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A case of giant paraganglioma of the cauda equina is presented. This is only the second reported case in a minor and the first with magnetic resonance imaging. At 13 cm long, this is the largest paraganglioma of the cauda equina ever recorded.
AIMS: Data on lower urinary tract (LUT) function obtained in larger, systematically studied populations of patients with cauda equina lesions are limited. We report urinary function in 65 patients with chronic lesions. METHODS: A urinary function questionnaire was used, and neurological examination, quantitative electromyography (EMG) of the external anal sphincter (EAS) muscles, EMG assessment of the sacral reflex, and conventional urodynamic measurements were performed. RESULTS: Severe LUT dysfunction was found in 14%/15%, moderate in 27%/46%, and mild in 46%/39% men/women. Urinary symptoms interfered with daily life in 88%/92% and sexual life in 72%/67% of sexually active men/women. Symptoms of disturbed bladder emptying were the most common (95%/92% men/women), followed by urinary incontinence (56%/71%) and symptoms of overactive bladder (40%/56%). Perianal sensation was abnormal in 96%, EMG of the EAS muscle in 88%, and sacral reflex in 84% of patients. In 40%/17% men/women, a postvoid residual (>100 ml) was found. On filling cystometry overactive bladder was found in 21%/0%, reduced detrusor capacity in 9%/15%, and during voiding phase an acontractile detrusor or detrusor underactivity were found in 59%/85% men/women. Using multiple linear regression analysis, perianal sensory loss (P=0.0001) and female gender (P<0.02) had a significant positive effect on urinary incontinence score. CONCLUSIONS: Our study demonstrated significant LUT dysfunction, which disturbed the life of the majority of patients with chronic lesions of the cauda equina. Due to poor correlation between patients' symptoms and urodynamic findings cystometric surveillance is proposed in all patients with significant cauda equina lesions.
Nitric oxide is thought to be involved in the pathophysiology of radiculopathy attributable to herniated intervertebral disc, but its effect on ectopic firing, which is the main source of sciatica, has not been investigated. The authors investigated whether ectopic firing is elicited when the lumbar nerve root is exposed to nitric oxide using rats with and without cauda equina compression. A group of animals had partial L3 laminectomy, and a silicone tube was inserted in the epidural space to compress the cauda equina. A sham operation group and nontreated control group also were prepared. Seven days later, ectopic firing of the nerve root was recorded from the sural nerve. The animals with cauda equina compression showed significantly higher spontaneous firing rates than other groups. After a lumbar epidural administration of sodium nitroprusside, only the animals with cauda equina compression showed a marked increase in the firing rate. These results showed that the nerve roots became hyperexcitable under compression as indicated by increased spontaneous firing and marked sensitivity to nitric oxide. This mechanism may play an important role in the development of sciatica.
STUDY DESIGN: An animal model of lumbar spinal stenosis, in which the pathophysiology of this condition could be examined, was retrieved according to Delamarter's method. OBJECTIVES: The purpose of this study was to develop a reproducible animal model of lumbar spinal stenosis to further understanding of the long-term electrophysiologic changes, and to detect prognostic indices of the long-term anatomic and physiologic status of chronic compression of the cauda equina. SUMMARY OF BACKGROUND DATA: Somatosensory-evoked potentials and bulbocavernosus reflexes revealed abnormalities before neurologic signs and symptoms appeared. If delayed somatosensory-evoked potentials and bulbocavernosus reflexes were recovered with the lapse of time, neurologic findings showed gradual recovery. The loss of somatosensory-evoked potentials, bulbocavernosus reflexes, and neurologic, histological abnormalities occurred at 50% constriction of the cauda equina; at the same time, that was the critical point of possible recovery. METHODS: Four experimental groups, each containing six dogs, were studied. One group had a laminectomy of the sixth and seventh lumbar vertebrae only; these animals served as controls. In the three other groups, a laminectomy was performed, and the cauda equina was constricted by 25%, 50%, or 75% to produce chronic compression according to Delamarter's method. RESULTS: Somatosensory-evoked potentials and bulbocavernosus reflexes revealed neurologic abnormalities before the appearance of neurological signs and symptoms. Constriction of more than 50% was the critical point; it resulted in loss of evoked potentials, reflexes, neurologic deficits, and histological abnormalities. CONCLUSION: To accurately forecast prognosis of chronic cauda equina compression, the combined diagnostic study of somatosensory-evoked potential with bulbocavernosus reflex is recommended.
