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The clinical, radiological and pathological features of a paraganglioma of the cauda equina are described, including magnetic resonance imaging features. The literature is reviewed and discussed.
Cavernous angiomas are comparatively rare vascular malformations in the central nervous system. Their location at the spinal level is rare, being but 3 to 16% of such vascular malformations. Among spinal intradural cavernous malformations most are intramedullar, the extramedullar type being less frequent. We have only came across five cases in the literature of intradural extramedullar cavernous angiomas affecting the cauda equina. We present a new such case with acute onset and later chronic evolution affecting the cauda equina through an intradural cavernous malformation at the level.
Twenty-seven cases of complete subarachnoid block discovered through myelography are analysed with regard to the causes of obstruction, the neurologic symptoms, and the cerebrospinal fluid. The neurologic signs in cases of cauda equina compression, most often caused by massive disc protrusions (20 patients), vary considerably and rarely correspond to the gross myelographic findings. Bilateral neurologic symptoms of any degree with or without sphincter disturbance were observed in 21 among 27 cases and are signs of cauda compression. In contrast to cases of sciatica with unilateral root compression and radicular symptoms neurological symptoms are not reliable in revealing the site of the lesion in cases of massive central disc protrusions. Therefore radiculography (myelography of the cauda equina) is necessary for diagnosis. In addition to the well-known elevation of the spinal fluid protein and pleocytosis, the presence of neutrophile granulocytes is frequently found (11 of 20 cases) in cytological analysis.
We present the radiological features of a 42-year-old man with long-standing inactive ankylosing spondylitis (AS), demonstrating that arachnoiditis is a cause of a cauda equina syndrome (CES) in this disease. CT showed a dorsal arachnoid diverticulum causing scalloped erosion of the laminae, and punctate and curvilinear dural calcification. MRI revealed adhesion and convergence of the cauda equina dorsally into the arachnoid pouch, causing the dural sac to appear empty canal. To the best of our knowledge, dural calcification on CT is a new finding in AS, which may be related to the CES. Our findings support the hypothesis that chronic adhesive arachnoiditis with subsequent loss of meningeal elasticity may be the main cause of CES in AS.
AIM: To review the management and clinical outcome of 10 patients, presenting to a single centre with symptoms and signs of spinal cord or cauda equina compression secondary to epidural metastatic disease from a testicular germ cell cancer. METHODS: Clinical data regarding presenting history, physical examination, staging investigations, treatment and clinical outcome were retrospectively obtained from patient records. RESULTS: Eight patients exhibited neurological deficits at the time of initial presentation of germ cell cancer or as a first manifestation of relapse following dog leg irradiation. Four of these cases were managed with chemotherapy alone, with excellent neurological recovery, whilst four underwent decompressive laminectomy--in three cases prior to referral and in one case after commencing chemotherapy. Five of the eight patients relapsed. Four required further chemotherapy (high dose in two cases). The remaining patient underwent thoracic surgery, with resection of teratoma differentiated. Six of the eight patients are currently alive and disease free. Two patients had chemorefractory disease and died, though one was treated in the pre-cisplatin era. Two patients presented with cord compression as a feature of disease relapse following chemotherapy, and were managed with radiotherapy alone in an attempt to achieve local disease control and limit neurological dysfunction. However, both subsequently died with progressive disease. CONCLUSION: Epidural spinal cord or cauda equina compression is a rare complication of metastatic germ cell cancer, which can be successfully managed in chemo-naive patients with good neurological outcome.
Hemangioblastomas are dysontogenetic tumors of the central nervous system. They occur as single tumors or multiple. Hereditary and sporadic cases are known. The most frequent localisations are the retina and cerebellum but they can be localized at any site of the neuraxis. In a 37 year old male patient a solitary hemangioblastoma of the cauda equina was demonstrated by myelography and totally removed by laminectomy. In the literature 17 cases of isolated hemangioblastomas of the cauda equina are described. A further 16 cases of were observed within a Lindau-complex, 10 of which remained without symptoms. For diagnosis of the type of tumor a myelography is rarely sufficient. The only successful therapeutic measure is total surgical removal.
