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PubMed1987

[Arachnoiditis ossificans after repeated myelographies and spinal operations--a case report and review of the literature].

A 58-year-old female was admitted because of lumbago and dysesthesia on the lateral aspect of the left leg. She had myelographies and spinal operations 4 years ago. Metrizamide myelogram on admission revealed the findings of adhesive arachnoiditis. During operation, four plaques involving the cauda equina were found, removed and histologically proved to be osseous tissue. In reviewing the previously published cases of arachnoiditis ossificans, it is divided into two forms. One is incidentally found in the arachnoid membrane at the time of an autopsy or spinal operation. The other is a progressive form causing impairment of the spinal cord and cauda equina. Compared with the former, the latter is extremely rare. At present, there appears to be a general agreement about the pathological process to ossification in the latter. The ossified plaque has its origin in meningothelial cell clumps located at the junction of the arachnoid sheet and the trabecula. The ossification occurs secondarily as a result of degenerative change in these clumps after myelography, spinal operation, subarachnoid hemorrhage, spinal trauma and spinal anesthesia. In our case, it is presumed that repeated spinal operations or myelographies played a role as a trigger toward ossification.

Arachnoiditis↗
PubMed2005

Donut-shaped high-dose configuration for proton beam radiation therapy.

BACKGROUND: The authors report on the conception and first clinical application of a donut-shaped high-dose configuration for proton therapy (PT). This approach allows one to intensify target volume dose coverage for targets encompassing a critical, dose-limiting structure--like here, the cauda equina--, whilst delivering minimal dose to other healthy structures surrounding the target, thereby reducing the integral dose. METHODS AND RESULTS: Intensity-modulated PT methods (IMPT) for spot scanning were applied to create and deliver a donut-shaped high-dose configuration with protons, allowing treating > 75% of the target with at least 95% of the prescribed dose of 72.8 CGE, whilst restricting dose to the cauda equina to 60-65 CGE. Integral dose was lower by a factor of 3.3 as compared to intensity-modulated radiotherapy with photons (IMXT). CONCLUSION: IMPT and spot scanning technology allow a potentially clinically useful approach which is also applicable to spare other critical structures passing through a target volume, including spinal cord, optic nerves, chiasm, brain stem, or urethra.

Artifacts↗
PubMedDate not supplied

[Spinal metastatic tumor in a patient with tuberous sclerosis complex].

Most of the cauda equina tumors are primary tumors and metastases (especially from some tumors like renal carcinoma [RC]) are very unusual. We report a 28-yearold- man with tuberous sclerosis complex (TSC) who had undergone a left nephrectomy one year before for the treatment of RC. He presented with a 2-3 month history of lower back pain that radiated to both legs and weakness in lower limbs. He denied bowel and bladder symptoms. A magnetic resonance scan of the dorsolumbar spine revealed an intradural extramedullary cauda equina mass that demonstrated uniform homogeneous enhancement, which was a metastasis. Therapeutical and diagnostic aspects are discussed. We review the previous literature on this topic.

Adult↗
PubMed2005

Effects of lumbar acupuncture stimulation on blood flow to the sciatic nerve trunk--an exploratory study.

INTRODUCTION: Acupuncture may have a role in the treatment of intermittent claudication of the cauda equina due to lumbar spinal canal stenosis. The aim of this study was to explore the possible physiological mechanisms. METHODS: In a laboratory experiment, manual acupuncture was performed at a point adjacent to the sixth lumbar vertebra of 13 animals and its effect on sciatic nerve blood flow was measured using a laser Doppler flowmetry. Simultaneously, changes in blood pressure and cardiac rate were observed. Each animal was stimulated four to eight times, making a total of 58 experiments. RESULTS: Acupuncture stimulation did not produce consistent changes in sciatic nerve blood flow, with increased and decreased blood flow as well as no change in blood flow observed. Among the 58 individual experiments, sciatic nerve blood flow was increased in 33, reduced in 12, and unchanged in 13. Approximately half of the stimulations showed a correlation between blood flow and blood pressure change. CONCLUSION: Our results indicate that lumbar acupuncture stimulation can have an influence on sciatic nerve blood flow. The effect is dependent not only on blood pressure but also other factors, for example vasodilator and vasoconstrictor nerve activity. This mechanism may contribute to a clinical effect on intermittent claudication of the cauda equina.

Acupuncture Therapy↗
PubMed1976

Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine.

