A.  Urgent MRI

B.   CT head

C.   X-ray of leg

D.  X-ray of spine

E.   Admit the patient

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The correct answer is A.

• This patient is experiencing symptoms of cauda equina syndrome. The cauda equina is formed by nerve roots caudal to the level of spinal cord termination. Cauda equina syndrome (CES) is caused by compression of the nerves, causing one or more of the following: bladder and/or bowel dysfunction, reduced sensation in the saddle (perineal) area, and sexual dysfunction, with possible neurological deficit in the lower limb (motor/sensory loss, reflex change). This is a medical emergency and requires an immediate referral for investigation. Early diagnosis is essential. Early surgical decompression is crucial for a favourable outcome in most patients with CES. MRI scan is the preferred investigation to confirm the diagnosis and determine the level of the compression and any underlying cause which in this case could be due to spinal metastases thus it is the correct answer. 

Why not B?

• CT head is not the most suitable method here as the level of compression is better visualized on an MRI scan.

Why C or D?

• X-rays are unreliable and less sensitive when it comes to cord compression. Therefore, these answers are not correct. 

Why E?

• Admitting the patient would be done after the MRI scan has been performed to confirm the diagnosis. He would need to go under surgery as urgent surgical spinal decompression is indicated for most patients to prevent permanent neurological damage. If surgery cannot be performed, radiotherapy may relieve cord compression caused by malignant disease.

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