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PubMedDate not supplied

Commentary: neurotoxicity of local anesthetics--an issue or a scapegoat?

BACKGROUND AND OBJECTIVES: To evaluate the etiologies of cauda equina syndrome (CES) and transient radicular irritation (TRI) or transient neurologic symptoms (TNSs) following hyperbaric spinal anesthesia. METHODS: A review of recent (since 1991) and prior (since 1941) investigations regarding CES and TRI (TNSs) was conducted. RESULTS: Recent publications fail to recognize significant prior information regarding CES and TRI (TNSs). CONCLUSIONS: Cauda equina syndrome is, in all probability, explainable. Further investigation to pinpoint the etiology of TRI (TNSs) is needed.

Anesthesia, Spinal↗
PubMed1988

An immunohistological study of 66 ependymomas.

Sixty-six ependymomas were examined immunohistologically to determine their distribution of glial fibrillary acidic proteins, S-100 protein and vimentin. The neoplasms were subdivided into four groups: (1) ependymomas from the cauda equina, predominantly of the myxopapillary type; (2) benign ependymomas; (3) malignant ependymomas; and (4) ependymoblastomas. Marked differences in antigen reactivity were observed between each group. The intensity of the reaction with the three antibodies was strongest in malignant ependymomas. Ependymomas from the cauda equina showed a patchy distribution of positivity for the three antigens in cells surrounding blood vessels but there was no staining of collagenous septa or the myxoid areas. In ependymoblastomas, the cells of the rosettes were negative for glial fibrillary acidic protein, but there was focal positivity for vimentin and S-100. Other areas showed tumour cells containing moderate amounts of vimentin and small amounts of S-100, and a few bands of filaments positive for glial fibrillary acidic protein. The cytogenetic and biological implications of these findings are discussed.

Cauda Equina↗
PubMed1984

Spinal somatosensory evoked potentials in juvenile diabetes.

Spinal somatosensory evoked potentials to stimulation of the peroneal nerves in the popliteal fossa were recorded from 46 insulin-dependent neurologically normal patients with juvenile diabetes. Conduction velocities of these potentials were determined over proximal peroneal nerve, cauda equina, and spinal cord and were compared with those obtained from 46 age-matched control subjects. Mean values for overall spinal conduction velocity (L3-C7 spines) and conduction velocity over rostral spinal cord (T6-C7 spines) and peroneal nerve-cauda equina (stimulus to L3 spine) were lower in the diabetic group (p less than 0.001). Peripheral nerve conduction velocity alone was slow in 5 patients, and spinal conduction velocity was slow in 8; in 2 patients both peripheral and spinal velocities were slow. This study suggests that in addition to impairment of peripheral nerve function, patients with juvenile diabetes without clinical evidence of neurological involvement can have a defect in spinal afferent transmission.

Adolescent↗
PubMed1991

Spinal instability secondary to metastatic cancer.

Fifty-five patients with severe pain from spinal instability secondary to metastatic cancer were referred to Hope Hospital, none being judged to be in a terminal condition. One patient had too extensive disease for surgery so 54 were treated by 55 spinal stabilisations; 49 obtained complete relief of pain and two had partial relief. There were three failures. Twenty-eight of the patients had clinical evidence of spinal cord or cauda equina compression and were decompressed at the time of stabilisation. Of these, 20 had major recovery of neurological function. Patients with pre-operative evidence of extradural tumour had 'prophylactic' decompression at the time of stabilisation; none of these patients later developed signs of cord or cauda equina compression. The results suggest that alleviation of pain and restoration of mobility are best achieved by segmental spinal stabilisation; a few patients require a combined anterior and posterior stabilisation. Postoperative radiotherapy should be given whenever possible, and the causative tumour should be treated by endocrine or chemotherapy, as indicated.

Cauda Equina↗
PubMed1987

[Critical study of radiculomedullary and neuromuscular complications of ankylosing spondylitis].

Medullo-radicular and neuro-muscular involvements of ankylosing spondylarthritis, often reported in an analytic fashion in the literature, deserve to be the subject of a critical study. Various neurological manifestations secondary to exceptional atlo-occipital and sometimes axis-atlas subluxations and medullary lesions as well as syndromes of the cauda equina. The medullary lesions have an epidural origin (3 cases in the literature, 2 cases from the authors) or are secondary to a spondylodiscitis (4 cases in the literature) or secondary to both (1 case reported by the authors). As for syndromes of the cauda equina the authors report 3 cases to be added to the 55 published previously. It concerns always old spondylarthritis. The lesions combine posterior diverticula and lesions of the lamina. The treatment is usually ineffective. A special case is represented by forms with trophic disorders. More debatable are the radicular lesions, which, except for intercostal pain, should be linked to local pain. Electromyographic abnormalities are of no significance. Alterations of the paravertebral muscles viewed on the scanner X have, for now, an uncertain significance. Finally, various associations, without significance such as multiple sclerosis, diffuse muscular lesions and the classic spondylotic pseudo-tabes, should be rejected.

