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A unique intradural neoplasm of the cauda equina is presented. The tumor was composed of two neoplastic populations: ependymal cells in a papillary pattern and ganglion cells occurring individually or in clusters. The patient remains asymptomatic 1 year after resection of the tumor.
A case of staphylococcal subdural abscess at cauda equina level region in a 42 year old male patient is reported. The neurological signs presented in this condition are discussed briefly and it is pointed out the importance of laminectomy associated to antibiotic treatment to achieve good outcome.
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OBJECTIVE: Conventional treatment methods of lumbusacral radiculopathy are physical therapy, epidural steroid injections, oral medications, and spinal manipulative therapy. Cauda equina syndrome is a rare complication of epidural anesthesia. The following case is a report of cauda equina syndrome possibly caused by epidural injection of triamcinolone and bupivacaine. CLINICAL FEATURES: A 50-year-old woman with low back and right leg pain was scheduled for epidural steroid injection. INTERVENTION AND OUTCOME: An 18-gauge Touhy needle was inserted until loss of resistance occurred at the L4-5 level. Spread of the contrast medium within the epidural space was determined by radiographic imaging. After verifying the epidural space, bupivacaine and triamcinolone diacetate were injected. After the injection, there was a reduction in radicular symptoms. Three hours later, she complained of perineal numbness and lower extremity weakness. The neurologic evaluation revealed loss of sensation in the saddle area and medial aspect of her right leg. There was a decrease in the perception of pinprick test. Deep-tendon reflexes were decreased especially in the right leg. She was unable to urinate. The patient's symptoms improved slightly over the next few hours. She had a gradual return of motor function and ability of feeling Foley catheter. All of the symptoms were completely resolved over the next 8 hours. CONCLUSION: Complications associated with epidural steroid injections are rare. Clinical examination and continued vigilance for neurologic deterioration after epidural steroid injections is important.
There are many imaging modalities available for evaluating the canine lumbosacral region. These include conventional radiography, stress radiography, myelography, epidurography, transosseous and intravenous venography, discography, linear tomography, computed tomography, and magnetic resonance imaging. Myelography, epidurography and discography are commonly used, but often lack sensitivity. Myelography is of little value when evaluating the cauda equina because the dural sac is elevated from the vertebral canal floor and frequently ends before the lumbosacral junction. Epidurography will identify a ventrally located compressive lesion and discography can delineate the dorsal extent of the diseased disc; however, both are sometimes difficult to interpret. Therefore, more than one of these imaging techniques must be used in order to make a diagnosis. Computed tomography and magnetic resonance imaging have become valuable in evaluating the lumbosacral region in dogs. These modalities have proven to be both sensitive and specific for determining cauda equina compression in both humans and in dogs.
Two new cases of cauda equina metastases from visceral cancers are reported. This diagnosis is only infrequently considered in patients with intra-dural lesions visualized by magnetic resonance imaging or saccoradiculography. The diagnosis is especially difficult in patients with no known primary cancer. Diagnosis rests on surgery during which only a biopsy is performed. Treatment is symptomatic and focuses on relieving pain. Prognosis is bleak.
We present a case of inadvertent sacral bar transfixation of the cauda equina as a complication of posterior pelvic internal fixation. The "safe zone" for sacral bar placement is narrow, especially in the presence of fracture displacement. This complication can be avoided by achieving fracture reduction before internal fixation. Intraoperative fluoroscopy, including inlet and lateral sacral views, should be used in addition to tactile guidance to confirm the reduction. Even after prolonged compression, hardware removal under direct visualization can alleviate radicular symptoms with less effect on motor deficit.
A clinical entity described as "redundant nerve root syndrome" of the cauda equina is reviewed. Eighteen reported cases with typical gross features are analyzed. Considerable speculation has existed regarding the pathogenesis of this syndrome, chiefly because the involved nerve root was not biopsied in the majority of instances. In one reported case, when the redundant root was examined histologically, a plexiform neurofibroma was found to be the cause of the thickening and redundancy of the nerve. In the case presented here, the enlarged nerve roots were part of a malignant plexiform neurofibroma with a short clinical course, and the tumor led to the death of the patient. It is suggested that biopsy of the involved nerve root is crucial in establishing the definitive diagnosis.
