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Three new cases of intradural lumbar disc hernia are added to the 25 previously published cases. The clinical features of the lesion, which usually occurs at the level of the cauda equina, and its pathogenesis are discussed.
Not infrequently the lumbosacral root-compression syndrome is due to stenosis of the lumbal spinal canal. The clinical symptoms, usually emerging in the middle-aged, may be characterized by either simple radicular pain with or without neurological deficit or by exercise-dependent transient functional disturbance of the cauda equina, namely, the so-called neurogenic intermittent claudication (NIC). In most cases, NIC is due to mechanical compression of the cauda fibers as a result of extension of the patient's lumbar spine. In some patients, exercise-induced ischemic radiculopathy is assumed to be the main factor. Differential diagnosis must take into account true intermittent claudication, certain rare myopathies (if the exercise-dependent pain is the main feature), and certain transient disturbances in spinal cord function (if a motor and/or sensory deficit arises during the NIC attack).
Clear cell meningioma (CCM) is a rare variant of meningioma. Only 17 cases have been previously reported in children. Although it has bland cytologic features, it has a higher rate of recurrence than does conventional meningioma. This variant has been reported in sites such as spinal/intradural (lumbar and thoracic), cerebellopontine angle, and supratentorial. The differential diagnosis of CCM includes microcystic meningioma, hemangioblastoma, and clear cell ependymoma. The characteristic histology and immunohistochemistry leads to the diagnosis. We present a case of a 7-year-old boy with a CCM of the cauda equina and a review of pediatric CCM.
There are many reasons for the formation of cavities in the spinal cord. A focal cavitation is distinguished from syringomyclia by the absence of an ependymal lining in the former as opposed to the latter. The authors report a case of an isolated eccentrically placed syringomyelia of the conus medullaris, which caused a cauda equina syndrome and resembled a tumour on MRI.
A case of radiation induced sarcoma presenting seven years after radiotherapy for a conus cauda equina astrocytoma is reported.
In the field of lumbar spine disorders, three-dimensional (3-D) magnetic resonance imaging (MRI) can clearly depict a lumbar nerve root from the distal region to the dorsal root ganglion. In this study, we used a gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) enhanced-three-dimensional (3-D) fast low-angle shot (FLASH) sequence when examining lumbosacral disorders. The subjects were 33 patients (14 men and 19 women) in whom lumbosacral neural compression had been diagnosed clinically. Twenty-one patients had lumbar disc herniation, 11 had lumbar spinal stenosis, and 1 had lumbar radiculopathy caused by rheumatoid arthritis. Five subjects with low back pain were also studied as a control group. In all patients and in all 5 of the controls, the dorsal root ganglion of every root was enhanced clearly. There was no root enhancement in the 5 controls. Enhancement of the symptomatic nerve roots, caused by compression, was found in 11 of the 33 patients. All 11 patients had radiculopathy, and muscle weakness was more frequent in patients with enhanced nerve roots than in those without enhancement. There was no enhancement of the cauda equina, even in the patients with cauda syndrome. The enhancement effect may reflect some pathological condition of the compressed nerve root and needs to be studied further.
Bladder and urethral innervation was studied in 18 patients with protruded lumbar disk or persistent back pain after laminectomy. A high incidence of neurogenic dysfunction of the detrusor muscle was found, whereas impaired function of the striated external urethral sphincter was rare. The lesions were encountered among the patients with protruded lumbar disk as well as among the patients with sequelae after laminectomy, suggesting that neurogenic bladder dysfunction in cauda equina injury due to protruded disk is often irreversible.