The clinical findings and operation results in two series of patients with medial prolapse of an intervertebral disc with total or partial occlusion of the spinal canal are reported. In one of the series (30 patients) symptoms of cauda equina compression, with bladder and rectal disturbances, were present, and in the other series (28 patients) these symptoms were absent. The observation period was five years (median value). The late results are evaluated in relation to the time interval between the onset of symptoms and operation. In the series with caudal compression syndrome, sphincter disturbances persisted in 10 patients, six of whom underwent operation during the first week after the onset of symptoms. The prognosis was most favourale when the symptoms developed slowly. Seventeen patients have returned to work. The importance of early operation in patients with classical compression syndrome of the cauda equina is emphasized. In the series without caudal compression syndrome, the symptomatalogy varied. The duration of symptoms was strikingly long. Only 19 patients are able to work. The others are prevented from working by persistent backache and leg pains, and in four cases by pareses of the extremities. In these cases also the importance of early operation is stressed.
Paget's disease of bone affects a significant percentage of adult and elderly patients. Although generally asymptomatic, the inflammatory changes and hypervascularity of the affected bone is prone to pathologic fracture and resultant hemorrhage. Epidural hematoma is well-described with vertebral fractures and can present as acute cauda equina syndrome. We describe a case in which an elderly female with Paget's disease sustained a minor coccygeal fracture and developed local hemorrhage and edema, which caused a sacral plexopathy that presented identical to acute cauda equina syndrome. A literature review will follow.
BACKGROUND CONTEXT: Lymphangiomas, benign hamartomatous lesions of the lymph tissue, result from a failure of lymph channels to communicate with the venous system or normal lymph channels. Previously, two reports described lymphangiomas arising in the peripheral nerve (ulnar nerve and posterior tibial nerve). PURPOSE: To report a rare case of cystic lymphangiomas of the cauda equina not previously reported. STUDY DESIGN: Case report. PATIENT SAMPLE: A 56-year-old Japanese man. METHODS: Not applicable. RESULT: The patient recovered from most of his symptoms after tumor extirpation. He had no symptoms at a 5.8-year follow-up. CONCLUSIONS: We believe this is the first case report of lymphangiomas originating from the cauda equina, which was effectively treated by surgery.
Metastatic involvement of the cerebro-spinal fluid (CSF) pathway in oligodendrogliomas is not uncommon; however, symptomatic involvement of the spinal cord is very rare: less of 10 cases have been published. To our knowledge, an intracranial oligodendroglioma presenting with symptoms of drop metastases in the cauda equina has never been reported. We report a case of 67-year-old woman who after 1 month of severe low back and legs pain developed symptoms of raised intracranial pressure. A spinal cord MRI showed multiple intradural nodular lesions at the level of the cauda equina, a MRI of the brain showed an intraventricular brain tumor. The histopathological diagnosis of both surgically treated lesions was anaplastic oligodendroglioma. The choices adopted in planning diagnostic and therapeutical procedures are discussed. The importance of the clinical and neuroradiological data in the diagnosis is stressed. Pathophysiology of the seeding of intracranial tumours via the cerebrospinal fluid is reviewed.
The myelographic pattern of diffuse meningo-vascular infiltration of the cauda equina is presented as characterized by marked enlargement of the nerve root shadows and occasional nodulation. This appearance, when coupled with appropriate clinical and laboratory findings, allows a specific diagnosis to be made.
This article describes a case of the cauda equina syndrome associated with ankylosing spondylitis. The typical myelographic features and the computerized tomography (CT) scan of the lumbar spine are included. The CT scan may aid in elucidating the pathogenesis of the disorder.
The role of urgent surgery in improving the outcome of cauda equina compression following lumbar central disc prolapse remains controversial. Some series claim improved outcome from emergency decompression whilst others have found no benefit. Resolution of this issue is important because the opportunity to reverse neurological impairment may already have been lost by the time of hospital admission. Removal of a large central disc prolapse can be considerably more difficult than routine discectomy, and may require an extensive exposure. When performed under less than optimal conditions, as often exists in the emergency setting, surgery may even add to rather than alleviate morbidity. This article reviews the pathophysiology of cauda equina syndrome, its definition, and the controversies surrounding management. Where urinary retention with overflow incontinence extists at presentation we believe that urgent decompression confers no benefit.