Adult↗
PubMedDate not supplied

Redundant nerve roots in patients with degenerative lumbar spinal stenosis.

Extensive fundamental and clinical investigations have been performed concerning redundant nerve roots (RNR) and the pathogenesis of cauda equina claudication (CEC) in degenerative lumbar canal stenosis (DLCS). These investigations consisted of (1) anatomic observations on RNR in 117 fixed cadaveric specimens, (2) myelographic study in 117 patients with or without DLCS, (3) operative observation on neural elements with special reference to the cauda equina in 56 DLCS patients (including a postoperative follow-up), and (4) electrophysiologic tests using spinal cord action potential recording under walking load preoperatively and intraoperative measurement of nerve conduction velocity of RNR. The RNR have neuronal losses resulting from a longer duration stenosis that suggests a sort of friction neuritis. Complicated factors contribute to the pathogenesis of CEC and the development of root gripping, such as the magnitude of RNR, the extent of the stenosis, a narrowed sac, age-dependent axial shortening of the spinal canal, and dynamic or postural factors. In cases with severe RNR, satisfactory operative results can be obtained only after thorough decompression with dural incision.

Action Potentials↗
PubMed1990

[The diagnosis of posttraumatic neuroma via sonography and CT].

The sonographic CT and myelographic findings in three peripheral amputation neuromas are described, as well as a cauda equina neuroma following a tear of the lumbar plexus. Sonographically, the peripheral neuromas produced low intensity echoes with sharp differentiation from their highly echogenic surroundings. On CT the neuromas were hypodense, compared with muscle, measuring between 40 and 60 HU and showing only minimal enhancement after contrast. The cauda equina neuroma was shown on myelography as an intradural filling defect situated on the cranial aspect of a traumatic pseudomeningocoele. In view of their characteristic appearances, and the possibility of identifying trigger points, sonography appears to be the method of choice in the diagnosis of peripheral neuromas.

Adult↗
PubMed2002

Lumbar intrathecal ligaments.

A meticulous examination was performed on 56 vertebral columns from cadavers between 64 and 89 years of age. Identification of all contents within the dural sac was completed; however, the main focus was the cauda equina and lumbar region. In addition to scope dissection, radiographs and histological preparations were used to identify structures, tissue types, and any possible pathology. Discrete intrathecal ligamentous bands were observed in all cadavers examined. They were found randomly binding the dorsal nerve roots of the cauda equina to the dura. Occasional binding of the ventral nerve roots to the dorsal roots was observed. Histological examination demonstrated a dense collagen ligament varying between 0.13 and 0.35 microm in thickness and from 3 mm to 3.5 cm in length. The average number of ligaments found per cadaver was 18. These ligaments displayed a broad base attachment to the nerve root or dura of approximately 3 mm. Looping of the nerve roots associated with these ligaments was seen in one cadaver with a burst fracture. Electron microscopic studies of these ligaments demonstrated similarities to denticulate ligaments. It is suggested that the intrathecal ligaments represent remnants from fetal development of the denticulate ligaments.

Aged↗
PubMed2004

Cystic mature teratoma of the filum terminale in an adult. Case report and review of the literature.

Intradural spinal teratoma is a very rare entity, more prevalent in childhood, that may associate with dysraphic defects. The authors report a 46 years old man with a cauda equina syndrome and an L1-2 tumor. An L1-2 laminectomy was performed and a mass was resected at the base of the filum terminale, which was in contact with the conus medullaris. Histopathological diagnosis was of cystic mature teratoma. Spinal teratomas may be found anywhere along the spine, but are more frequent in the cauda equina. We discuss the origin of these tumors and review the literature concerning these lesions.

Cauda Equina↗
PubMed1995

Surgical treatment of degenerative spondylolisthesis in the lumbar spine: no reposition without prior decompression.