The lateral extracavitary approach to the spine was used for resection of displaced bpne and disc located anterior to the dura in 62 patients with traumatic lesions of the thoracic and lumbar spine. Fifty-two patients had closed vertebral fractures and 10 had gunshot wounds. The spinal cord was involved in 44 patients, and the cauda equina in 18. A spinal subarachnoid block was demonstrated in 17 of 57 preoperative gas myelograms. Evoked potential recordings, although related to preception of joint rotation, tended to reflect the overall neurological condition and had some prognostic value. Significant improvement followed surgery in 46 patients with incomplete neurological lesions, and one was transiently worse. Before operation 18 patients were able to walk; nine with assistance and nine without. After operation 47 patients were able to walk; 12 with assistance and 35 without. Adequate bladder function was present in 17 patients before surgery, and in 44 after surgery. A laminectomy had been done previously in 16 patients, 11 of whom improved significantly after anterior resection. Spine fusions were required in 26 patients, five of whom had a prior laminectomy. The major factor in the pathogenesis of the incomplete neurological deficit appeared to be distortion of the cord and roots by displaced bone and disc. Consequently, the primary object of treatment was the restoration and maintenance of normal anatomical relationships between the spinal cord or cauda equina and the spinal canal.

Adult↗
PubMed1990

Histological differences between rootlets sectioned during selective posterior rhizotomy by two surgical techniques.

During selective posterior rhizotomy, for the treatment of spasticity in infantile cerebral palsy, the rootlets to be divided are chosen by the type of electromyographic response elicited by intraoperative electrical stimulation. Two different surgical techniques were used for exposing the lumbar roots. The first approach was to expose the conus medullaris through a T 12-L 1 laminectomy, while the other approach to the dorsal roots was distally in the cauda equina through a L 2-L 3 to S1 laminectomy. Although the clinical results obtained with either of them are not very different, there is anatomical evidence that suggests that the histological structure of the divided rootlets may be different in the two techniques. We designed our study to determine of a significant difference in the number of large myelinated fibers was found between rootlets divided close to the conus medullaris and those divided distally in the cauda equina. Two groups of five children with spasticity secondary to cerebral palsy where randomly designed to be operated upon by one of the techniques. The divided rootlets were processed with standard histological techniques and the large myelinated fibers were counted on enlarged (40 x) photomicrograph of the rootlet. A significantly (p less than 0.001) larger number of large myelinated axons was found in the rootlets dissected and divided close to the conus medullaris.

Cauda Equina↗
PubMed1993

[Thoracolumbar injuries. Surgical treatment of patients with neurological damage].

This article presents the neurological outcome after surgery of a series of 54 patients with damage to the spinal cord and/or cauda equina caused by thoracolumbar injuries. The fractures, dislocations or fracture-dislocations were all reduced and stabilized by a Harrington distraction device or transpedicular fixation system (posterior segment fixator). Peroperative inspection revealed that correction and distraction alone may be inadequate to achieve intraspinal decompression. Additional anterior decompression by posterolateral approach was necessary in 31 patients (57%). In this series there was an unexpected high rate of dural rents. Tears were found in 11 patients (20%) and nerve roots (cauda equina) appeared to have herniated through the tear in eight. Significant improvement of the neurological deficits was obtained in 81%. The improvement rate was much better in patients with incomplete lesions than among those with complete lesions. We are convinced that surgery improves the neurological outcome if carried out at the proper time, after sufficient decompression of the spinal cord and nerve roots, and repair of dural rents.

Adolescent↗
PubMed2000

Somatosensory evoked potentials after multisegmental lower limb stimulation in focal lesions of the lumbosacral spinal cord.

OBJECTIVES: Recording techniques permit the separate analysis of the response from cauda equina roots and the spinal potential that is probably generated by the activation of dorsal horn cells. To improve the functional assessment of focal lesions of the lumbosacral cord, lower limb somatosensory evoked potentials (SEPs) were measured by multisegmental stimulation. METHODS: Common peroneal and tibial nerves SEPs were recorded in 14 patients in whom MRI demonstrated compressive cord damage ranging from T9 to L1 levels. SEPs were recorded in each patient at the lumbar level (cauda equina response), lower thoracic level (spinal response), and from the scalp (cortical response). RESULTS: Abnormalities in spinal response occurred in 50% and 70% of tibial and common peroneal nerve SEPs respectively; these findings were well explained by the radiological compression level, involving in most of the patients lumbar rather than sacral myelomeres. The SEPs were often more effective than the clinical examination in showing the actual extension of damage. CONCLUSIONS: The recording of spinal SEPs after multisegmental lower limb stimulation proved useful in assessing cord dysfunction and determining the cord levels mainly involved by the compression.

