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DR. ANKUR NANDAN VARSHNEY
DEPARTMENT OF GENERAL MEDICINE
            IMS, BHU
   A 21-yr- old male, unmarried

 c/o:-
1. Difficulty in urination X 2 ½ year
2. Lower back pain X 2 year
3. Pain in both lower limb with numbness X 2
   year
4. Weakness in right lower limb along with
   thinning of limb X 1 year
    Vitals = WNL

    General Condition = within normal limit

 CNS =
1. Higher mental fxn WNL
2. Cranial nerves = WNL
3. Upper limb = WNL
4. Findings confined to lower limb


     Sensory
1.    Pain and temperature lost up to 20% - L2 level.
2.    In saddle area , sensation lost up to 90%.
3.    Vibration = 50% reduced right side
4.                 mildly reduced on left side
   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            left
1. Mid thigh = 36 cm            37.5 cm
2. Leg       = 26.5 cm           28 cm

    Tone = normal to slight decreased right
     side , left side WNL
 POWER =              Right            Left
1. Hip flexion          wnl            wnl
2. Hip adduction        4/5             5/5
3. Knee extension      4/5             5/5
4. Knee flexion         4/5             5/5
5. Dorsiflexion foot    3/5            5/5

    REFLEXES =
1.   Knee                -               -
2.   Ankle              -               -
3.   Abdominal         WNL              WNL
4.   Bulbocavernous     -               -
5.   Anal reflex                -
6.   Anal tone               reduced
   Functional

   Anatomical

   Pathological

   Etiological
    VERTEBRAL                             NON VERTEBRAL
                                       1.    Meningioma
1.   Infections = TB                   2.    Neurofibroma
2.   Tumour affecting spine =          3.    Ependyoma
     secondaries , multiple myeloma    4.    Astrocytoma
3.   Lumbar spondylosis , PID          5.    Epidural abscess
                                       6.    Spinal arachnoiditis
4.   Cong lumbar canal stenosis        7.    cyst- dermoid
5.   Spondylosis , spondyloarthrosis         , epidermoid
6.   Spina bifida , tethered cord            , hydatid
     syndrome                          8.    Leukemia
                                             , lymphoma
7.   Metabolic = osteoporosis                deposits.
     , osteomalcia , osteosclereosis   9.    Intramedullary
                                             deposits
                                       10.   Arterio- venous
                                             malformations
◦ a constellation of signs and symptoms
 including:
    Bowel dysfunction
    Bladder dysfunction
    Sexual dysfunction
    Poor rectal tone
    Perianal sensory changes
    Sometimes, lower extremity weakness
   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.
   Etiologies
    ◦   Tumor
    ◦   Vascular lesion
    ◦   Diabetic neuropathy
    ◦   Trauma
    ◦   Disc herniation
   Symptoms
    ◦   Back pain
    ◦   Unilateral or bilateral leg pain
    ◦   Bladder dysfunction
    ◦   Bowel dysfunction
    ◦   Sexual dysfunction
    ◦   Diminished rectal tone
    ◦   Perianal sensory loss
    ◦   Lower extremity weakness
   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
   Etiologies
    ◦ Disc herniation

    ◦ Disc fragment migration

    ◦ Iatrogenic epidural hematoma
      Post LP or spinal anesthesia
      Postoperatively

    ◦ Infection

    ◦ Tumor

    ◦ Trauma
   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
   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
 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
CAUDA EQUINA       CONUS               CAUDA- CONUS
                SYNDROME           MEDULLARIS          SYNDROME
                                   SYNDROME



ROOT PAIN       +++                        _                    ++
                asymmetric

MOTOR           ++ IN HIGH CAUDA               +/-         ++
WEAKNESS        +/- IN LOW CAUDA


SENSORY         +                  SADDLE              +
                                   ANESTHESIA

REFLEXES        ++ in high          visceral ( bladder , ++
( knee , ankle, +/- in low         anal ,
plantar ,                          bulbocavernous )
bulbocavernous)                    impaired



Sphinctor       Late               early               Late/early
involvement
CONUS MEDULLARIS          CAUDA EQUINA
                        SYNDROME                  SYNDROME
Presentation            Sudden and bilateral      Gradual and unilateral

Reflexes                Knee jerk preserved but   Both affected
                        ankle jerks affected
Radicular pain          Less                      More

Low back pain           More                      Less

Impotence               Frequent                  Less
Sensory dissociation    Present                   No dissociation

Numbness                Symmetrical               Asymmetrical

Motor strength          Symmetric                 Asymmetric
                        Hyperreflexic             Areflexia
                        Distal paresis of lower   Paraplegia
                        limbs
Sphincter dysfunction   Present early             Present later
                        Both urinary and fecal    Only urinary retention
Cauda conus syndromes