In the present note, the cause of root compression in cases with degenerative lumbar spondylolisthesis is discussed in order to clarify the best method of surgery and to avoid iatrogenic damage of the cauda equina if a transpedicular fusion is going to be performed. The root compression is due to osteophytes growing out from the upper articular facets and from the upper ridge of the lamina of the lower vertebra. Therefore, the repositioning of the anteriorly displaced vertebra by the instrumentation could lead to the squeezing of the cauda equina between the withdrawn vertebral body and the degeneratively enlarged and hypertrophic facet joints of the lower vertebra. The reposition (even if incomplete) must always be preceded by decompression on both sides, even if radicular complaints are unilateral.

Cauda Equina↗
PubMed2001

Neurourologic findings in patients with traumatic thoracolumbar vertebra junction lesions.

OBJECTIVE: To investigate neurourologic involvement in injuries to the thoracolumbar vertebra junction with magnetic resonance imaging (MRI) and electrophysiologic and urodynamic measurements and to characterize the neurogenic mechanisms of voiding dysfunctions. DESIGN: Baseline comparisons among 3 anatomic groups before neural repair. SETTING: Tertiary care center. PATIENTS: Thirty-five T11 to L2 spinal cord injury patients consecutively admitted to a rehabilitation unit. Eight patients (Group 1) had above-conus lesions without denervation and polyphasic waves revealed in the anal sphincter electromyography; 13 patients (Group 2) had conal and/or above-conus lesions and anal sphincter electromyographic abnormalities; and 14 patients (Group 3) had below-conus lesions and anal sphincter electromyographic abnormalities. MAIN OUTCOME MEASURES: Comparison of features identified on pudendal nerve terminal motor latency, urethral pressure profiles, and multichannel voiding pressure-flow study. RESULTS: The pudendal nerve terminal motor latency in Group 3, showing a significantly higher abnormal ratio (100%; p =.011, Fisher's exact test), indicated that cauda equina lesions might be the cause. Urodynamic data from Group 3 showed a significant decrease in maximal urethral closure pressure (48 +/- 17cm H2O, p =.0022, analysis of variance [ANOVA], repeated measure) and an increase in bladder capacity (429 +/- 194mL, p =.037, ANOVA, repeated measure). There were no significant changes in the other groups. CONCLUSION: Neurourologic abnormalities are less predictable with injuries to thoracolumbar junction, except in patients with cauda equina lesions.

Adult↗
PubMed1984

Colonic dysfunction in patients with thoracic spinal cord injury.

Severe constipation is a debilitating concomitant of complete traumatic thoracic spinal cord injury. In order to investigate the pathophysiology of this symptom, we studied colonic compliance, as well as motor and myoelectrical activity, in the fasting and postprandial states and after neostigmine stimulation in 9 patients with clinically and electrophysiologically documented complete thoracic spinal cord injury. Electrophysiologic studies, including nerve conduction velocities, cortical and spinal somatosensory-evoked responses, and bulbocavernosus reflex responses, as well as urinary bladder cystometry, documented normal peripheral somatosensory function, integrity of the distal spinal cord, conus medullaris and cauda equina, and interruption of the somatosensory and descending spinal pathways proximal to the cauda equina. These 9 patients with spinal cord injury demonstrated a decrease in colonic compliance compared with a control group (p less than 0.01). They failed to demonstrate the postprandial increase in colonic motor and myoelectrical activity observed in a control group (p less than 0.01), but did respond to neostigmine with an increase in both motor and myoelectrical activity (p less than 0.02), suggesting an intact myogenic component. In these patients, decreased colonic compliance and absent postprandial colonic motor and myoelectrical activity may be mediated by ablation of outflow from higher centers to the lower spinal cord and may be correlates of visceral neuropathy and severe constipation.

Adult↗
PubMed1992

Peripheral nervous system (PNS) expression of mRNAs encoding myelin proteins and Fc gamma RIII during experimental allergic neuritis.

Experimental allergic neuritis (EAN) was induced in Lewis rats by injection of 'SP26', a peptide homologous to amino acids 53-78 of bovine myelin P2 protein, in complete Freund's adjuvant. The rats developed signs of EAN which began on day 14, were maximal on day 18, and had subsided by day 30. RNA content of cauda equina and sciatic nerves increased more than 2-fold at the height of EAN. Expression of myelin P0 and P1 mRNAs did not fall during EAN, nor rise during recovery. Fc gamma R mRNA, which encodes Fc gamma RIII, an immunoglobulin-binding protein mediating activation of natural killer cells and macrophages by immune complexes, was transiently, but markedly induced in scattered endoneural cells, presumably macrophages, in cauda equina and sciatic nerves during the period of increasing weakness.

