Back Pain, Sciatica and Cauda Equina Syndrome

In this article we explore the difference between back pain, sciatica and cauda equina syndrome.

Generalised back pain

Back pain is a very common complaint in general practice. It is responsible for 7 to 10% of all consultations in general practice – which would imply a few hundred consultations every year for a full-time GP.

The great majority of back complaints are simply mechanical problems with the spine and associated soft tissues. A small proportion are due to nerve root compression, usually caused by prolapsed intervertebral discs. This usually manifests itself as ‘sciatica’ or pain running down the leg.

Sciatica

Sciatica, otherwise known as peripheral nerve root pain, is commonly seen in general practice. It is caused by extruded material from a disc prolapse pressing on the roots of peripheral nerves as they exit from the spinal canal between vertebrae.

In severe or persistent cases, referral may be made to an orthopaedic surgeon, but the problem is rarely an emergency. Consequences can include weakness and wasting of muscles, as well as pain and sensory disturbances. An absent ankle jerk reflex can occur.

Cauda equina syndrome

Cauda equina syndrome is, by contrast, rare. The average GP might see a case only every 15 years or more. Some GPs would not see a case in a whole professional career.

The cauda equina are the nerve tissue occupying the portion of the lower spinal canal below the dura. Compression of these nerves causes lower motor neurone signs (such as weakness, diminished reflexes, and decreased muscular tone) as well as bilateral symptoms. Importantly the sacral nerve outflows controlling bower/bladder function below the site of compression can be affected.

Acting on signs of cauda equina compression

Cauda equina compression might be expected to cause loss of bladder sensation and sphincter tone, resulting in urinary incontinence. It may also render the bladder unable to relax, causing retention of urine. In practice, any symptom of sphincter disturbance has to be taken seriously.

Signs and symptoms that suggest the need to consider cauda equina compression are:

• Bilateral sciatica – normally with pain or sensory disturbance below the knee
• Saddle anaesthesia
• Loss of bladder sensation and urinary incontinence
• Bowel sphincter disturbance

Failing to diagnose cauda equina syndrome

If medical practitioner fail to differentiate between back pain, sciatica and cauda equina syndrome, resulting in a delayed diagnosis of cauda equina syndrome, there could be grounds for a compensation claim.

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