Cauda equina syndrome (CES) is defined as the constellation of symptoms that includes low-back pain, sciatica, saddle anesthesia, decreased rectal tone and perineal reflexes, bowel and bladder dysfunction, and variable amounts of lower-extremity weakness. There are several causes of this syndrome including trauma, central disc protrusion, hemorrhage, and neoplastic invasion. In this manuscript the authors reviewed CES in the setting of both primary and secondary neoplasms. They examined the various primary tumor types in this region as well as those representative of metastatic spread. Both surgical and nonsurgical management in this setting were studied.
BACKGROUND: This paper addresses a specific experimental design to suggest the possible role of the greater omentum in the modulation of pain in rats. METHODS: Fifteen male Sprague-Dawley rats weighing between 275 and 325 g were selected. The animals were randomized and then anesthetized with pentobarbital (35 mg/kg) and divided into three groups: (1) sham: laparotomy followed by laminectomy with exposure of the spinal epidural space (n=5); (2) transposition of pedicled omentum (n=5) to the cauda equina epidural space; and (3) transposition of pedicled omentum (n=5) to the cauda equina intradural space. The animals were operated upon and once more randomized by an independent investigator, so that the groups were thought to be similar during post-operative testing. The latency of paw withdrawal to noxious heat stimulation was tested and the values (seconds) plotted for 1, 3, 6, 11, 14 and 30 days after surgery. Randomization codes were open after the animals were euthanized. The analysis of variance (ANOVA) without replication was applied for each of the dataset and comparisons established among the different study groups involved. The omenta were removed and standard immunohistochemistry was performed for gamma-amino-butyric acid (GABA), serotonin, calcitonin-gene related protein (CGRP), vascular intestinal peptide (VIP) and Met-enkephalin. RESULTS: The response to high heating rates of stimulation favored intradural versus sham and epidural omental transpositions. High and low noxious heat stimulation suggested an increased threshold to noxious stimulation after the 3 and 30 days of omental transposition. In the low heat stimulation series, responses were comparatively higher than in the sham animals. CONCLUSIONS: The suggested increased threshold of response to noxious stimulation after transposition of the greater omentum onto the spinal cord of rats suggested a novel role of the omentum and a potential future application in the clinical arena.
We describe the case of a 31-year-old woman who was first treated for a pigmented choroid plexus papilloma of the fourth ventricle. Ten year later, she developed a new tumor in the region of the cauda equina. This second neoplasm contained areas of papillary ependymoma that displayed phosphotungstic acid hematoxylin-positive glial fibers and immunoreactivity for glial fibrillary acidic and S-100 proteins. Areas of ependymoma merged with others that displayed the appearance of a paraganglioma, including lobules and nests of chief cells immunoreactive for neuron-specific enolase, synaptophysin, chromogranin, and serotonin. Satellite cells, but not chief cells, stained for glial fibrillary acidic and S-100 proteins. Electron microscopy showed features of both ependymal and paraganglionic differentiation, including intercellular lumina with microvilli, junctional complexes, cell processes with closely packed filaments, and dense core granules. Our case represents a rare example of a cauda equina neoplasm with simultaneous ependymal and paraganglionic differentiation. To our knowledge, this is the first described example of a tumor of this region showing features of both ependymoma and paraganglioma.
Some new ultrastructural observations are documented in paraganglioma in the cauda equina region. These include the presence of nerve fibers in the tumor capsule, clear vesicles and tubulo-vesicular structures in some cytoplasmic processes in the tumor, fenestrated endothelial cells, and numerous tubular bodies in some endothelial cells.
Two cases of claudication of the cauda equina due to ischaemia secondary to distal aortic disease in the Small Aorta syndrome are reported. The association has not been previously reported and the appropriate management is discussed.