Epidemiology
CES is a rare but serious condition.[6] Estimates of the overall incidence of CES are around 1 to 2 cases per 100,000 population per year.[8][9] One systematic review reported an incidence for CES of 0.3 to 0.5 per 100,000 per year in asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working-age population.[10]
An estimated overall prevalence of CES of between 1 in 30,000 to 1 in 100,000 population has been reported. The point prevalence of CES in patients presenting with low back pain has been estimated as 0.04% to 0.08% in primary care, 0.27% in secondary care, and 0.40% in tertiary care.[9][10] One systematic review calculated that, of adults with suspected CES in a neurosurgical or spinal unit, 19% of those imaged were found subsequently to have radiological and clinical CES.[10]
Risk factors
The most common cause of CES overall. CES has been reported to be associated with 1% to 6% of all cases of lumbar disc herniation requiring surgery.[6]
Vertebral fracture, disc rupture, or extra-axial haematoma due to trauma may result in CES.[2] This is usually within 24 hours of trauma.
Injury to the cauda equina can occur either during spinal surgery (from direct damage to the nerves) or postoperatively (due to haematoma). CES usually develops within 24 hours of surgery, but may not become apparent until later.[6]
Characterised by inflammation with accumulation of pus within the epidural space, which may compress the thecal sac and press on the cauda equina. Risk factors for spinal epidural abscess include diabetes mellitus, intravenous drug use, spinal trauma or surgery, indwelling spinal catheter, local or systemic infection, and immunosuppression (e.g., due to long-term systemic corticosteroid therapy).[12]
Anticoagulation therapy increases the risk of haematoma, particularly after neuraxial anaesthesia or spinal surgery.[6]
The most common cause of thecal sac compression in older people. The progress of spinal stenosis is slow, and symptomatic CES affects only a relatively small number of patients with this condition.[2] However, asymptomatic spinal stenosis is a common incidental finding in older people and in most cases is not of clinical significance.[13]
A primary or (more commonly) metastatic spinal cord tumour below the first lumbar vertebra may compress the thecal sac and press on the cauda equina.[2] Typically, symptoms are of insidious onset, although this is not always the case (e.g., sudden vertebral body collapse due to weakening of bone by the tumour).
Low back pain with other symptoms in a patient under 50 years is more likely to be indicative of acute CES than in older patients.[14]
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