Short latency SEPs to peroneal nerve stimulation were recorded from the scalp of 22 normal adults. The scalp topography and the effect of different frequency filters on these potentials were investigated. Using a wider bandpass (5-3000 Hz), this response usually consisted of 3 positive potentials (peak latencies 17, 22 and 27 msec) followed by a negative potential (peak latency 34 msec). Using a narrower bandpass (150-3000 Hz), these potentials were fractionated into subcomponents and up to 6 positive potentials were followed by an often bilobed negative potential occurring 4-10 msec earlier than the first negative potential recorded with the wider bandpass filters. The negative potential and the preceding major positive potentials were well defined and stable within and across normal subjects which suggests they will be useful in the clinical evaluation of patients with spinal cord pathology and in monitoring patients during surgery. Certain of these potentials recorded using the wider bandpass were often characterized by progressive differences in their peak latencies over the scalp. Evidence is provided which suggests that this occurred because subcomponents of these potentials, observed in recordings using the narrower bandpass had different scalp distributions. Evoked potentials were also recorded from surface electrodes placed over the spine of some of these subjects. These recordings when combined with the scalp recordings provided information concerning the conduction characteristics of SEPs from cauda equina to cerebral cortex.
This is a case report of a patient with bowel, bladder and sexual dysfunction associated with low back pain. This patient had an essentially normal neurological examination. There was radiological evidence of a disk lesion, and urodynamic findings consistent with lower motor neuron bladder dysfunction. His symptoms are attributed to a L4-5 disk herniation resulting in a partial cauda equina syndrome. The relevant anatomy is reviewed, and the differential diagnosis is discussed.
A 67-year-old woman with a sensory polyneuropathy was shown to have a serum monoclonal immunoglobulin M lambda antibody with a titer of 1:10,000 toward GD1b ganglioside. The immunoglobulin M also reacted with some other gangliosides containing disialosyl groups such as GD2, GD3, and GQ1b, but it did not react with GM1, LM1, or GD1a. The principal reactive ganglioside in human cauda equina was GD1b.
A survey based on interviews with all Norwegian hospitals, 62 in number, showed that in 1974 and 1975 respectively 65 and 66 traumatic spinal cord and cauda equina lesions were treated in Norway, a total of 131 or 16 . 5/million inhabitants/year.
The mixed results of two studies on intradiscal therapy with collagenase versus chymopapain are presented. The first study was performed from January 1983 to March 1984 and consisted of 71 patients treated with collagenase injection (600 ABC units) and 93 patients treated with chymopapain injection (4,000 units) into lower lumbar discs. The second study was started in May 1985 and ended December 1985. The results of 41 patients injected with chymopapain and 45 patients injected with collagenase (400 ABC units) are reported. The overall success rate after 3 months was 69%/63% for chymopapain/high-dose collagenase and 73%/71% for chymopapain/low-dose collagenase and 75%/72% after 6 months for chymopapain/high-dose collagenase. Eighteen percent of the chymopapain-treated patients and 21% of the collagenase-treated patients of the first study had to be operated on within 6 months and 12% of chymopapain patients and 29% of collagenase patients within 3 months in the second study. Six of the 134 patients who had chymopapain treatment had slight allergic reactions. Patients who had collagenase treatment had no allergic reactions under the same regimen of systemic prophylactic measures. Patients who had high-dose collagenase injections suffered significantly more from postinjectional pseudoradicular and low-back pain in the first 3 months. In the first study, no permanent neurologic complications occurred. Two patients in the low-dose collagenase group developed cauda equina syndromes in the 2 weeks after injection because of large extruded disc fragments.
The increased use of continuous spinal anesthesia (CSA) in recent years has resulted in research efforts directed at reducing the complications associated with the technique. Complications of CSA are categorized as general, the same as those associated with single-shot spinal anesthesia, and specific, those associated solely with CSA. General complications include infection, backache, hematoma, and neurological sequelae. Specific complications are all related to catheter use. The risk of developing the neurological complication of postdural puncture headache (PDPH) led to the use of microcatheters designed specifically for CSA. While the incidence of PDPH decreased with the use of microcatheters, the risk of developing the more serious complication of cauda equina syndrome increased, resulting in a Safety Alert being issued by the Food and Drug Administration.