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Cauda conus syndromes

  • 1. DR. ANKUR NANDAN VARSHNEY DEPARTMENT OF GENERAL MEDICINE IMS, BHU
  • 2. A 21-yr- old male, unmarried  c/o:- 1. Difficulty in urination X 2 ½ year 2. Lower back pain X 2 year 3. Pain in both lower limb with numbness X 2 year 4. Weakness in right lower limb along with thinning of limb X 1 year
  • 3. Vitals = WNL  General Condition = within normal limit  CNS = 1. Higher mental fxn WNL 2. Cranial nerves = WNL 3. Upper limb = WNL 4. Findings confined to lower limb  Sensory 1. Pain and temperature lost up to 20% - L2 level. 2. In saddle area , sensation lost up to 90%. 3. Vibration = 50% reduced right side 4. mildly reduced on left side
  • 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 left 1. Mid thigh = 36 cm 37.5 cm 2. Leg = 26.5 cm 28 cm  Tone = normal to slight decreased right side , left side WNL
  • 5.  POWER = Right Left 1. Hip flexion wnl wnl 2. Hip adduction 4/5 5/5 3. Knee extension 4/5 5/5 4. Knee flexion 4/5 5/5 5. Dorsiflexion foot 3/5 5/5  REFLEXES = 1. Knee - - 2. Ankle - - 3. Abdominal WNL WNL 4. Bulbocavernous - - 5. Anal reflex - 6. Anal tone reduced
  • 6. Functional  Anatomical  Pathological  Etiological
  • 7.
  • 8.
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  • 10.
  • 11. VERTEBRAL  NON VERTEBRAL 1. Meningioma 1. Infections = TB 2. Neurofibroma 2. Tumour affecting spine = 3. Ependyoma secondaries , multiple myeloma 4. Astrocytoma 3. Lumbar spondylosis , PID 5. Epidural abscess 6. Spinal arachnoiditis 4. Cong lumbar canal stenosis 7. cyst- dermoid 5. Spondylosis , spondyloarthrosis , epidermoid 6. Spina bifida , tethered cord , hydatid syndrome 8. Leukemia , lymphoma 7. Metabolic = osteoporosis deposits. , osteomalcia , osteosclereosis 9. Intramedullary deposits 10. Arterio- venous malformations
  • 12. ◦ a constellation of signs and symptoms including:  Bowel dysfunction  Bladder dysfunction  Sexual dysfunction  Poor rectal tone  Perianal sensory changes  Sometimes, lower extremity weakness
  • 13. 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.
  • 14. Etiologies ◦ Tumor ◦ Vascular lesion ◦ Diabetic neuropathy ◦ Trauma ◦ Disc herniation
  • 15. Symptoms ◦ Back pain ◦ Unilateral or bilateral leg pain ◦ Bladder dysfunction ◦ Bowel dysfunction ◦ Sexual dysfunction ◦ Diminished rectal tone ◦ Perianal sensory loss ◦ Lower extremity weakness
  • 16. 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
  • 17. Etiologies ◦ Disc herniation ◦ Disc fragment migration ◦ Iatrogenic epidural hematoma  Post LP or spinal anesthesia  Postoperatively ◦ Infection ◦ Tumor ◦ Trauma
  • 18. 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
  • 19.
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  • 22.
  • 23. 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
  • 24.  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
  • 25. CAUDA EQUINA CONUS CAUDA- CONUS SYNDROME MEDULLARIS SYNDROME SYNDROME ROOT PAIN +++ _ ++ asymmetric MOTOR ++ IN HIGH CAUDA +/- ++ WEAKNESS +/- IN LOW CAUDA SENSORY + SADDLE + ANESTHESIA REFLEXES ++ in high visceral ( bladder , ++ ( knee , ankle, +/- in low anal , plantar , bulbocavernous ) bulbocavernous) impaired Sphinctor Late early Late/early involvement
  • 26. CONUS MEDULLARIS CAUDA EQUINA SYNDROME SYNDROME Presentation Sudden and bilateral Gradual and unilateral Reflexes Knee jerk preserved but Both affected ankle jerks affected Radicular pain Less More Low back pain More Less Impotence Frequent Less Sensory dissociation Present No dissociation Numbness Symmetrical Asymmetrical Motor strength Symmetric Asymmetric Hyperreflexic Areflexia Distal paresis of lower Paraplegia limbs Sphincter dysfunction Present early Present later Both urinary and fecal Only urinary retention