- The conus medullaris syndrome involves compression of the lower end of the spinal cord known as the conus medullaris, located around the L1-L2 vertebrae. This can result in saddle anesthesia, absent bulbocavernous and anal reflexes, and both upper and lower motor neuron signs and symptoms below the level of compression. - The cauda equina syndrome involves compression of the bundle of spinal nerve roots in the lower back called the cauda equina. It can cause radicular pain, urinary retention, and asymmetric sensory loss. MRI is key for diagnosis and treatment involves decompression through procedures like discectomy, laminectomy, or corpectomy. -

1. - S H U C H I J O S H I
CONUS MEDULLARIS
SYNDROME

2. ANATOMY

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Source: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006
Source:
Keith L. Moore and Anne Agur. Essential Clinical Anatomy, 3rd Edition

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6. ETIOLOGY
• Trauma:
- Fracture, subluxation
- Penetrating trauma
• Herniated disc:
- 90% at L4-L5 and L5-S1
• Spinal stenosis:
- Developmental abnormality
- Degenerative disease
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Picture from: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006

7. • Neoplasm:
- Primary (schwannoma, paraganglioma)
- Metastatic (intracranial, lung, breast
and renal cell ca)
• Inflammations and infections:
- Paget disease, epidural abscess
- Pyogenic and non pyogenic
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Picture from: http://emedicine.medscape.com/

8. • Iatrogenic:
- Misplaced pedicle screw, laminar hooks
- Continuous spinal anesthesia
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Picture from: http://www.science-art.com

9. CONUS MEDULLARIS SYNDROME
• 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.:
• LMN- at the level
• UMN- below the level

10. 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 spasticity: specifically in muscles supplied by
myotomes S1-S5

12. CAUDA EQUINA SYNDROME
 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

14. • Early radicular pain in the distribution of the lumbosacral roots due to the compression of the lumbar and sacral roots
below the L3 vertebral level.
• With extensive lesions, patients develop flaccid, hypotonic, areflexic paralysis that affects the glutei, posterior
thigh muscles, and anterolateral muscles of the leg and foot, resulting in a true peripheral type of paraplegia.
• Sensory testing usually reveals an asymmetric sensory loss in the saddle region, involving the anal, perineal, and
genital regions extending to the dorsal aspect of the thigh, the anterolateral aspect of the leg, and the outer aspect
of the foot.

17. CAUDA EQUINA SYNDROME
• Etiologies
• Disc herniation
• Disc fragment migration
• Iatrogenic epidural hematoma
• Post LP or spinal anesthesia
• Postoperatively
• Infection
• Tumor
• Trauma

18. CONUS MEDULLARIS
SYNDROME
CAUDA EQUINA
SYNDROME
Presentation Sudden and bilateral Gradual and unilateral
Reflexes Diminished- at the level
Brisk- below the level
Diminished
Radicular pain - +
Low back pain More Less
Impotence Frequent Absent
Numbness Symmetrical Asymmetrical
Motor strength Symmetric
Hyperreflexic
Distal paresis of lower limbs
Asymmetric
Areflexia
Paraplegia
Sphincter dysfunction Present early
Both urinary and fecal
incontinence
Present later
Only urinary retention

20. INVESTIGATIONS
• Radiology – MRI
• Laboratory – FBC, ESR
• Needle electromyography of the bilateral external anal
sphincter muscles
• Lumbar puncture
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Sagittal and axial CT scans of
thoracolumbar spine
demonstrating an L4 burst
fracture with retropulsion of
bone into the spinal canal
Source: Harrop, J. S., G. E. Hunt Jr, et al. (2004). "Conus medullaris and
cauda equina syndrome as a result of traumatic injuries: management
principles." Neurosurgical Focus 16(6): 1-23.

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Sagittal MRI images
demonstrating large
central disc
extrusion at L5-S1
(arrows) with
compression on the
cauda equina.
Source: Levis, J. T. (2009). "Cauda
equina syndrome." Western
Journal of Emergency Medicine
10(1): 20.

23. METHOD TO RELIEVE CORD
COMPRESSION• Discectomy - A discectomy (also called open discectomy) is the
surgical removal of herniated disc material that presses on a nerve
root or the spinal cord. The procedure involves removing the central
portion of an intervertebral disc, the nucleus pulposus, which
causes pain by stressing the spinal cord or radiating nerves.
• Laminectomy - a surgical operation to remove the lamina- , usually
to give access to the spinal cord or to relieve pressure on nerves.
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Corpectomy