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PubMed2006

Cord and cauda equina injury complicating elective orthopedic surgery.

STUDY DESIGN: Presented is a case series of 3 patients, all of whom developed neurologic deficits due to cord or cauda equina compression during elective extremity surgery. OBJECTIVES: To identify characteristics of presentation that may differentiate cord or cauda equina injury from peripheral nerve palsy following extremity surgery and to establish the value of early decompression in patients with intraoperative injury. SUMMARY OF BACKGROUND DATA: Intraoperative neural injury has been described in association with epidural and spinal anesthesia, with cervical or spinal manipulation in the face of instability, and with ischemic injury suffered during extensive vascular repair. However, it has not been described after uncomplicated elective extremity surgery. METHODS: Retrospective review of a case series. RESULTS: In 1 patient, intraoperative paraplegia occurred after routine shoulder arthroscopy. A second patient underwent elective bilateral total hip replacement and awoke with neurologic deficits in both lower extremities, then went on to develop an acute cauda equina syndrome. The third patient developed a central cord syndrome following an otherwise uncomplicated total hip replacement. Two patients were initially misdiagnosed as peripheral nerve palsies. All 3 patients had preexisting spinal stenosis at the level of neural injury. All underwent routine positioning and anesthetic care but were recognized as having a neural injury early in the recovery period. In only 1 case was the diagnosis of a cord level injury made immediately. All 3 patients were treated with urgent surgical decompression once diagnosed. Following surgery, neurologic symptoms improved in each of the 3 patients allowing early mobilization. CONCLUSIONS: Spontaneous neural injury is rare but can occur to the anesthetized patient. Neurologic examination should be routinely performed in the recovery room; and if significant neurologic deficits are seen, investigative workup should not be delayed. If an intraspinal lesion is identified, immediate decompression may offer favorable results. Neurologic deficits should not be dismissed as peripheral palsies without careful evaluation.

Adult↗
PubMedDate not supplied

Cauda equina syndrome: a neurologist's perspective.

The cauda equina region is prone to injury from a variety of causes, all of which have to be considered during the performance of spinal anesthesia. This article reviews these causes and discusses their approach.

Cauda Equina↗
PubMed1992

Paraganglioma of the cauda equina.

A case of paraganglioma of the cauda equina is presented. Usually reported to be benign with good prognosis, the present patient had a somewhat different course. The behaviour of the tumour was unusual, with rapid recurrence seen within first month of surgery. The need for total surgical excision and role of adjuvant radiotherapy is highlighted.

Cauda Equina↗
PubMed1986

Late urodynamic findings after surgery for cauda equina syndrome caused by a prolapsed lumbar intervertebral disk.

Bladder function was evaluated urodynamically in 17 patients operated on 2 to 3 years previously for the cauda equina syndrome caused by a prolapsed lumbar intervertebral disk. Of the patients 10 (59 per cent) reported the bladder function to be normal, while the other 7 had symptoms of obstruction or incontinence. Urodynamic findings were normal in 4 patients (24 per cent). In 3 patients (18 per cent) no detrusor contraction could be demonstrated in the pressure-flow electromyography study. Two patients (12 per cent) used the detrusor and straining during voiding. Cystometry showed an unstable detrusor in 3 patients (18 per cent). The remaining 5 patients (29 per cent) had either an increased bladder capacity or a decreased maximum flow rate. Neurological findings were normal in 2 patients (12 per cent). All of the patients with a decentralized detrusor had defective perianal sensation but detrusor contraction could be demonstrated in 3 who also had sensory impairment in the perianal region. Bladder function can be disturbed seriously in cauda equina patients without symptoms and, thus, all patients with the cauda equina syndrome should be tested urodynamically. An emergency operation seems to be capable of reducing late disturbances in bladder function. Regeneration of the autonomous nerves supplying the bladder and genitals may require an interval of several months to years.

Adult↗
PubMed1983

Cauda equina paraganglioma.

