Gray662Cauda.png
| caption         = The [[cauda equina]] begins at the end of the [[spinal cord]]
| pronounce       =
| width           = 150
| field           = [[Neurosurgery]], [[orthopedics]]
| symptoms        = [[Low back pain]], [[sciatica|pain that radiates down the leg]], numbness around the anus, loss of bowel or bladder control<ref name=Gar2011/>
| complications   =
| onset           = Rapid or gradual<ref name=Gar2011/>
| duration        =
| types           =
| causes          = [[Disc herniation]], [[spinal stenosis]], [[cancer]], [[major trauma|trauma]], [[epidural abscess]], [[epidural hematoma]]<ref name=Gar2011/><ref name=NIH2015/>
| risks           =
| diagnosis       = [[Medical imaging]] ([[MRI]], [[CT scan]])<ref name=Gar2011/><ref name=AO2014/>
| differential    =
| prevention      =
| treatment       = Surgery ([[laminectomy]])<ref name=Gar2011/>
| medication      =
| prognosis       = 20% risk of poor outcome
| frequency       = 1 in 70,000 a year
| deaths          =
}}

{{Infobox ICD
| 01-CODE = G83.4
| 01-BEZEICHNUNG = Cauda-(equina-)Syndrom
| 02-CODE = S34.3
| 02-BEZEICHNUNG = Verletzung der Cauda equina
}}
<!-- Definition and symptoms -->
'''Cauda equina syndrome''' ('''CES''') is a condition that occurs when the bundle of [[nerves]] below the end of the [[spinal cord]] known as the [[cauda equina]] is damaged.<ref name=NIH2015>{{cite web|title=Cauda equina syndrome|url=https://rarediseases.info.nih.gov/diseases/10987/cauda-equina-syndrome|website=Genetic and Rare Diseases Information Center (GARD)|accessdate=9 November 2017|language=en|date=2015}}</ref> Signs and symptoms include [[low back pain]], [[sciatica|pain that radiates down the leg]], numbness around the anus, and loss of bowel or bladder control.<ref name=Gar2011/> Onset may be rapid or gradual.<ref name=Gar2011/>

<!-- Cause and diagnosis -->
Ursache ist meist ein [[Bandscheibenvorfall]] im Bereich der [[Lendenwirbel|Lendenwirbel]].<ref name=Gar2011/> Andere mögliche Ursachen sind [[spinal stenosis]], [[cancer]], [[major trauma|trauma]], [[epidural abscess]], und [[epidural hematoma]].<ref name=Gar2011/><ref name=NIH2015/> Eine Verdacht auf Grundlage der Symptome wird durch  [[medical imaging]] wie [[MRI]] oder [[CT scan]] bestätigt.<ref name=Gar2011/><ref name=AO2014>{{cite web|title=Cauda Equina Syndrome-OrthoInfo - AAOS|url=http://orthoinfo.aaos.org/topic.cfm?topic=a00362|website=orthoinfo.aaos.org|accessdate=9 November 2017|date=March 2014}}</ref>

<!-- Treatment and epidemiology -->
CES wird operativ durch eine  [[laminectomy]] behandelt.<ref name=Gar2011/> Inkontinenz, [[Impotenz]] oder Taubheitsgefühle können trotz Operation bestehen bleiben.<ref name=Gar2011/><ref name=AO2014/> Bei ca. 20 % der Betroffenen verläuft die Erkrankung trotz Behandlung ungünstig.<ref name=Gar2011/> Es kommt zu ca. 700.000 Neuerkrankungen pro Jahr.<ref name=Gar2011>{{cite journal|last1=Gardner|first1=A|last2=Gardner|first2=E|last3=Morley|first3=T|title=Cauda equina syndrome: a review of the current clinical and medico-legal position.|journal=European Spine Journal |date=May 2011|volume=20|issue=5|pages=690–7|doi=10.1007/s00586-010-1668-3|pmid=21193933|pmc=3082683}}</ref> Das Syndrom wurde 1934 erstmals beschrieben.<ref>{{cite journal|last1=Chau|first1=AM|last2=Xu|first2=LL|last3=Pelzer|first3=NR|last4=Gragnaniello|first4=C|title=Timing of surgical intervention in cauda equina syndrome: a systematic critical review.|journal=World Neurosurgery|date=2014|volume=81|issue=3–4|pages=640–50|doi=10.1016/j.wneu.2013.11.007|pmid=24240024}}</ref>