A 49-year-old male presented with a rare case of acute cauda equina syndrome secondary to a sequestrated lumbar disc mimicking pure conus medullaris syndrome. He consulted the emergency room of Otsu Municipal Hospital because saddle anesthesia and complete urinary retention which had started 2 days before admission. Additionally, he complained of constipation and impotence. Abnormality of the deep tendon reflexes, sciatica, and leg weakness were not organized. Emergent myelography and subsequent computed tomography revealed a sequestrated disc in the sacrum compressing the lower cauda equina, but not the conus medullaris. Emergent surgical decompression was performed about 60 hours after the onset. The patient almost fully recovered from sphincter dysfunction, impotence, and saddle anesthesia 3 months after the operation. When a syndrome like conus medullaris compression is encountered, the lower cauda equina should be examined as well as the conus level. Such cases require urgent diagnosis and treatment.
A paraganglioma of cauda equina region is extremely rare and except for secreting tumour, the pre-operative diagnosis of paraganglioma is very difficult. Two cases of non-functional paragangliomas of the cauda equina region are reported, one was attached to the filum terminale and the other to a rootlet looking very much like a vascular neurinoma. Both were successfully removed by surgery. An extensive review of the literature permits one to find 77 other cases. The clinical, radiological, pathological (ultrastructural and immunohistochemical) features and surgical findings of all theses cases are discussed. Surgery remains the treatment of choice. No effect of radiotherapy on recurrence prevention has ever been demonstrated.
Spinal cord or cauda equina compression secondary to epidural metastasis rarely develops in patients with endometrial carcinoma and the early signs and symptoms of compression can therefore be inadvertently overlooked. A 78-year-old patient who developed bone metastasis with destruction of the fifth lumbar vertebral body and blockage of the cauda equina at L-4, L-5 as the only sites of metastasis is reported. This occurred 2 years after initial treatment of a stage IB, well-differentiated, grade I, adenosquamous carcinoma of the endometrium. The patient remains alive, with good neurological function and free of metastatic disease, 2 1/2 years following vertebrectomy, radiation therapy, and adjuvant Provera (medroxyprogesterone acetate) therapy. This patient represents the only case of metastatic endometrial cancer with cauda equina compression in the literature in whom long-term disease-free follow-up has been noted.
STUDY DESIGN: A case report is presented. OBJECTIVE: To describe a case of a spinal epidural lipoma presenting as a cauda equina compression syndrome secondary to trauma. SUMMARY OF BACKGROUND DATA: Epidural lipomas are rare lesions that present as back pain with progressive neurologic symptoms. METHODS: A patient presenting with cauda equina compression after an injury was investigated and treated surgically. The clinical follow-up period was 3 years. RESULTS: Imaging of the lumbar spine showed an extradural mass compressing the cauda equina. The patient underwent emergency surgery, and an adipose mass was removed. Neurologic recovery was observed and maintained 3 years after surgery. CONCLUSIONS: Previously asymptomatic epidural masses such as lipomas can present with neurologic deficit after trauma. Appropriate imaging can help in the diagnosis and management of such cases.
This case report contains a description of a 61-year-old patient who presented with a progressive truncal ataxia 22 years after complete removal of a small paraganglioma of the cauda equina. Magnetic resonance imaging of the neuraxis revealed a large cystic lesion in the cerebellar midline, three small cortical-to-subcortical nodular tumors in the posterior fossa, and local recurrences of the paraganglioma of the cauda equina. Pathological examination showed the cerebellar midline lesion to be a paraganglioma, most likely a metastasis from the cauda equina localization.
The consequences of signs of emergency compression of cauda equina in combination with a normal lumbar myelography are reported in 19 patients. Two of them had a tumor and a herniated disc, respectively, in the thoracic spine discovered by a second myelography. One patient was considered to have a hysterical paresis. In 3 patients the symptoms were attributed to diseases not related to the spine. Thirteen patients recovered spontaneously. We conclude that the prognosis for patients with signs of compression of the cauda equina is favorable provided the myelography is normal; surgical exploration is then not indicated. However, if severe unexplained symptoms persist and computed tomography is normal, myelography of the thoracic spine should be considered.
