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Conus medullaris and cauda equina syndromes

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  • 1. Conus Medullaris andCauda Equina Syndromes Temple University Hospital November 22, 2006 Presented by Darric E. Baty, M.D.
  • 2. Outline of Discussion• Introduction• Anatomical Overview• Conus Medullaris Syndrome• Trauma As An Etiology• Cauda Equina Syndrome• Questions
  • 3. Introduction• Conus medullaris and cauda equina syndromes are clinical entities – Diagnosis based on clinical findings • History and Physical Examination – Diagnosis prompts emergent acquisition of appropriate radiographic workup • Exclude psychogenic causes • Identify the pathology to aid in formulation of a treatment plan – Etiology is variable
  • 4. Introduction• What’s the Difference? – Idealistically • Patients with conus medullaris syndrome typically present with symptoms consistent with: – Spinal cord compression – Spinal cord dysfunction – “Intrinsic pathology” • Patients with cauda equina syndrome typically present with symptoms consistent with: – Lumbosacral radiculopathies – “Extrinsic pathology” – Practically • There is much overlap in symptomatology • Both require complete evaluation, including imaging, to manage appropriately
  • 5. Anatomical Overview• For Zak • For Bong Soo
  • 6. Anatomical Overview
  • 7. Conus Medullaris Syndrome• Definitions – Historically (i.e., in the “pure, classic” syndrome) defined as signs consisting of: • Paralytic bladder incontinence • Bowel incontinence • Impotence • Perineal sensory changes • Absence of lower extremity weakness – Presently, a constellation of signs and symptoms including: • Bowel dysfunction • Bladder dysfunction • Sexual dysfunction • Poor rectal tone • Perianal sensory changes • Sometimes, lower extremity weakness
  • 8. Conus Medullaris Syndrome• Etiologies – Tumor – Vascular lesion – Diabetic neuropathy – Trauma – Disc herniation
  • 9. Conus Medullaris Syndrome• Symptoms – Back pain – Unilateral or bilateral leg pain – Bladder dysfunction – Bowel dysfunction – Sexual dysfunction – Diminished rectal tone – Perianal sensory loss – Lower extremity weakness
  • 10. Trauma As An Etiology
  • 11. Trauma As An Etiology• Acute Spinal Cord Injury Syndromes in Trauma Patients – Complete spinal cord injury • ASIA/IMSOP Grade A • Unilevel: no zone of partial preservation • Multiple level: zone of partial preservation – Incomplete spinal cord injury • ASIA/IMSOP Grades B, C, and D • Cervicomedullary syndrome • Central cord syndrome • Anterior cord syndrome • Posterior cord syndrome • Brown-Séquard syndrome • Conus medullaris syndrome – Complete cauda equina injury • ASIA/IMSOP Grade A – Incomplete cauda equina injury • ASIA/IMSOP Grade B, C, and D – Reversible or transient syndromes • Cord concussion • Burning hands syndrome • Contusio cervicalis • Hysteria
  • 12. Trauma As An Etiology• Conus Medullaris Syndrome: Trauma Definition – Combination of upper and lower motor neuron deficits, with initial flaccid paralysis of the legs and anal sphincter
  • 13. Trauma As An Etiology• Conus Medullaris Syndrome: Trauma Symptoms – Acute Phase • Flaccid paralysis of the legs • Paralysis of the anal sphincter – Chronic Phase • Muscle atrophy of the legs • Lower extremity spasticity • Lower extremity hyperreflexia – Extensor plantar response may be present • Development of a low-pressure, high-capacity neurogenic bladder – Sensory deficits are variable
  • 14. Cauda Equina Syndrome• Definitions – Historically • Bilateral sciatica – Expanded to include unilateral sciatica • What about a central disc herniation at L5-S1 sparing the motor and sensory roots of the lower extremities but affecting bowel and/or bladder function? • The frequency of daily urination is much greater than bowel evacuation, so… – Presently • Bladder dysfunction with a decrease in perianal sensation
  • 15. Cauda Equina Syndrome• Etiologies – Disc herniation – Disc fragment migration – Iatrogenic epidural hematoma • Post LP or spinal anesthesia • Postoperatively – Infection – Tumor – Trauma
  • 16. Cauda Equina Syndrome• Symptoms – Back pain – Radicular pain • Bilateral • Unilateral – Motor loss – Sensory loss – Urinary dysfunction • Overflow incontinence • Inability to void • Inability to evacuate the bladder completely – Decrease in perianal sensation
  • 17. Cauda Equina Syndrome• Avoid the Trap – Acute central disc herniation at L4-5 or L5-S1 • The sacral roots lie centrally within the dural sac • Sparing of the lumbar, and even S1, roots may be present – Total preservation of leg strength possible – Bowel and bladder may be completely paralyzed – Perineal anesthesia present • The sacral roots are very delicate – Recovery may not occur, even with relatively expeditious decompression
  • 18. Questions• Please give two etiologies of conus medullaris and/or cauda equina syndrome• Please recall the most common location for the end of the spinal cord in the adult human