Amino Acid Isomerases↗
PubMed1993

The frequency of intradural conjoined lumbosacral dorsal nerve roots found during selective dorsal rhizotomy.

The frequency of occurrence of conjoined nerve roots (CR) in the cauda equina has been reported to range from 0.3% to 2%. We found intradural conjoined nerve roots in 13 of 123 (10.6%) patients undergoing selective dorsal rhizotomy for spasticity due to cerebral palsy. The anomaly occurred most commonly at L5-S1 and S1-S2. There was no consistent relationship to other anomalies of segmental anatomy. Our finding of a significantly higher number of conjoined nerve roots in these patients is primarily due to the surgical exposure of the entire cauda equina. This anomaly is more common than previous reports have indicated.

Adolescent↗
PubMed1984

Normal intraoperative spinal sonography.

The normal intraoperative sonographic features of the spinal canal, spinal cord, conus medullaris, and cauda equina are described and illustrated. Important observations concerning the normal spinal cord include its highly reflective dorsal and ventral surfaces, its uniform hypoechogenicity, and the presence of a central echo. Other easily identified structures within the spinal canal include the dura-arachnoid layer, subarachnoid space, denticulate ligament, dorsal arachnoid septations, and the roots of the cauda equina. In addition the sonographic appearance of commonly encountered iatrogenically introduced material including Gelfoam, Pantopaque, cottonoid pledgets, suture material, Harrington rods, and freeze-dried dura is also demonstrated. These normal images can serve as a baseline for the interpretation of various pathologic conditions of the spinal canal and its contents as seen with intraoperative spinal sonography.

Cauda Equina↗
PubMed1998

Somatosensory evoked potentials after posterior tibial nerve stimulation--normative data in children.

We report normative data of somatosensory evoked potentials to posterior tibial nerve stimulation from 47 children 4-15 years of age. We recorded near-field potentials from the peripheral nerve, the cauda equina, the lumbar spinal cord and the somatosensory cortex. Far-field potentials were recorded from the scalp electrodes with a reference at Erb's point and on the earlobe. The near-field potentials N8 (peripheral nerve) and P40 (cortex) were present in all children. N20 (near-field from the cauda equina) was recorded in 38 subjects. N22 (near-field from the lumbar spinal cord), P30 and N37 ( both far-field waveforms probably generated in the brainstem) were recorded in 46 subjects each. The latencies and the peripheral conduction time (N8-N22) increased with age, while the central conduction time (N22-P40) and the intracranial conduction time (P30-P40) both decreased with age (up to about 10 years of age). The spinal conduction time (N22-P30) was relatively independent of age. The interpeak latencies allow the assessment of specific portions of this pathway. The subcortical posterior tibial nerve-somatosensory evoked potentials are of particular interest in children when the cortical peaks are influenced by sedation and sleep, or by anaesthesia.

Adolescent↗
PubMed1990

Acute bleeding into a filum terminale ependymoma.

We present a case of a 63-year-old male patient who was admitted to our hospital due to an acute compression syndrome of the cauda equina. He had complained about a sciatica for at least one year. CT-diagnosis appeared to be negative, whereas a lumbar myelogram revealed a complete block at L2/3. Emergency surgery was performed, and an ependymoma of the filum terminale was removed into which it had bled massively. The case is compared to the literature findings. These relate ependymomas in the described region with acute onset more often to symptoms caused by subarachnoid bleeding. Mechanical and/or histopathological factors are discussed as the cause of acute bleeding. Spinal ependymomas represent a rare event compared to other neurosurgical diseases. Even more seldom are tumors of this kind causing an acute cauda equina compression syndrome.

Acute Disease↗
PubMed1996

Conus medullaris injury following both tetracaine and lidocaine spinal anesthesia.

Multiple reports of cauda equina syndrome and transient radicular nerve root irritation have suggested that lidocaine spinal anesthesia may be responsible. In this case report, a patient with a preexisting diabetic neuropathy received a partial block following a tetracaine spinal, which was followed by a lidocaine spinal. Following block resolution, a new conus medullaris syndrome was diagnosed. Because of the close proximity of the cauda equina and the conus medullaris, differentiation between these syndromes can be difficult. The preexisting diabetic neuropathy may have predisposed this patient to neurologic injury. The choice of a different local anesthetic drug with less neurotoxic potential such as bupivacaine may have prevented this injury.

Anesthesia, Spinal↗