Two paragangliomas resected from the cauda equina had similar morphology, both containing cells having dense core secretory granules with no associated sustentacular or supporting cells. The cells were arranged in characteristic lobules that were surrounded by basement membrane and separated by a fibrovascular stroma. This tumor, although rarely found elsewhere in the central nervous system, does occur in the region of the filum terminale, and causes a clinical syndrome typical of tumors in that area.

Adult↗
PubMed1996

Paraganglioma of the cauda equina. A case report and review of the literature.

A 59-year-old man presented with clinical evidence of a primary tumor of the cauda equina region. It was well circumscribed and was completely removed by neurosurgery. Routine staining showed that it had structural similarities to an ependymoma, but immunohistochemistry with antisera to synaptophysin, NSE, chromogranin-A and PGP 9.5 proved it to be a neuroendocrine tumor, i.e. a paraganglioma. We propose the use of endocrine markers in cases with tumors of the cauda equina to differentiate a paraganglioma from an ependymoma. Paragangliomas appear to have a better clinical outcome than ependymomas. Recurrence after surgery for a paraganglioma in the cauda equina region, especially if it is encapsulated, is rarely encountered.

Biomarkers, Tumor↗
PubMed1989

[Spinal subarachnoid hemorrhage due to neurinoma of the cauda equina].

A case of neurinoma of the cauda equina which showed spinal subarachnoid hemorrhage was reported. A 39-year-old man was admitted to our hospital because of left lumboischialgia, on August 7, 1987. Myelography disclosed a round mass at L2, and cerebrospinal fluid was slightly xanthochromic. MRI demonstrated a round isointensity mass by T1 weighted image, and slightly high intensity by T2 weighted image. On August 26, 1987, the patient developed sudden onset of headache, but his headache disappeared under medication. On August 27, 1987, laminectomy L1-3 and total removal of the tumor were carried out. At operation, marked subarachnoid hemorrhage was discovered. He was discharged with slight hypesthesia of the dermatome of left S2.

Adult↗
PubMed1970

Extraneural metastases in ependymoma of the cauda equina.

A case of ependymoma of the cauda equina, presumably originating from the filum terminale in a girl aged 17 at the onset of illness, eventually developed remote metastases in the lungs, pleura, and one para-aortic lymph node. This case is compared with three other previously reported examples. The unusual features in the present instance were (1) the total length of the clinical history, amounting to 29 years; (2) the development, six years after the removal of the original spinal tumour, of another ependymomatous mass in the fourth ventricle, interpreted as a rostral metastasis that seeded via the cerebrospinal fluid; and (3) the demonstration of anaplastic cytological changes at the primary site, interpreted as the result of irradiation. The salient aspects of this and the three other reported cases are briefly reviewed, and the pathway of distant dissemination, resulting from venous permeation at the primary site, is emphasized.

Adolescent↗
PubMed1999

[Cauda equina tumors in adults].

Large series of cauda equina tumors in adults are seldom reported. This study was based on the 231 cases collected in the French neurosurgery units for the congress of the Société Française de Neurochirurgie in October 1996. Schwannomas were the most frequent benign tumor in this series, followed by ependymomas. Very few malignant tumors were recorded, usually malignant neurinomas nearly always arising in patients with neurofibromatosis. Some other rare tumors were also observed including paragangliomas. This series confirms the contribution of pre-therapeutic neurological status to functional prognosis. All schwannomas can be cured while ependymomas and paragangliomas may recur after a very long delay. Surgery must be as complete as possible since adjuvant therapies have proven to have little efficacy. This type of tumor requires a very long follow-up. Prognosis is good for hemangioblastoma. When present, abnormal sphincter function is an argument for poor prognosis. It may appear after primary surgery or more often after treatment of recurrence.

Adult↗
PubMed1993

Discogenic compression of the cauda equina: a surgical emergency.