The rare occurrence of a paraganglioma of the cauda equina is described. The correct diagnosis was made only retrospectively after examination of a recurrence nine years after initial surgery. Paragangliomas have not been mentioned in large tabulations of spinal cord tumors, perhaps reflecting the fact that it is only within the last decade that such tumors have been recognized in this unusual location. A literature review has revealed six cases of paraganglioma of the cauda equina reported since 1970. An awareness of the possibility of a paraganglioma intimately associated with the spinal cord as well as the histopathologic appearance are the bases of a correct diagnosis. These tumors are histopathologically similar to paragangliomas in conventional locations, exhibit ultrastructural granules and may, as in the current case, also demonstrate argyrophilic granules.
Early postmyelographic cauda equina syndrome in an asymptomatic young acromegalic is presented. The patient was asymptomatic for more than 1 yr despite myelographic evidence of acquired spinal stenosis at the L2-L4 level. Radiographic and/or myelographic findings should be clinically correlated. It is postulated that, in acromegaly, the combined simultaneous bony apposition-remodeling resorption mechanism is involved in the spine as platyspondyly, hyperostosis of spinous processes and vertebral scalloping to counteract soft tissue hyperplasia within the spinal canal; entrapment myelopathy, cauda equina syndrome and/or radiculopathy are ascribed to a soft tissue edematous mechanism superimposed on congenital or degenerative spinal stenosis, traumatic or postoperative spondylolisthesis, postmyelographic and/or postoperative arachnoiditis and a traumatic swollen or protrused intervertebral disc.
The clinical and imaging features of a paraganglioma of the cauda equina are presented. A peridural anesthesia revealed the cauda equina compression syndrome in a 68 years old man who presented first with a urinary retention. Total surgical excision of a long round-shaped encapsulated tumor was uneventful. Macroscopically this lesion filled up the spinal canal and resembled to a meningioma. It was firmly attached to the filum terminale. Adjacent large arterialized vessels visible on MRI were spared. Although the diagnosis could be evoked pre-operatively on some suggestive patterns on the MRI, the pathological findings finally confirmed the diagnosis of paraganglioma. Along with the evidence of specific light microscopic features, the use of an immunocytochemical demonstration of synaptophysine in these tumors allows a confident diagnosis to be made.
This review was undertaken to determine the efficacy of using dorsal root entry zone (DREZ) lesions to treat intractable pain caused by trauma to the conus medullaris and cauda equina. Traumatic lesions of this area are unique in that both the spinal cord and the peripheral nerve roots are injured. Although DREZ lesions have been shown to relieve pain of spinal cord origin in many patients, they have been shown not to relieve pain of peripheral nerve origin. Therefore, 39 patients with trauma to the conus medullaris and cauda equina who underwent DREZ lesioning for intractable pain were reviewed retrospectively. The results of this review demonstrate the efficacy of DREZ lesions in these patients. At a mean follow-up period of 3.0 years, 54% of patients were pain-free without medications, and 20% required only nonnarcotic analgesic drugs for pain that no longer interfered with their daily activities. Better outcomes were noted in patients with an incomplete neurological deficit, with pain having an "electrical" character, and with injuries due to blunt trauma. Operative complications included weakness (four patients), bladder or sexual dysfunction (three), cerebrospinal fluid leak (two), and wound infection (two), but overall, 79.5% of patients (31 of 39) were without serious complications. Complications were limited to patients with prior tissue damage at the surgical exploration site and were most prevalent in patients who underwent bilateral DREZ lesions. In conclusion, this preliminary report suggests that DREZ lesions may be useful in combating intractable pain from traumatic injuries to the conus medullaris and cauda equina, with some risk to neurological function that may be acceptable in this group of patients.
PURPOSE: To describe a rare adverse outcome resulting from lumbar epidural steroid injections for the treatment of chronic lower back pain. CLINICAL FEATURES: We report a case of staphylococcus aureus meningitis and cauda equina syndrome following a series of epidural steroid injections for chronic back pain. Although rare, bacterial meningitis following epidural analgesia has been reported, but epidural steroid injections have not been associated with either bacterial meningitis or cauda equina syndrome. The causal relationship between epidural steroid injections, bacterial meningitis, and cauda equina syndrome is discussed. CONCLUSION: A through pre-procedure assessment with attention to the neurologic examination and signs/symptoms of infection is essential.