==Krankheitsbild==
[[File:Saddle anesthesia.png|thumb|Approximate area of "saddle anesthesia" seen from behind (yellow highlight)]]
* Starke Rückenschmerzen
* [[Saddle anesthesia]] (siehe Diagramm), d.h., [[anesthesia]] oder [[paraesthesia]] involving [[Sacral spinal nerve 3|S3]] to [[Sacral spinal nerve 5|S5]] [[dermatome (anatomy)|dermatome]]s,<ref name=Larner2006>{{cite book|last=Larner|first=A.J.|title=A Dictionary of Neurological Signs|date=2006|publisher=Springer Science+Business Media, Inc.|location=[New York]|isbn=9780387262147|edition=2nd}}</ref>{{rp|26}} including the [[perineum]], [[external genitalia]] and [[anus]]; or more descriptively, numbness or "pins-and-needles" sensations of the groin and inner thighs which would contact a saddle when riding a horse.
* Inkontinenz,<ref name=Kraemer2009 />{{rp|216}} durch verminderte Versorgung der [[Schließmuskel]]. Detrusor weaknesses causing [[urine|urinary]] retention and post-void residual [[Urinary incontinence|incontinence]] as assessed by [[bladder scan]]ning the patient after the patient has [[urinated]].
* [[Sciatica]]-type pain on one side or both sides, although pain may be wholly absent
* Schwache Muskulator im Bereich der unteren Beine (häufig [[paraplegia]])
* Beidseitiges Ausbleiben des [[Ankle jerk reflex|Achilles (ankle) reflex]].<ref name=Kraemer2009>{{cite book|last=Kraemer|first=Juergen|title=Intervertebral disk diseases causes, diagnosis, treatment, and prophylaxis|date=2009|publisher=Thieme|location=Stuttgart|isbn=9783131495617|edition=3rd|author2=Christiane  |author3=Solodkoff, Michael von }}</ref>{{rp|216}}
* [[Sexual dysfunction]]
* Absent [[anal reflex]] and [[bulbocavernosus reflex]]
*[[Gait disturbance]]
Severe back pain, saddle anesthesia, incontinence and sexual dysfunction are considered "red flags", i.e. features which require urgent investigation.<ref name=GARDNER2010>{{cite journal|last=Gardner|first=Alan|author2=Gardner, Edward |author3=Morley, Tim |title=Cauda equina syndrome: a review of the current clinical and medico-legal position|journal=European Spine Journal|date=31 December 2010|volume=20|issue=5|pages=690–697|doi=10.1007/s00586-010-1668-3|pmid=21193933|pmc=3082683}}</ref>

==Ursachen==
After the conus medullaris, the canal contains a mass of nerves (the [[cauda equina]] or "horse-tail") that branches off the lower end of the spinal cord and contains the nerve roots from L1-5 and S1-5.  The nerve roots from L4-S4 join in the sacral plexus which affects the sciatic nerve, which travels caudally (toward the feet).  Compression, trauma or other damage to this region of the spinal canal can result in cauda equina syndrome.