The filum terminale is an exceptional location for isolated hemangioblastoma. Only five cases are reported in literature, prior to the magnetic resonance imaging era. A 57-year-old man was referred to our Department with a prolonged history of progressive back pain, particularly severe when recumbent, and recurrent unilateral sciatalgia. Computed tomography demonstrated a non-homogeneous mass at L4 level. Magnetic resonance imaging displayed earliness and homogeneous enhancement of the mass with tortuous vessels above the rostral pole of the tumour, suggesting the diagnosis of a vascular tumour. The tumour was totally removed. Histological examination confirmed the hemangioblastoma diagnosis. The case indicates that hemangioblastoma, although uncommon, must be taken into consideration in cauda equina tumour diagnosis, and also emphasises the specificity of magnetic resonance features.
The results of surgical treatment of the tethered spinal cord syndrome in twenty-five children in the age range six weeks to nineteen years are reported. After a description of the symptomatology, the importance of neuroradiologic investigations including myelography and CT-scanning as well as urodynamic studies are explained. The operative techniques are described in cases of tight filum terminale, lipoma of the filum terminale, diastematomyelia, lipomyelomeningocele and meningocele. Early operation is essential to avoid the neurological damage which results from awaiting the onset of symptoms. The aim of the operation is to free the conus medullaris and cauda equina before mechanical traction or compression damages function in lumbosacral cord.
OBJECTIVE: In a retrospective study, the extent of functional recovery and the merits of surgical exploration versus conservative management for spinal cord injuries were evaluated for 145 casualties from the front lines of the Iran-Iraq conflict. METHODS: Eighty-seven patients who underwent surgical exploration and 58 patients who were conservatively treated were monitored for 6 to 140 months (average, 57 +/- 31 mo) for any changes from their baseline neurological status, using the Frankel Scoring System. RESULTS: Twenty-two of 90 patients (24.4%) with complete injuries (Frankel score A) and 53 of 55 (96.4%) with incomplete injuries (Frankel scores B, C, and D) experienced changes in their neurological status as they recovered. Improvement was noted for 42 of 87 surgically treated patients (13 of 55 with complete injuries and 29 of 32 with incomplete injuries). Among conservatively treated patients, improvement was noted for 32 of 58 (55%), including 25.7% of those with complete injuries and 100% of those with incomplete injuries. Independent walking (Frankel scores D and E) was achieved by 10 of 90 patients with complete injuries and by 52 of 55 patients with incomplete injuries. Surgery did not affect the final outcome. Thirteen of 17 (76%) cerebrospinal fluid fistulas, 13 of 15 (87%) meningitides, and 4 of 6 (67%) local septic complications were encountered in the surgically treated group. CONCLUSION: Surgery did not enhance functional recovery from spinal cord missile injuries but did correlate with an increased prevalence of complications (fistulas, meningitis, and local sepsis). With or without surgical exploration, patients with seemingly complete cauda equina injuries demonstrated better functional outcome than did those with spinal cord injuries.
In a 56-year-old woman with multiple myeloma involving the leptomeninges diffusely, MR of the spine showed multiple vertebral compression fractures and marked enhancement of the cauda equina region. Intracranial MR showed pathologic enhancement of the left third and fifth cranial nerves.
Intraosseous pressure (IOP) and cerebrospinal fluid pressure (CSFP) in the lumbar region were measured simultaneously in two groups of patients with either spinal canal stenosis or disc herniation, to compare dynamic changes with positional changes, and to learn whether these pressure changes may have some role in the onset of claudication. IOP and CSFP showed almost the same change patterns with positional changes in two groups. They were lowest in the prone position and highest at the standing position. In standing with flexion, they were almost the same as in the prone position, but in extension they increased above the standing pressure. These dynamic pressure changes could act as a compression force to the cauda equina in the patient with spinal canal stenosis.