UNLABELLED: Paragangliomas are unusual neuroendocrine tumours, rare in the cauda equina and filum terminale. Due to their low frequency, no classical patterns and dual immunophenotype, may be misinterpreted as others neoplasms more frequent in this site. It is our aim to report a case of paraganglioma of the cauda equina and filum terminale (PGCCFT), standing out it's histological-immunohistochemical pattern, differential diagnosis, prognostic and treatment. We reviewed the clinical presentation, NMR features and morphological aspect of one PGCCFT, diagnosed in the ABC Medical Center's Surgical Pathology Department of Mexico City. Report of the case: 26 years old man, who had been suffering a low lumbar pain for one year before he came to our hospital. The NRM showed heterointense lesion in the level of first and second vertebra, suggesting ependymoma. The tumor was totally resected. Histologically it was papillary, the chief cells have stained with chromogranin, synaptophysin, and cytokeratin. The few sustentaculars cells were S100 positive. The patient have haven a favorable course. CONCLUSIONS: The certainty and differential diagnosis of paragangliomas of the cauda equina and filum terminale needs correlation between histological pattern and immunophenotype, the last must be considered in the peculiar context of this anatomic region.
Ventral and dorsal nerve roots can be identified in the cauda equina partly by a combined anatomical-electrical method. The cross-section of dorsal and ventral roots in the lower thoracic and lumbo-sacral range are somewhat spherical with the exception that the large roots are more elliptically shaped. Ventral roots consist mainly of one subgroup, dorsal roots normally of several. The larger diameter of ventral and dorsal roots are about 1 mm in the lower thoracic region. It rises to about 2 mm between L 3 and S 1 and then reduces again. The dorsal roots are always slightly bigger than the ventral ones. Nerve roots can be easily identified by their rootlets. More ventral roots can be identified without having access to the rootlets by continued counting from the last distinguished rootlet, knowing that the last thick root is the S 1 root. The reduction in size from the first ventral sacral root (2 mm) to the second (1.2 mm) is so pronounced that it can normally be recognized. Dorsal roots also reduce in size in the sacral range. But because each dorsal root consists of several subgroups they cannot be counted up and identified. Of some anatomical help is the following: the dorsal roots emerging from the conus medullaris form on each side a bulk, and the top of this bulk consists mostly of the S 1 root and the medial falling phase of the S 2 root. In the liquor free cauda equina about 5 cm away from the medullaend the two bulks fall to the middle and touch each other.(ABSTRACT TRUNCATED AT 250 WORDS)
MRI findings for a patient with Miller Fisher syndrome (MFS) are reported. A 25-year-old woman presented with blephaloptosis, double vision, and gait disturbance after antecedent upper respiratory infection. Neurologic examination on admission revealed bilateral blephaloptosis and restriction of extraocular movement. She was unable to maintain an upright posture, nor able to walk because of severe truncal ataxia. Mild limb ataxia was also seen. The tendon reflexes were generally absent and she had hypesthesia in her shoulder and upper limbs. On the next day, her eyes became fixed in the central position. Based on these characteristic symptoms, she was diagnosed as having MFS and underwent plasmapheresis therapy six times. Although ataxia gradually reduced, ophthalmoplegia did not improve and severe symmetric facial nerve palsy appeared. Antiganglioside IgG antibodies (anti-GQ1b and GD1b) were detected in the sera on admission. Spinal fluid examination on day 18 revealed 5 cells/microliter and protein 171 mg/dl. T1-weighted images with Gd-DTPA on day 15 demonstrated enhancement of the posterior nerve roots of the cauda equina. MRI on day 32 revealed swelling and enhancement of the bilateral oculomotor nerves, as well as the facial nerves and the abducens nerves. Marked improvement of ophthalmoplegia followed high dose intravenous immunoglobulin therapy. Gd-enhanced MRI after recovery showed no enhancement of the cauda equina, nor the cranial nerves. These findings well correlated with her clinical features. Although abnormal Gd-enhancement of the cranial nerves or cauda equina in several neurological disorders has been documented, similar findings have been rarely reported in MFS. In our patient, IgG anti-GQ1b and GD1b antibodies were detected and the distribution of Gd-enhanced lesions was compatible with the distribution of the involved gangliosides. We suggest that contrast enhanced MRI is useful for identifying affected cranial nerves and cauda equina nerve roots. In addition, MRI may play a significant role in disclosing the pathophysiology of this disease.