Disorders of the spinal cord and cauda equina.
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Cauda Equina↗
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[Cauda equina neurinoma associated with intracranial hypertension--case report].
A case of cauda equina neurinoma associated with intracranial hypertension is reported. A 59-year-old female with a history of disturbed orientation was admitted. A neurological examination upon admission revealed the disorientation and gait disturbance. Superficial sensation under L3 was impaired. A computed tomographic(CT) scan presented the enlargement of ventricles and the slightly poor description of cerebral sulci. Since the patient had a high fever up to 40.1 C, meningitis was suspected. Cerebrospinal fluid revealed that cell count was only 2/3, while the protein concentration was markedly elevated (389mg/dl). Froin reaction was extremely positive and fibrin was observed. Based upon these findings, the spinal tumor was considered. Plain lumber film showed the posterior scalloping of the L5 and S1 vertebral bodies. Gd-DTPA enhanced MRI showed a high signal intensity area at the cauda equina. Diagnosed as a cauda equina tumor, the total resection of the tumor was performed via laminectomy of L3-S1. The tumor was involved with nerve filaments at the cauda equina. The pathological diagnosis was neurinoma. After the operation, her symptoms improved and a CT scan revealed the reduction of the ventricular size. However, the protein concentration of cerebrospinal fluid did not normalized.
Cauda Equina↗
Cauda equina syndrome in patients undergoing manipulation of the lumbar spine.
Cauda equina syndrome has been implicated as a potential complication of spinal manipulation. A review of the literature from 1911 to 1989 revealed ten reported cases of cauda equina syndrome in patients undergoing manipulation without anesthesia. This article presents three new cases where a temporal association was found between the onset of cauda equina symptoms and lumbar manipulation. The type of manipulation administered and the relationship between the treatment and symptoms is reviewed. In each of these cases both the chiropractic practitioner and the emergency room physician failed to comprehend the nature of the problem and take appropriate action. As a consequence, the patients went untreated for several days. This may have led to residual symptomatology. It is concluded that patients who present with bowel or bladder disturbances, leg weakness, or rectal and genital sensory changes after manipulation, be recognized as experiencing a cauda equina syndrome.
Adult↗
Experimental nerve root compression. A model of acute, graded compression of the porcine cauda equina and an analysis of neural and vascular anatomy.
Nerve root compression has been suggested as one important pathogenetic factor in low-back pain syndromes and sciatica. The underlying pathophysiologic mechanisms are, however, incompletely known, partly because of the lack of experimental data on this topic. In the present study, a model for experimental compression of the porcine sacrococcygeal cauda equina is presented. The model consists of surgical exposure of the cauda equina and compression of the cauda equina toward the ventral aspect of the spinal canal by an inflatable balloon fixed to the spine. This compression system was shown to have a high accuracy in pressure transmission from the balloon to the cauda equina. The gross and microscopic neural anatomy and the vascular anatomy of the porcine cauda equina were analyzed with light microscopic and ink-perfusion techniques. The porcine cauda equina showed a close anatomic resemblance to the human lumbosacral cauda equina. The presented model offers unique possibilities for experimental studies on nerve root compression injury because of the easy surgical exposure and the sufficient length of the nerve roots. In separate studies, this model, along with investigations of solute transport to the nerve tissue and of impulse propagation, has been used to analyze the effects of acute, graded compression on blood flow and edema formation in the cauda equina. The porcine cauda equina would also be particularly suitable for chronic compression studies because any neurologic deficit acquired would be restricted to the tail.
Animals↗
Angiotropic lymphoma (intravascular large cell lymphoma) presenting with cauda equina syndrome.
A 50-year-old man developed cauda equina syndrome of unknown etiology that was stable for 20 months. Two months prior to sudden death, he experienced new back pain, confusion, seizures, and multiple cranial nerve palsies. Neuropathologic examination revealed angiotropic lymphoma without parenchymal involvement or infarcts in the brain, spinal cord, and muscle. In addition, nerve roots in the cauda equina contained angiotropic lymphoma and infarcts of various ages. Angiotropic lymphoma should be considered as a cause of cauda equina syndrome and of disorders that affect the central and peripheral nervous systems concurrently.
