Cauda conus syndromes

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Cauda conus syndromes

  1. 1. DR. ANKUR NANDAN VARSHNEYDEPARTMENT OF GENERAL MEDICINE IMS, BHU
  2. 2.  A 21-yr- old male, unmarried c/o:-1. Difficulty in urination X 2 ½ year2. Lower back pain X 2 year3. Pain in both lower limb with numbness X 2 year4. Weakness in right lower limb along with thinning of limb X 1 year
  3. 3.  Vitals = WNL General Condition = within normal limit CNS =1. Higher mental fxn WNL2. Cranial nerves = WNL3. Upper limb = WNL4. Findings confined to lower limb Sensory1. Pain and temperature lost up to 20% - L2 level.2. In saddle area , sensation lost up to 90%.3. Vibration = 50% reduced right side4. mildly reduced on left side
  4. 4.  Gait = unable to walk alone try to avoid weight on right side no apparent foot drop Motor examination =1. Wasting of thigh and calf muscles. right left1. Mid thigh = 36 cm 37.5 cm2. Leg = 26.5 cm 28 cm Tone = normal to slight decreased right side , left side WNL
  5. 5.  POWER = Right Left1. Hip flexion wnl wnl2. Hip adduction 4/5 5/53. Knee extension 4/5 5/54. Knee flexion 4/5 5/55. Dorsiflexion foot 3/5 5/5 REFLEXES =1. Knee - -2. Ankle - -3. Abdominal WNL WNL4. Bulbocavernous - -5. Anal reflex -6. Anal tone reduced
  6. 6.  Functional Anatomical Pathological Etiological
  7. 7.  VERTEBRAL  NON VERTEBRAL 1. Meningioma1. Infections = TB 2. Neurofibroma2. Tumour affecting spine = 3. Ependyoma secondaries , multiple myeloma 4. Astrocytoma3. Lumbar spondylosis , PID 5. Epidural abscess 6. Spinal arachnoiditis4. Cong lumbar canal stenosis 7. cyst- dermoid5. Spondylosis , spondyloarthrosis , epidermoid6. Spina bifida , tethered cord , hydatid syndrome 8. Leukemia , lymphoma7. Metabolic = osteoporosis deposits. , osteomalcia , osteosclereosis 9. Intramedullary deposits 10. Arterio- venous malformations
  8. 8. ◦ a constellation of signs and symptoms including:  Bowel dysfunction  Bladder dysfunction  Sexual dysfunction  Poor rectal tone  Perianal sensory changes  Sometimes, lower extremity weakness
  9. 9.  Most distal bulbous part of spinal cord situated at level of L1-L2 vertebral bodies and comprises of sacral segments S1-S5. Signs shows involvement of:-1. Saddle anesthesia ( S3-S5)2. Absent Bulbocavernous reflexes ( S2-S4)3. Absent anal reflexes ( S4-S5) Symptoms include both upper and lower motor neuron lesions.
  10. 10.  Etiologies ◦ Tumor ◦ Vascular lesion ◦ Diabetic neuropathy ◦ Trauma ◦ Disc herniation
  11. 11.  Symptoms ◦ Back pain ◦ Unilateral or bilateral leg pain ◦ Bladder dysfunction ◦ Bowel dysfunction ◦ Sexual dysfunction ◦ Diminished rectal tone ◦ Perianal sensory loss ◦ Lower extremity weakness
  12. 12.  Cauda equina is the collection of nerve containing nerve roots from L1-L5 and S1-S5. Most centrally located nerve roots are from most caudal segments. Lesions give rise to lower motor neurons symptoms. Radicular pain is prominent and symptoms are usually unilateral. Bladder dysfunction with a decrease in perianal sensation
  13. 13.  Etiologies ◦ Disc herniation ◦ Disc fragment migration ◦ Iatrogenic epidural hematoma  Post LP or spinal anesthesia  Postoperatively ◦ Infection ◦ Tumor ◦ Trauma
  14. 14.  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
  15. 15.  Distribution of pain / paresthesia in certain dermatomes. Segmental / sensory changes Alteration in motor function ( weakness and wasting ) Reflex abnormalities Site of vertebral deformities and tenderness Imaging - X-ray , CT- myelo , MRI
  16. 16.  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” There is much overlap in symptomatology Both require complete evaluation, including imaging, to manage appropriately
  17. 17. CAUDA EQUINA CONUS CAUDA- CONUS SYNDROME MEDULLARIS SYNDROME SYNDROMEROOT PAIN +++ _ ++ asymmetricMOTOR ++ IN HIGH CAUDA +/- ++WEAKNESS +/- IN LOW CAUDASENSORY + SADDLE + ANESTHESIAREFLEXES ++ in high visceral ( bladder , ++( knee , ankle, +/- in low anal ,plantar , bulbocavernous )bulbocavernous) impairedSphinctor Late early Late/earlyinvolvement
  18. 18. CONUS MEDULLARIS CAUDA EQUINA SYNDROME SYNDROMEPresentation Sudden and bilateral Gradual and unilateralReflexes Knee jerk preserved but Both affected ankle jerks affectedRadicular pain Less MoreLow back pain More LessImpotence Frequent LessSensory dissociation Present No dissociationNumbness Symmetrical AsymmetricalMotor strength Symmetric Asymmetric Hyperreflexic Areflexia Distal paresis of lower Paraplegia limbsSphincter dysfunction Present early Present later Both urinary and fecal Only urinary retention

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