Neurosarcoidosis is a great mimicker. It is often difficult to diagnose particularly when there is no prior history of systemic sarcoidosis. Although certain sites of the neuraxis are more commonly involved than others, any site of the central or peripheral nervous system can be affected. We report a case of sarcoidosis involving the cauda equina in a 38-year-old African American male without prior history of systemic disease. Initial clinical presentation was suggestive of Guillian-Barré syndrome, but the evaluation proved this case to be neurosarcoidosis involving the cauda equina. We have followed this patient for 8 years, and he remains clinically stable on prednisone 5 mg/day.
Fourteen patients with cauda equina syndrome secondary to long-standing ankylosing spondylitis are described. The roughly symmetrical neurological deficits were very slowly progressive and began long after the onset of the spondylitis, usually well after the rheumatological symptoms had stopped. Eventually every patient had cutaneous sensory loss in the fifth lumbar and sacral dermatomes. All patients developed urinary sphincter disturbances of a lower motor neuron type. There was prominent loss of rectal sphincter tone, and all but 2 patients had bowel complaints, including incontinence and severe constipation. Seven patients had mild to moderate weakness in the lumbosacral myotomes. Seven patients had pain in the rectum or lower limbs. Electromyographic abnormalities were consistent with multiple lumbosacral radiculopathies. Myelography and computed tomographic scanning of the lumbosacral spine showed characteristic enlargement of the caudal sac and dorsal arachnoid diverticula that had eroded the laminae and spinous processes. Recognition of this syndrome, coupled with computed tomographic scanning of the lower spinal canal, allows one to omit myelography, a procedure that is difficult because of the associated spine abnormalities. Surgical intervention should be avoided.
INTRODUCTION: Primary epidural lymphoma is generally manifested by isolated epidural involvement. On rare occasions it can lead to cauda equina syndrome. CASE: A 56-year-old man was hospitalized for lumbago, weakness in the legs and sphincter problems. A dorsolumbar MRI revealed that the anterior and posterior peridural space from D11 to L3 was filled by a mass compressing the marrow and compacting the roots. The L2 to L4 laminectomy revealed an extradural tissue leading to the diagnosis of large B-cell lymphoma. Metastatic workup demonstrated unremarkable findings. DISCUSSION: Primary epidural lymphoma accounts for less than 10% of epidural tumours and less than 1% of non-Hodgkin lymphomas. Its clinical manifestations are related to the tumoral process or involvement of medullar vessels. It can be, but rarely is, manifested by cauda equina syndrome. Diagnosis is based on histological analysis of tissue taken during the decompression laminectomy. Prognosis is relatively good.
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A 42-year-old, non-obese man with a three-month history of headache, pulsatile tinnitus, transient visual obscurations, and scintillations later developed low back pain with right lower extremity radiation. Brain MRI and magnetic resonance venography were normal, but spine MRI revealed a mass in the cauda equina. Neuro-ophthalmologic examination disclosed bilateral optic disc edema with normal visual function. During spine surgery, cerebrospinal fluid, released under high pressure despite prior hyperventilation, contained a glucose level of 51 mg/dl and a protein level of 1840 mg/dl. Histologic and immunohistochemical features of the lesion were compatible with a capillary hemangioma. Although spinal cord tumors have been associated with papilledema, this is the first report of a capillary hemangioma of the cauda equina in this context. If papilledema is present, spinal cord imaging should be performed when lumbar puncture discloses unexplained protein elevation and in cases that lack clinical features typical of idiopathic intracranial hypertension.
The patient, who was a non-obese woman with no predisposing conditions of lipomatosis, slowly developed cauda equina syndrome. Spinal magnetic resonance imaging (MRI) presented mass lesion of high intensity on T1-weighted image (WI) and an intermediate signal intensity in T2 WI in the epidural space of S1 to coccyges. It has been reported that most idiopathic epidural lipomatosis (IEDL) is observed in obese men, and all cases have involved the thoracic or lumbar region. This is the first report of a patient with cauda equina syndrome caused by idiopathic sacral epidural lipomatosis (EDL).