Adult↗
PubMed2002

Fracture of L7 vertebral articular facets and pedicles following dorsal laminectomy in a dog.

A 6.5-year-old German Shepherd Dog underwent decompressive surgery for cauda equina syndrome. On the basis of intraoperative findings, the dorsal laminectomy was extended from L6 to S2. Partial dorsal annulectomies were also performed on the L6-7 and L7-S1 intervertebral disks. Two weeks following discharge, the dog had an acute onset of signs of pain and worsening of the neurologic status. Radiography and surgical exploration revealed bilateral fractures of the vertebral pedicles and caudal articular facets of L7. Vertebral stabilization was achieved with intramedullary pins and methylmethacrylate. The dog fully recovered. Although the destabilizing effect of various procedures on the vertebral column has been documented in vitro, vertebral fractures associated with instability have not been reported. Our description of a vertebral fracture following a cauda equina decompressive procedure in a dog emphasizes the need for caution when performing multi-level dorsal laminectomy and diskectomy.

Animals↗
PubMedDate not supplied

[Intradural lumbar disk herniation (ILDH). Case report and literature review].

In this report, the author presents a rare case of a 59 year-old man with ILDH. It was the only case of ILDH among 960 patients surgically treated, during the period 1989-1996. Clinically the patient demonstrated an acute cauda equina syndrome. The diagnosis was established by radiculograms, which showed a total block at the L3-L4 level. There was a 3 days time interval between the diagnosed syndrome itself and the operation. At surgery the L3-L4 level was intact, whereas dense adhesions were found between the L4-L5 disc and the dura. Root retraction to expose the nucleus pulposus mass was impossible. A laminectomy of the L4 was undertaken. An incision was made in the dura and arachnoid, revealing an extruded discal mass, lying between the roots of the cauda equina. It was carefully removed. The state of the patient at follow-up 1 year after surgery was unsatisfactory. The patient has moderate flaccid paraparesis, bladder dysfunction improved. The prognosis appeared to be linked to the preoperative duration of symptoms.

Cauda Equina↗
PubMed1997

Effects of intravenous lipoprostaglandin E1 on neurogenic intermittent claudication.

Circulation disturbances in the cauda equina and nerve roots have been implicated in the genesis of neurogenic intermittent claudication (NIC) in patients with lumbar spinal stenosis (LSS). We report the clinical results of lipoprostaglandin E1 (lipo-PGE1) treatments in patients with NIC. Lipo-PGE1 was administered intravenously for 10 consecutive days to 40 patients, 31 of whom showed a response to the treatment. Of the clinical symptoms examined, walking ability and leg numbness were significantly improved with an average effective period of 2.5 months. However, patients with radicular pain and severely affected patients did not respond well. Nerve root circulation in eight patients who subsequently underwent surgery was measured with a laser Doppler flowmeter. We observed increased blood flow in seven of these eight patients, after the intraoperative administration of lipo-PGE1. Lipo-PGE1 produced symptomatic improvement for a limited period in the treatment of NIC associated with LSS. The drug appeared to exert its effects through an increase in the circulation of blood in the nerve roots and the cauda equina.

Adult↗
PubMed1988

Neurological outcome after surgery for thoracic and lumbar spine injuries.

New techniques for internal fixation, employed by neurosurgeons and orthopaedic surgeons, provide reduction and stabilization with early mobilization of patients after injuries of the thoracolumbar spine. It has, however, appeared difficult to prove that the neurological outcome after surgery may be superior to conservative treatment. In this study the neurological results after surgery are evaluated in 30 patients with injuries of the spinal cord and/or cauda equina. Canal encroachment was found on tomograms or CT in all patients. The unstable fractures, dislocations or fracture-dislocations were all reduced and stabilized by the Harrington distraction device. However, peroperative inspection revealed that the Harrington instrumentation alone may be inadequate in achieving intraspinal decompression. Additional anterior decompression by posterolateral approach was necessary in 13 of the 30 patients (43%). In this series there was an unexpectedly high rate of dural tears. These were found in 8 patients (27%) and nerve roots (cauda equina) appeared to have herniated through the tear in 6 of the 8 patients. Significant improvement of the neurological deficit was obtained in 22 of the 30 patients (73%), and the improvement rate in patients with incomplete lesions of the spinal cord was 83% (25 of 30 patients). In this series there was a definite trend toward greater neurological recovery when compared to the results obtained in patients treated conservatively. The importance of a neurosurgical approach in diagnosis and treatment of these patients is stressed.