The syndrome of cauda equina compression due to central disc rupture is uncommon but its importance greatly transcends its rarity. Key symptoms and signs are bilateral leg pain, weakness or numbness (although unilateral symptoms or even absence of leg pain do not exclude the diagnosis), perineal numbness and, in 60% of patients, bladder and bowel incompetence ranging from dysuria to vesical and anal sphincter paralysis. Diagnosis and treatment are often delayed due to lack of recognition of the condition and failure to appreciate the surgical imperative for its treatment. At the present time myelography is the one essential investigation, although this may become supplanted in time by magnetic resonance imaging. Arrangements for myelography should be planned so that immediate operation can be commenced following the procedure. The onset of disc rupture may be acute and massive and result in intradural sequestration of disc fragments in 7.5% of cases. Intradural exploration and/or transdural sequestrectomy avoids traction on already compromised nerve roots and is often safer than extradural sequestrectomy. The onset of bladder paralysis is a most important indication for immediate surgery. The cases presented show that there is a highly significant difference in the outcome of those cases operated on within 24h of bladder paralysis compared to those operated on after this period.

Adult↗
PubMed1996

Effects of OP-1206 (prostaglandin E1) on nerve-conduction velocity in the dog cauda equina subjected to acute experimental compression.

The effect of OP-1206, a prostaglandin E1 derivative, on cauda equina function was analyzed in a model for acute cauda equina compression in the dog. An inflatable balloon was placed under the lamina of the seventh lumbar vertebra in the dog and muscle action potential area (MAP area) and nerve-conduction velocity (NCV) were monitored during 2 h of compression and 1.5 h of recovery. OP-1206 was infused systemically at three concentrations. Only the highest concentration (30 ng/kg/min) of OP-1206 could prevent the reduction in NCV. However, this concentration had no similar effect on the MAP area. The data suggest the potential therapeutic use of prostaglandin E1 analogues for the future treatment of intermittent claudication.

Action Potentials↗
PubMed1978

[Knotted neurinoma or plexiform neurofibroma in the cauda equina (author's transl)].

A rare case of a plexiform neurofibroma in the cauda equina is reported. In literature single cases are described as "redundant or knotted nerve roots", but mainly without microscopic description. Our patient was complained of bilateral pain in the legs for several years. The myelogram revealed a complete block with a serpentine-shaped structure. In operation we found a elongated and redundant nerve root in the cauda equina. The biopsy showed a plexiform neurofribroma. The operative technique is described.

Aged↗
PubMed1988

Lumbosacral stenosis and injury of the cauda equina.

Idiopathic (congenital) L/S stenosis, acquired (degenerative) L/S stenosis, and traumatic injury to the vertebral column caudal to L6 often produce signs of neurologic dysfunction attributed to compression, displacement, entrapment, or trauma of the cauda equina. Clinical signs vary from animal to animal and depend upon which roots of the cauda equina are involved and the nature of the compromise. An understanding of the anatomy of the area and an appreciation for the functional relationship between the cauda equina and structures innervated are essential for accurate evaluation, workup, diagnosis, treatment, and outcome.

Animals↗
PubMed2004

Cavernous angioma of the cauda equina: case report.

We present a rare case of cavernous angioma of the cauda equina and review the eleven cases available in the literature. A 44-year-old woman presented with low back pain and sciatica associated with bowel and bladder dysfunction and motor weakness of the lower extremity. The MRI revealed an enhancing, heterogeneous and hyperintense intradural lesion compressing the cauda equina roots at the L4 level. Laminectomy at L3-L4 and total removal of the tumor were performed without additional neurological deficit. Pathology revealed a cavernous angioma. The literature, clinical presentation, technical examinations, and treatment are reviewed.

Adult↗
PubMed2004

[Cauda equina syndrome following intrathecal dibucaine].

We report three cases of cauda equina syndrome following spinal anesthesia with dibucaine. In two cases, the lumbar puncture was repeated and additional doses of dibucaine were administered to obtain adequate sensory blockade. In the last case, spinal anesthesia worked well with single injection of dibucaine. In all cases patients complained of varying degrees of bladder and bowel dysfunction, perineal sensory loss and lower extremity motor weakness on the next day, and the diagnosis of cauda equina syndrome was made. With only one case, the symptom disappeared four months later, but the rest of the patients suffered from sensory disturbance and defecation for more than four months after the surgery. One possible cause is a direct neurotoxic effect of high concentration dibucaine due to its maldistribution within the subarachnoid space. We have to consider the neurotoxicity and dose of the local anesthetic for obtaining a safer method and for preventing this complication.

