1. The patient is a 21-year-old male who presents with a 2.5 year history of difficulty urinating, 2 year history of lower back pain, and numbness and weakness in the lower limbs over the past 2 years. 2. On examination, the patient has reduced sensation in the saddle area and lower limbs, weakness in the right lower limb, and wasting of thigh and calf muscles on the right side. 3. Based on the history and examination findings, the patient likely has conus medullaris syndrome, with signs and symptoms consistent with spinal cord compression and dysfunction in the lower lumbar and sacral regions.

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

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

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