The symptoms may also appear as a temporary side-effect of a sacral extra-dural injection:<ref name="Backache from Occiput to Coccyx Gerald L Burke, MD">{{Cite web|url=http://www.macdonaldpublishing.com/Chapter_8.html |title=Backache from Occiput to Coccyx| author=Gerald L Burke, MD |accessdate=2014-07-23 }}</ref>

===Trauma===
Direct trauma can also cause cauda equina syndrome. Most common causes include as a complication of lumbar punctures, burst fractures resulting in posterior migration of fragments of the vertebral body, severe [[Spinal disc herniation|disc herniations]], spinal anaesthesia involving trauma from catheters and high local anaesthetic concentrations around the cauda equina, [[penetrating trauma]] such as [[knife]] [[wound]]s or [[ballistic trauma]].<ref name="emed">{{cite web |url=http://www.emedicinehealth.com/cauda_equina_syndrome/article_em.htm#Cauda%20Equina%20Syndrome%20Causes |title=Cauda Equina Syndrome Causes |work=Cauda Equina Syndrome |first=Jason C |last=Eck |publisher=[[WebMD]] |accessdate={{Date|2009-04-25|dmy}} |date={{Date|2007-05-11|dmy}}}}</ref>

===Spinal stenosis===
CES can be caused by [[lumbar spinal stenosis]], which is when the diameter of the spinal canal narrows. This could be the result of a degenerative process of the spine (such as [[osteoarthritis]]) or a developmental defect which is present at birth. In the most severe cases of [[spondylolisthesis]] cauda equina syndrome can result.<ref name="emed"/>

===Inflammatory conditions===
Chronic spinal inflammatory conditions such as [[Paget's disease of bone|Paget disease]], [[neurosarcoidosis]], [[chronic inflammatory demyelinating polyneuropathy]], [[ankylosing spondylitis]] and chronic tuberculosis can cause it. This is due to the spinal canal narrowing that these kinds of syndromes can produce.<ref name="emed"/>

===Risikofaktoren===
No set [[risk factors]] have been clearly defined for CES at this point in time.<ref name=Schoenfeld2012/> Individuals most at risk for [[disc herniation]] are the most likely to develop CES. Race has little influence with the notable exception that African Americans appear slightly less likely to develop CES than other groups; similarly, men are slightly more likely to develop CES than women.<ref name=Schoenfeld2012/><ref name=Radcliff2011/><ref name=Small2005/> Middle age also appears to be a notable risk factor, as those populations are more likely to develop a herniated disc; heavy lifting can also be inferred as a risk factor for CES.<ref name=Schoenfeld2012/><ref name=Small2005/>

==Diagnose==
[[File:MRI of the lumbar spine with abscess in the posterior epidural space, causing cauda equina syndrome.jpg|thumb|MRI of an abscess causing cauda equina syndrome.]]
Examination for pain sensation, by pinprick, shows leg (lumbar nerves) [[analgesia]] with [[perineal nerve|perineal]] (sacral nerves) escape.  The maintenance of perineal sensation with absence of pain sensation over the lumbar nerve roots is typical for an extra-medullary and intra-thecal (outside the cord and within the dural sheath) process. Inability to walk, with this unusual sensory examination completes a triad of signs and usually represents spinal tuberculosis. The triad is paraplegia with lumbar loss of pain sensation and presence of perineal altered sensation.

Diagnosis is usually confirmed by an [[MRI scan]] or [[CT scan]], depending on availability.<ref name=":1" /> Bladder scanning and loss of catheter sensation can also be used to diagnose an onset of cauda equina syndrome and can aid diagnosis before MRI scanning.{{citation needed|date=March 2019}} Early surgery in acute onset of severe cases has been reported to be important.<ref name=":1" />

==Prävention==
Early diagnosis can allow for preventive treatment. Signs that allow early diagnosis include changes in bowel and bladder function and loss of feeling in groin.<ref name="emed2">{{cite web |title=Prevention |work=Cauda Equina Syndrome|url=http://www.emedicinehealth.com/cauda_equina_syndrome/page10_em.htm#Prevention |last=Eck |first=Jason C |publisher=[[WebMD]]|accessdate={{Date|2009-04-25|dmy}} |date={{Date|2007-05-11|dmy}}}}</ref> Changes in sensation can start as pins and needles leading to numbness. Changes in bladder function may be changes to stream or inability to empty bladder fully. If a person progresses to full retention intervention is less likely to be successful.{{citation needed|date=March 2019}}