Brain Neoplasms↗
1991 Volvo Award in experimental studies. Cauda equina syndrome: neurologic recovery following immediate, early, or late decompression.
An animal model of cauda equina syndrome was developed. Neurologic recovery was analyzed following immediate, early, and delayed decompression. Five experimental groups, each containing six dogs, were studied. Compression of the cauda equina was performed in all 30 dogs following an L6-7 laminectomy. The cauda equina was constricted by 75% in each group. The first group was constricted and immediately decompressed. The remaining groups were constricted for 1 hour, 6 hours, 24 hours, and 1 week, respectively, before being decompressed. Somatosensory evoked potentials were performed before and after surgery, before and immediately after decompression, and 6 weeks following decompression. Daily neurologic exams using the Tarlov grading scale were performed. At 6 weeks postdecompression, all dogs were killed, and the neural elements analyzed histologically. Following compression, all 30 dogs had significant lower extremity weakness, tail paralysis, and urinary incontinence. All dogs recovered significant motor function 6 weeks following decompression. The dogs with immediate decompression generally recovered neurologic function within 2-5 days. The dogs receiving 1-hour and 6-hour compression recovered within 5-7 days. The dogs receiving 24-hour compression remained paraparetic 5-7 days, with bladder dysfunction for 7-10 days and tail dysfunction persisting for 4 weeks. The dogs with compression for 1 week were paraparetic (Tarlov Grade 2 or 3) and incontinent during the duration of cauda equina compression. They recovered to walking by 1 week and Tarlov Grade 5 with bladder and tail control at the time of euthanasia. Immediately after compression, all five groups demonstrated at least 50% deterioration of the posterior tibial nerve evoked potential amplitudes.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina.
Midline prolapse of a disc causing compression of the cauda equina is rare but needs urgent diagnosis and surgical treatment. The onset of bladder and rectal paralysis with saddle anaesthesia should be viewed with a high index of suspicion in a patient with backache and sciatica. Eight cases were seen over a period of five years, and they fell into three clinical groups. Group I patients presented with a sudden onset without any previous symptoms related to the back. Group II patients had a history of recurrent episodes of backache and sciatica, the latest episode resulting in involvement of the cauda equina. The group III patient was indistinguishable from one with a tumour as he presented with backache and sciatica slowly progressing to paralysis of the cauda equina. The prolapse was at the disc between L5 and S1 vertebrae in 50 per cent of the patients, most of whom did not have any limitation of straight leg raising. Urgent myelography and equally urgent removal of the disc within two weeks of the onset of the symptoms resulted in almost complete motor and bladder recovery within five months after the operation in most cases. However, recovery of sensation and sexual function was incomplete even four years after the operation.
Adult↗
[A case of traumatic spinal subarachnoid hematoma causing compression of the cauda equina].
A case of traumatic spinal subarachnoid hematoma causing compression of the cauda equina is reported here. The patient, a 76 year-old woman, who had fallen down by accident 1 month before, was admitted to our hospital presenting lumbar pain radiating into her right thigh, monoplegia of the right leg and urinary incontinence. Myelography and metrizamide CT demonstrated a filling defect mimicking intradural extramedullary tumor at the level of L1 and L2. Magnetic resonance imagings (MRI) revealed a subacute or chronic hematoma compressing the conus medullaris and the cauda equina. Operation was performed and an old hematoma, which occupied most of the spinal subarachnoid space and compressed the conus and cauda equina from right to left, was removed. No definite bleeding point was detected and no traumatic change was seen on the cord. Neither tumor nor abnormal vessel was detected. After surgery, the symptoms improved partially. On a review of the literature, we found only 4 cases of traumatic spinal subarachnoid hematoma, all of which occupied the cervical or thoracic portion of the spine. Our case is the first report, except for the cases following lumbar spinal tap, of traumatic spinal subarachnoid hematoma causing compression of the cauda equina. Though usually blood in CSF diffuses immediately, a clot may be formed when a large amount of bleeding obstructs the spinal canal. In our case, furthermore, deformity and narrowing of the spinal canal had preceded for many years, following lumbar vertebral compressed fracture related with osteoporosis. This might have promoted the process of canal obstruction and clot formation.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Spinal nerve root compression. Nutrition and function of the porcine cauda equina compressed in vivo.