Adolescent↗
PubMed1975

[Paraplegia following acute infrarenal aortic occlusion (author's transl)].

The clinical syndrome of paraplegia following acute occlusion of the infrarenal aorta may be caused by either ischemic spinal cord damage or ischemia of the cauda equina and sacral nerve roots and ganglia. The neurologic manifestations are similar and therefore specific anatomic diagnosis is difficult. From October 1972 to February 1975 a total of 31 patients with infrarenal aortic occlusion were treated at the Medizinische Hochschule in Hannover. In nine cases the occlusion up to the renal arteries was acute. Three of these patients presented beside acute ischemic manifestations on both legs and the lower abdominal wall, neurologic symptoms of paraplegia. The anatomic and hemodynamic aspects of ischemic spinal cord damage and those of ischemic lesions of the cauda equina and peripheral nerves are discussed. There appear to be three main mechanisms responsible for vascular paraplegia following acute infrarenal occlusion of the aorta: 1. it may be caused by thrombotic occlusion of a major radicular artery which arises below the level of occlusion. 2. it may be produced by thrombosis of a lumbar collateral acting as major supply to the cord when arteriosclerotic narrowing of the major radicular artery is present. Especially in states of severe hypotension critical interference of blood supply to the spinal cord will result. 3. Paraplegia by ischemia of the cauda and peripheral nervous tissue may also follow prolonged interruption of circulation to this area supplying spinal vessels from low lumbar and sacral arteries.

Aged↗
PubMed2002

Immunological study of hereditary motor and sensory neuropathy type 1a (HMSN1a).

OBJECTIVES: Fifty three patients were studied to investigate whether autoimmune or inflammatory mechanisms could explain the phenotypic heterogeneity of patients with hereditary motor and sensory neuropathy type 1a (HMSN1a). METHODS: Serum samples were examined for antibodies to peripheral nerve myelin protein 22 (PMP22), ganglioside GM1 and cauda equina homogenate, and interleukin-6 (IL-6) and soluble tumour necrosis factor receptor 1 (sTNF R1) concentrations. Serological results were compared with those from patients with other neuropathies (ONPs, n=30) and with normal subjects (n=51). RESULTS: In the group as a whole, no relation emerged between clinical severity and any immune parameters. Immunohistochemical examination of four sural nerve biopsies did not show significant inflammatory infiltration. In a subset of 12 patients who experienced stepwise progression of disease, there was a trend towards a higher proportion having anti-PMP22 antibodies (33% v 15% of those with gradual disease progression, 3% ONPs, and no normal controls) and complement fixing antibodies to human cauda equina (25% v 5% with gradual progression, 8.6% ONPs, 3.9% normal controls, p=0.07). CONCLUSIONS: Patients with HMSN1a and a stepwise disease progression may have an inflammatory, autoimmune component superimposed on the genetic condition.

Adult↗
PubMed2005

A single re-implanted ventral root exerts neurotropic effects over multiple spinal cord segments in the adult rat.

Spinal cord injuries, particularly traumatic injuries to the conus medullaris and cauda equina, are typically complex and involve multiple segmental levels. Implantation of avulsed ventral roots into the spinal cord as a repair strategy has been shown to be neuroprotective and promote axonal regeneration by spinal cord neurons into an implanted root. However, it is not well known over what distance in the spinal cord an implanted ventral root can exert its neurotropic effect. Here, we investigated whether an avulsed L6 ventral root acutely implanted into the rat spinal cord after a four level (L5-S2) unilateral ventral root avulsion injury may exert neurotropic effects on autonomic and motor neurons over multiple spinal cord segments at 6 weeks postoperatively. Using retrograde labeling techniques and stereological quantification methods, we demonstrate that autonomic and motor neurons from all four lesioned spinal cord segments, spanning more than an 8 mm rostro-caudal distance, reinnervated the one implanted root. The rostro-caudal distribution suggested a gradient of neurotropism, where the axotomized neurons closest to the implanted site had the highest probability of root reinnervation. These results suggest that implantation of a single ventral root may provide neurotropic effects to injured neurons at the site of lesion as well as in the adjacent spinal cord segments. Our findings may be of translational research interest for the development of surgical repair strategies after multi-level conus medullaris and cauda equina injuries, in which fewer ventral roots than spinal cord segments may be available for implantation.