==Behandlung==
The management of true cauda equina syndrome frequently involves surgical decompression. When cauda equina syndrome is caused by a herniated disk early surgical decompression is recommended.<ref name="herniation">{{cite journal |vauthors=Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP |title=Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes |journal=Spine |volume=25 |issue=12 |pages=1515–22 |date=June 2000 |pmid=10851100 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0362-2436&volume=25&issue=12&spage=1515 |doi=10.1097/00007632-200006150-00010}}</ref>

Cauda equina syndrome of sudden onset is regarded as a  medical/surgical emergency.<ref name=":1">{{cite journal|author=Shapiro S|date=February 2000|title=Medical realities of cauda equina syndrome secondary to lumbar disc herniation|url=|journal=Spine|volume=25|issue=3|pages=348–51; discussion 352|doi=10.1097/00007632-200002010-00015|pmid=10703108}}</ref> Surgical decompression by  means of laminectomy or other approaches may be undertaken within 6,<ref name="timelimit6hours">{{cite web |url=http://emedicine.medscape.com/article/249203-overview |title=Neurosurgery for Cauda Equina Syndrome |date=November 11, 2013 |publisher=[[Medscape]] |accessdate=18 March 2015}}</ref> 24<ref name="timelimit24hours2">{{cite web |url=http://www.cjem-online.ca/v3/n4/p285 |title=Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life |date=July 10, 2001 |publisher=[[Canadian Association of Emergency Physicians]] |accessdate=18 March 2015}}</ref> or 48 hours of symptoms developing if a compressive lesion, e.g., ruptured disc, epidural abscess, tumor or hematoma is demonstrated. Early treatment may significantly improve the chance that long-term neurological damage will be avoided.<ref name="herniation"/><ref name="timelimit24hours2"/>

Surgery may be required to remove blood, bone fragments, a tumor or tumors, a herniated disc or an abnormal bone growth. If the tumor cannot be removed surgically and it is malignant then radiotherapy may be used as an alternative to relieve pressure, with spinal neoplasms chemotherapy can also be used. If the syndrome is due to an inflammatory condition e.g., ankylosing spondylitis, anti-inflammatory, including steroids can be used as an effective treatment. If a bacterial infection is the cause then an appropriate course of antibiotics can be used to treat it.<ref name="EMIS">{{cite web |url=http://www.patient.co.uk/doctor/Cauda-Equina-Syndrome.htm |title=Cauda Equina Syndrome |last=Tidy |first=Colin |date=16 Nov 2009 |publisher=[[Egton Medical Information Systems]] |accessdate=11 January 2010}}</ref>

Cauda equina syndrome can occur during pregnancy due to lumbar disc herniation; age of mother increases the risk. Surgery can still be performed and the pregnancy does not adversely affect treatment. Treatment for those with cauda equina can and should be carried out at any time during pregnancy.<ref name="pregnancy">{{cite journal |vauthors=Brown MD, Levi AD |title=Surgery for lumbar disc herniation during pregnancy |journal=Spine |volume=26 |issue=4 |pages=440–3 |date=February 2001 |pmid=11224893 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0362-2436&volume=26&issue=4&spage=440 |doi=10.1097/00007632-200102150-00022}}</ref>

Lifestyle issues may need to be addressed post - treatment. Issues could include the person's need for physiotherapy and occupational therapy due to lower limb dysfunction. [[Obesity]] might also need to be tackled.<ref name="EMIS"/>

===Bowel and bladder control===
Rehabilitation of CES depends on the severity of the injury. If permanent damage occurs, then impairment in bladder and bowel control may result.<ref name="Bladdder_Bowel">{{cite web|title=Cauda Equina|url=https://www.bladderandbowelfoundation.org/cauda-equina-2/|website=Cauda equina - Bladder and Bowel Community|publisher=Bladder and Bowel Support Company Limited|accessdate=15 January 2017}}</ref> Once surgery is performed, resting is required until the bladder and bowel dysfunction can be assessed. [[Urinary catheterization]] may help with bladder control. Gravity and exercise can help control bowel movement (Hodges, 2004). [[Pelvic floor exercise]]s assist in controlling [[bowel movements]] (Pelvic Floor Exercises, 2010).{{full citation needed|date=May 2013}} These exercises can be done standing, lying, or on all fours with the knees slightly separated. Full recovery of bowel and bladder control can take as long as two years.