A model for experimental studies of acute, graded compression of the cauda equina in pigs was presented (Olmarker et al. 1991a). Detailed analyses of the neural and vascular anatomy demonstrated a close resemblance to the human cauda equina. There were structural and vascular differences between spinal nerve roots and peripheral nerves that could contribute to differences in compression susceptibility between these two parts of the nervous system. The pressure transmission from the balloon to the nerve roots showed to have a high accuracy. The occlusion-pressures for the arterioles, capillaries and venules of the cauda equina were determined (Olmarker et al. 1989a). Arteriolar blood flow was stopped at a pressure close to the mean arterial blood pressure. Capillary blood flow was found to be dependent upon flow in the connected venules. The blood flow in some venules was found to be stopped at 5-10 mm Hg. However, venular occlusion pressures ranged from 5 to 60 mm Hg. Compression up to 200 mm Hg for 2 hours did not induce a "no-reflow" phenomenon when the compression was ended. However, a transient hyperemia was noted at all pressure/time relations studied, indicating nutritional deficit in the compressed segment during compression. Signs of edema were seen in nerve roots exposed to compression for 2 hours at either 50 or 200 mm Hg. The nutritional supply to the cauda equina was found to be impaired at low pressure levels (less than 10 mm Hg; Olmarker et al. 1990a). Diffusion from adjacent tissues with a better nutritional supply, including the cerebrospinal fluid, could thus not compensate completely for compression-induced effects on the transport of nutrients. However, a certain nutritional supply to the compressed segment was present even at 200 mm Hg compression. There were more pronounced effects on the nutritional supply induced by a rapid (0.05-0.1 sec.) than a slow (20 sec.) compression onset rate. Nutritional impairment was noted both within and outside the compressed nerve segment. An increase in vascular permeability was induced by compression at 50 mm Hg for 2 minutes (Olmarker et al. 1989b). The magnitude of this permeability increase was dependent on both the magnitude and the duration of compression. The permeability increase was more pronounced for the rapid than for the slow compression onset rate at all pressure/time relations studied. Reduction of muscle action potential (MAP) amplitude in tail muscles, after stimulation cranial to the compression zone, was induced by compression at 100 and 200 mm Hg for 2 hours (Olmarker et al. 1990b).(ABSTRACT TRUNCATED AT 400 WORDS)
Acute Disease↗
Morphologic and quantitative changes in neurotransmitters in the lumbar spinal cord after acute or chronic mechanical compression of the cauda equina.
Changes in the neurotransmitters associated with pain transmission and regulation in the lumbar spinal cord were studied after acute or chronic mechanical compression of the cauda equina in rats. Using glyoxylic acid histofluorescence and immunohistochemical methods, it was morphologically apparent that substance P-containing nerve ending were decreased after chronic compression of the cauda equina. Somatostatin nerve terminals were reduced, and aminergic fibers and serotonin were enhanced after both acute and chronic mechanical compressions. In addition, quantitative analysis revealed that the levels of norepinephrine and serotonin remained elevated after mechanical compression of the cauda equina. It is suggested that pain in the lower back and extremities after mechanical compression of the cauda equina is controlled by these complicated changes of neurotransmitters in the lumbar spinal cord.
Animals↗
Claudication of the cauda equina.
The term "claudication of the cauda equina" is examined. It has arisen from semantic errors, and a belief in ischaemia for which there is no scientific evidence. Its use tends to hamper rather than assist the investigation of patients with obscure pain in the lower limb. A preferable alternative term, "atypical sciatica", is suggested.