Adult↗
PubMed1992

Penetrating injuries restricted to the cauda equina: a retrospective review.

Thirty-three patients with penetrating injuries to the cauda equina were admitted to Ben Taub General Hospital (1980-1989). Thirty received gunshot injuries, and three had stab wounds. The average age was 30 years, and 30 patients were male. All patients had been admitted within 1 hour of injury and received spine films, myelography, or computed tomography. Deficits were "complete" if total loss of function existed and were "incomplete" if any function remained below the level of injury. Improvement at the end of followup was defined as any recovery of motor strength or regaining of a unilateral sensory level. Twenty-nine (88%) patients had incomplete neurological deficits. Of these, 15 (52%) had surgery, and of this patient group, 7 (47%) improved, 7 (47%) showed no change, and 1 (6%) worsened. Fourteen (48%) patients with incomplete deficits were treated conservatively; 10 (71%) improved, and 4 (29%) had no change. Four patients (12%) had complete deficits, 3 of whom had surgery, and all improved. One patient with a complete deficit was treated conservatively and did not improve. Ten (34%) patients had bowel or bladder dysfunction, and none improved regardless of the type of treatment. Complications (cerebrospinal fluid leak, pseudomeningocele, or wound infection) occurred in 5 (28%) operative patients and 1 (7%) conservatively treated patient. Early neurosurgical intervention for penetrating injuries of the cauda equina may be beneficial but carries an increased risk of complication.

Adult↗
PubMed2005

Penetrating spinal injury with wooden fragments causing cauda equina syndrome: case report and literature review.

STUDY DESIGN: Case report. OBJECTIVE: To report an unusual case of cauda equina syndrome following penetrating injury to the lumbar spine by wooden fragments and to stress the importance of early magnetic resonance imaging (MRI) in similar cases. SUMMARY OF BACKGROUND DATA: A 22-year-old girl accidentally landed on wooden bannister and sustained a laceration to her back. She complained of back pain but had fully intact neurological function. The laceration in her back was explored and four large wooden pieces were removed. However 72 h later, she developed cauda equina syndrome. MRI demonstrated the presence of a foreign body between second and third lumbar spinal levels following which she underwent emergency decompressive laminectomy and the removal of the multiple wooden fragments that had penetrated the dura. RESULTS: Post-operatively motor function in her lower limbs returned to normal but she continued to require a catheter for incontinence. At review 6 months later, she was mobilising independently but the incontinence remained unchanged. CONCLUSION: There are no reported cases in the literature of wooden fragments penetrating the dura from the back with or without the progression to cauda equina syndrome. The need for a high degree of suspicion and an early MRI scan to localise any embedded wooden fragments that may be separate from the site of laceration is emphasized even if initial neurology is intact.

Adult↗
PubMed2006

Herniated intervertebral disc associated with a lumbar spine dislocation as a cause of cauda equina syndrome: a case report.

To report a case of Cauda Equina syndrome with the completion of the paralysis after the reduction of a L4L5 dislocation due to a herniated disc. Although several articles have described a post-traumatic disc herniation in the cervical spinal canal, this is not well known in the lumbar region. A 30-year-old man was admitted to the emergency room with blunt trauma to the chest and abdomen with multiple contusions plus a dislocation of L4-L5 with an incomplete neurological injury. After an emergency open reduction and instrumentation of the dislocation, the patient developed a complete cauda equina syndrome that has resulted from an additional compression of the dural sac by a herniated disc. In a dislocation of the lumbar spine, MRI study is mandatory to check the state of the spinal canal prior to surgical reduction. A posterior approach is sufficient for reduction of the vertebral displacement, however an intra-canal exploration for bony or disc material should be systematically done.

Adult↗