==Prognose==
The prognosis for complete recovery is dependent upon many factors. The most important of these is the severity and duration of compression upon the damaged nerve(s). Generally, the longer the time before intervention to remove the compression causing nerve damage, the greater the damage caused to the nerve(s).

Damage can be so severe that nerve regrowth is impossible, and the nerve damage will be permanent. In cases where the nerve has been damaged but is still capable of regrowth, recovery time is widely variable. Surgical intervention with decompression of the cauda equina can assist recovery. Delayed or severe nerve damage can mean up to several years' recovery time because nerve growth is exceptionally slow.

Review of the literature indicates that around 50-70% of patients have urinary retention (CES-R) on presentation with 30-50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression. CES-I with its more favourable prognosis may become CES-R at a later stage.<ref>ADH Gardner, EMH Gardner, TR Morley (2011). Cauda equina syndrome: a review of the current clinical and medico-legal position [http://www.springerlink.com/content/vgg64458052082g6/ European Spine Journal; Vol. 20 Number 5, May 2011]</ref>

==Epidemologie==
[[File:Spinal cord diagram KIN 412.png|thumb|The nerve roots extending from the lumbar spine are susceptible to compression, leading to CES. Intervertebral discs can be dislocated to different degrees, contributing to such compression.]]

Various etiologies of CES include [[fractures]], [[abscesses]], [[hematomas]], and any [[compression (physical)|compression]] of the relevant [[nerve roots]].<ref name=Gitelman2008>
{{cite journal  |last1=Gitelman|first1=A.  |last2=Hishmeh|first2=S.  |last3=Morelli|first3=B.N.  |last4=Joseph Jr.|first4=S.A.  |last5=Casden|first5=A.  |last6=Kuflik|first6=P.  |last7=Neuwirth|first7=M.  |last8=Stephen|first8=M.  |year=2008  |title=Cauda equina syndrome: a comprehensive review  |journal=The American Journal of Orthopedics  |volume=37|number=11|pages=556–562}}</ref> Injuries to the [[thoracolumbar]] spine will not necessarily result in a clinical diagnosis of CES, but in all such cases it is necessary to consider. Few epidemiological studies of CES have been done in the United States, owing to difficulties such as amassing sufficient cases as well as defining the affected population, therefore this is an area deserving of additional scrutiny.<ref name=Schoenfeld2012>
{{cite journal  |last1=Schoenfeld|first1=A.J.  |last2=Bader|first2=J.O.  |year=2012  |title=Cauda equina syndrome: an analysis of incidence rates and risk factors among a closed North American military population  |journal=Clinical Neurology and Neurosurgery  |volume=114  |issue=7  |pages=947–950  |doi=10.1016/j.clineuro.2012.02.012|pmid=22402198  }}</ref>

Traumatic [[spinal cord injuries]] occur in approximately 40 people per million annually in the United States, resulting from traumas due to motor vehicle accidents, sporting injuries, falls, and other factors.<ref name=Radcliff2011>
{{cite journal  |last1=Radcliff|first1=K.E.  |last2=Kepler|first2=C.K.  |last3=Delasotta|first3=L.A.  |last4=Rihn|first4=J.A.  |last5=Harrop|first5=J.S.  |last6=Hilibrand|first6=A.S.  |last7=Albert|first7=T.J.  |last8=Vaccaro|first8=A.R.  |year=2011  |title=Current management review of thoracolumbar cord syndromes  |journal=Spine  |volume=11  |issue=9  |pages=884–892 |doi=10.1016/j.spinee.2011.07.022 |pmid=21889419}}</ref> An estimated 10 to 25% of vertebral fractures will result in injury to the [[spinal cord]].<ref name=Radcliff2011/> Thorough physical examinations are required, as 5 to 15% of [[Trauma (medicine)|trauma]] patients have fractures that initially go undiagnosed.<ref name=Harrop2004>
{{cite journal  |last1=Harrop|first1=J.S.  |last2=Hunt Jr.|first2=G.E.  |last3=Vaccaro|first3=A.R.  |year=2004  |title=Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles  |journal=Neurosurgery Focus  |volume=16  |issue=6 |pages=19–23  |doi=10.3171/foc.2004.16.6.4}}</ref>