Cauda Equina↗
Banded structures in cauda equina.
Banded structures identified in a cauda equina biopsy from a patient with compression are identical to those seen in schwannomas and several other conditions and identified as fibrous long-spacing collagen. They are present in relation to the basement membrane with a periodicity of about 1200 A. It was not possible to identify their substructure further. It is postulated that the initiating factor in their formation in this instance is compression of the spinal nerves.
Basement Membrane↗
Cerebrospinal fluid dynamics in the tardive cauda equina syndrome of ankylosing spondylitis.
Typical cauda equina syndrome secondary to long-standing ankylosing spondylitis is reported in a 63-year-old man. Radionuclide cisternography demonstrated a resorption defect of cerebrospinal fluid in the enlarged lumbosacral dural sac. After transient symptomatic improvement with acetazolamide, a lumboperitoneal shunt was placed. The rate of cerebrospinal fluid, isotope resorption became normal. In the 5 years of follow-up, partial remission has been observed.
Cauda Equina↗
Cauda equina compression presenting as spontaneous priapism.
Disturbance of autonomic function is an unusual feature of compression of the cauda equina. A 61 year old man who had complete occlusion of the lumbar spinal canal with compression of the cauda equina from a large centrally prolapsed disc, had spontaneous priapism, precipitated by walking and relieved by resting. This symptom was comparable to claudication by compression of cauda equina. It subsided completely after surgical removal of a prolapsed L4-5 disc.
Aged↗
Capillary hemangioma in the cauda equina: neuroradiological findings.
A case of capillary hemangioma of the cauda equina is reported. Myelography with water-soluble contrast material showed a complete obstruction of the contrast column at the L1-L2 level. Neither plain nor intravenously enhanced CT revealed the tumor. Spinal angiography showed a feeding vessel to the tumor and a faint tumor stain. Magnetic resonance imaging (MRI) showed a mass lesion of slightly higher than cauda equina intensity, which was clearly enhanced with Gd-DTPA. MRI, especially Gd-DTPA-enhanced study, plays the most important role in the diagnosis of a spinal capillary hemangioma. Spinal angiography was interesting in showing a tumour with a capillary blush.
Angiography↗
Diagnosis of cauda equina abnormalities by using electromyography, discography, and epidurography in dogs.
Electromyography (EMG), L7-S1 discography and epidurography were investigated in 15 dogs with clinical signs of cauda equina dysfunction and in 7 control dogs without such clinical signs. Electromyography of paraspinal and pelvic limb muscles was done in 13 of 15 affected dogs. An L7-S1 discogram followed by an epidurogram was performed in all 22 dogs using 20% iopamidol. Results of discograms, epidurograms, and gross necropsy examinations were normal in six of seven control dogs. The one dog in which these studies were abnormal had a mild L7-S1 disc protrusion that did not result in nerve root compression at necropsy. Electromyographic analysis was 100% accurate in predicting the presence or absence of cauda equina disease. None of the results of discograms were falsely negative. Twelve of 15 discograms in clinically affected dogs indicated dorsal disc protrusion, but 2 of these protrusions were found to be noncompressive at surgery (13% error). Abnormal epidurograms occurred in 9 of 15 clinically affected dogs. There was one false positive and two false negatives (20% error). Electromyography was a sensitive screening technique for the presence of cauda equina disease. Discography may be more sensitive for detection of L7-S1 disc protrusion than epidurography. An abnormal radiographic contrast study of the cauda equina may only be useful when combined with an abnormal EMG.
Animals↗
Mobile schwannoma of the cauda equina. Case report.
A patient with a mobile schwannoma of the cauda equina is described. The wide discrepancy between the myelographic and surgical locations of the tumor is most unusual. Awareness of the possibility of such an extreme degree of motility is important when dealing with cauda equina tumors.
Cauda Equina↗