We evaluated 42 patients with neurological deficits after civilian gunshot wounds to the spine. Thirty-five of these patients (the study population presented here) received their initial and follow-up care at Louisiana State University Medical Center in Shreveport over a 4-year period. Each patient had incurred a single gunshot wound to the spinal cord or cauda equina with an accompanying neurological deficit. The patient population was divided into three groups. Group 1 patients had incurred a complete motor and sensory loss below the injury (20 patients (57%]. Group 2 patients had incurred incomplete spinal cord injuries (9 patients (26%], whereas Group 3 patients had cauda equina injuries (6 patients (17%]. Myelography was performed for all Group 2 and 3 patients as well as Group 1 patients in whom the trajectory of the bullet did not explain a higher level of neurological injury (3 patients (15%]. A decompressive operation was performed in the patients whose myelography showed neural compression. Three patients in Group 1 (15%), 5 patients in Group 2 (56%), and 5 Group 3 patients (83%) underwent operation. All 3 Group 1 patients who underwent operation had some improvement of nerve root function postoperatively. All operated Group 2 and 3 patients had improvement of myelopathic or radicular function postoperatively. All began improving within several days of operation, implying a cause and effect relationship. None of the 17 nonoperated Group 1 patients improved neurologically, whereas 3 of the 4 nonoperated Group 2 patients improved. The single nonoperated Group 3 patient improved neurologically.(ABSTRACT TRUNCATED AT 250 WORDS)
According to the literature estimations, 10-25% of patients with spinal cord and cauda equina injuries eventually develop refractory pain. Due to the fact that most classical neurosurgical methods are considered of little or no efficacy in controlling this type of pain, the authors had recourse to microsurgery in the dorsal root entry zone (DREZ). This article reports on the long-term results of the microsurgical approach to the dorsal root entry zone (DREZotomy) in a series of 44 patients suffering from unbearable neuropathic pain secondary to spine injury. The follow-up ranged from 1 to 20 years (6 years on average). The series includes 25 cases with conus medullaris, 12 with thoracic cord, four with cauda equina and three with cervical cord injuries. Surgery was performed in 37 cases at the pathological spinal cord levels that corresponded to the territory of the so-called 'segmental pain', and in seven cases, on the spinal cord levels below the lesion for 'infralesional pain' syndromes. The post-operative analgesic effect was considered to be 'good' when a patient's estimation of pain relief exceeded 75%, 'fair' if pain was reduced by 25-75%, and 'poor' when the residual pain was more than 75% of preoperative estimations. Immediate pain relief was obtained in 70% of patients and was long-lasting in 60% of the total series. The results varied essentially according to the distribution of pain. Good long-term results were obtained in 68% of the patients who had a segmental pain distribution, compared with 0% in patients with predominant infralesional pain. Regarding pain characteristics, a good result was obtained in 88% of the cases with predominantly paroxysmal pain, compared with 26% with continuous pain. There were no perioperative mortalities. Morbidity included cerebrospinal fluid leak (three patients), wound infection (two patients), subcutaneous hematoma (one patient) and bacteremia (in one patient). The above data justify the inclusion of DREZ-lesioning surgery in the neurosurgical armamentarium for treating 'segmental' pain due to spinal cord injuries.
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We describe the case of a 16-year-old boy with idiopathic hydrocephalus, who developed cranial subdural hygromas and subsequent cranial subdural hemorrhage after a shunting procedure. Sciatica and radicular lumbar pain initially seemed to be unrelated to the proceeding implantation of a ventriculoatrial shunt. CT scan revealed a sharply demarcated hyperdensity in the lumbar subdural space with compression of the cauda equina. Differential diagnosis considerations included vascular malformations, vascular tumors, benign tumors of meninges or nerve sheets, ependymoma, lymphoma, and metastases. MR investigation did, in fact, clearly recognize this hyperintense space-occupying lesion as blood in the subdural space which outlined the cauda equina. We believe that the spinal subdural hematoma in our case represented an extension of intracranial subdural haemorrhage fluid into the spinal subdural space.