The most frequent injuries of the [[thoracolumbar]] region are to the [[conus medullaris]] and the [[cauda equina]], particularly between T12 and L2.<ref name=Radcliff2011/> Of these two syndromes, CES is the more common.<ref name=Radcliff2011/> CES mainly affects middle-aged individuals, particularly those in their forties and fifties, and presents more often in men.<ref name=Radcliff2011/><ref name=Small2005>
{{cite journal  |last1=Small|first1=S.A.  |last2=Perron|first2=A.D.  |last3=Brady|first3=W.J.  |year=2005  |title=Orthopedic pitfalls: cauda equina syndrome  |journal=American Journal of Emergency Medicine  |volume=23  |issue=2  |pages=159–163  |doi=10.1016/j.ajem.2004.03.006}}</ref><ref name=HHS>{{cite web  |publisher=[[United States Department of Health and Human Services]] Agency for Healthcare Research  |year=2012  |title=National and regional estimates on hospital use for all patients from the HCUP nationwide inpatient sample (NIS)  |url=http://hcupnet.ahrq.gov/HCUPnet.jsp  |access-date=2013-05-23  |archive-url=https://web.archive.org/web/20150301023658/http://hcupnet.ahrq.gov/HCUPnet.jsp  |archive-date=2015-03-01  |url-status=dead  }}</ref> It is not a typical diagnosis, developing in only 4 to 7 out of every 10,000 to 100,000 patients, and is more likely to occur proximally.<ref name=Schoenfeld2012/><ref name=Radcliff2011/><ref name=Small2005/> [[Disc herniation]] is reportedly the most common cause of CES, and it is thought that 1 to 2% of all surgical [[disc herniation]] cases result in CES.<ref name=Schoenfeld2012/><ref name=Radcliff2011/>

==Gesellschaftliche Auswirkungen==
[[File:Stats graphs KIN 412.png|thumb|upright=1.3|CES affects mainly middle-aged individuals. There is a significant cost associated with hospital admissions, as CES is considered an emergent condition.]]
CES is often concurrent with [[congenital]] or [[degenerative disease]]s and represents a high cost of care to those admitted to the hospital for surgery.<ref name=Radcliff2011/><ref name=HHS/> Hospital stays generally last 4 to 5 days, and cost an average of $100,000 to $150,000.<ref name=HHS/> Delays in care for cauda equina results in the [[English NHS]] paying about £23 million a year in compensation.<ref>{{cite news |title=Delayed spinal surgery costs £23m in compensation |url=https://www.hsj.co.uk/service-design/exclusive-delayed-spinal-surgery-costs-23m-in-compensation/7024296.article |accessdate=5 March 2019 |publisher=Health Service Journal |date=30 January 2019}}</ref>
{{-}}

==Quellen==
<references />
== Externe Links ==
{{Medical resources
|   DiseasesDB     = 31115
|   ICD10          = {{ICD10|G|83|4|g|80}}
|   ICD9           = {{ICD9|344.6}}
|   ICDO           =
|   OMIM           =
|   MedlinePlus    =
|   eMedicineSubj  = emerg
|   eMedicineTopic = 85
|   eMedicine_mult = {{eMedicine2|orthoped|39}}
| meshName        = Cauda+Equina+Syndrome
| meshNumber      = C10.668.829.800.750.700
}}
* {{MerckHome|06|093|c}}
{{Cerebral palsy and other paralytic syndromes}}
{{Neurotrauma}}
{{Lesions of spinal cord and brain}}

<nowiki>[[Kategorie:Erkrankung des peripheren Nervensystems]]</nowiki>

<nowiki>[[Kategorie:Rückenmark]]</nowiki>