Amidines↗
PubMed1999

Transitional lumbosacral vertebral anomaly in the dog: a radiographic study.

Transitional lumbosacral vertebral anomalies have for some time been suggested as a possible cause of cauda equina syndrome (especially in the German shepherd dog [GSD]), a condition recently thought to be inherited. The frequency of this condition within a large clinical population and the radiographic features used in its detection are reported. In a group of 143 patients, the sexes were similarly represented and the GSD was greatly overrepresented. The anomaly is characterised by separation of the first sacral segment that was identified on the lateral view by the presence of a radiolucent disc space between what are normally the first and second sacral segments. On the ventrodorsal view, the anomaly was characterised by separation of the spinous processes between what are normally the first and second sacral segments. In the presence of the transitional segment, the nature of the sacroiliac joint at the level of the anomalous segment varies from a strong ilial attachment, with the presence of a wing-like lateral process, to a weakened ilial attachment because of the presence of a lateral process, shaped as that seen on a lumbar segment. These patterns were present unilaterally or bilaterally and result in symmetrical or asymmetrical patterns. The effect of the weakening of the sacroiliac attachment was thought to result in premature disc degeneration, which, together with spinal canal stenosis, resulted in potential compression of the overlying spinal nerves and creation of a cauda equina syndrome. The condition is thought to have clinical significance and should be selected against in breeding, especially in the GSD.

Animals↗
PubMed1998

Magnetoneurographic 3D localization of conduction blocks in patients with unilateral S1 root compression.

OBJECTIVES: Tibial nerve somatosensory evoked magnetic fields (tSEFs) over the lower back reflect the propagation of compound action currents along fibers of plexus, nerve roots and cauda equina. One clinical perspective for this 'magnetoneurography' is the non-invasive 3D localization of focal slowing or blocks of conduction. Here, first tSEF mappings in 3 consecutive patients with acute unilateral S1 nerve root compression are reported. METHODS: Right and left tibial nerves were electrostimulated in alternation; tSEF responses were recorded using a multichannel SQUID-detector; additionally, spinal and cortical SEP, F-wave and H-reflex studies were performed. RESULTS: In all patients an intraindividual side-to-side comparison of spinal tSEF mappings was obtained: using a dipolar source model compound action currents could be visualized propagating along plexus, nerve roots and cauda equina on the non-affected side whereas on the affected side normally-propagating dipolar field patterns could be recorded only distal to the spinal transforaminal root entrance; this reflects focal slowing or block of conduction in nerve root fibers as indicated by the SEP, F-wave and H-reflex study results. CONCLUSIONS: With a registration time of 15 min a 3D localization of proximal slowing or block of conduction was successfully performed in patients suffering from acute nerve root lesions.

Cauda Equina↗
PubMed1988

Percutaneous electrical stimulation of lumbosacral roots in man.

High voltage percutaneous electrical stimulation over the lumbosacral spinal column was used to assess conduction in the cauda equina of 13 normal subjects. Electromyographic activity elicited by such stimulation was recorded from various muscles of the lower limbs. The stimulating cathode was placed over the spinous process of each vertebral body and the anode kept on the iliac crest contralateral to the studied limb. Shifting the cathode in a rostro-caudal direction shortened the response latency in quadriceps, tibialis anterior and extensor digitorum brevis muscles. At moderate intensities (60% maximum), this occurred abruptly when the cathode was placed at levels corresponding to the exit sites from the spinal canal of the roots innervating these muscles. At these intensities, the size of the response in each muscle was largest when the cathode was placed over the conus medullaris or at or below the exit of the motor roots from the spine. Latencies were always equal to or shorter than those obtained with F-wave measurements, suggesting that peripheral motor axons, rather than intraspinal structures were activated by the stimulus. Collision experiments demonstrated that activation occurred at two sites: near the spinal cord and at the root exit site in the vertebral foramina. Recordings made from soleus indicated that larger diameter proprioceptive afferent fibres also could be activated. This technique might have useful clinical applications in the study of both proximal and distal lesions of the cauda equina and provide a non-invasive method of localising such lesions electrophysiologically.

Adult↗