Quantifying the clinical aspects of the cauda equina syndrome - The Cauda Scale (TCS).

AIM: To quantify the clinical findings in patients with potential cauda equina syndrome (CES). METHODS: Three domains were selected: bladder function (B), perianal sensation (S) and anal tone/squeeze (T). A quantified score was given to symptoms and signs in each domain. RESULTS: The lowest score in each domain and the lowest sum score (the most severe lesion) is 0. The best sum score is 9 (the normal patient). CONCLUSION: TCS can improve the clinical assessment and management of patients with possible CES and improve communication between the doctors who are called upon to assess and treat such patients.

Do we know the outcome predictors for cauda equine syndrome (CES)? A retrospective, single-center analysis of 60 patients with CES with a suggestion for a new score to measure severity of symptoms.

OBJECTIVE: Despite the awareness and familiarity of almost every medical professional with the cauda equine compression syndrome (CES), risk factors for a poor prognosis of the disease remain elusive. Even the relationship between subsequent outcome and the time elapsed from the time of appearance of symptoms to surgery taking place remain obscure. The aim of our study, therefore, was to analyze a relatively large population of our own patients studied consecutively, to identify outcome predictors for CES and to propose a clinical score for CES symptoms (Berlin CES score). METHODS: We screened the hospital's electronic database retrospectively for patients admitted with CES between 2001 and 2010. Since our hospital is a superregional trauma center with standardized emergency room procedures, all patients included in the study underwent the same routine. Using baseline data, we analyzed the following parameters: duration of symptoms, period of time between diagnosis and imaging, respectively, surgery; pre- and postoperative pain, motor deficits, reflex changes, urinary and bowl dysfunctions, reduced anal wink, saddle anesthesia, genital or perianal sensations and residual urine. The semi-quantitative assessment of the neurological outcome was performed by application of the Berlin CES score. RESULTS: Surprisingly, we were not able to identify any single parameters that could reliably predict the outcome of the disease. We were able to show statistically significant correlations between a high preoperatively Berlin CES score (i.e., a weighted summation of bladder dysfunction, rectal dysfunction, genital sensation, perianal sensation, rectal tone and saddle anesthesia) and a poor outcome regarding the postoperative existence of perianal (p < 0.001) and genital (p = 0.001) hypoesthesia, as well as reduced rectal tone (p = 0.0047). There was no significant interference of bladder or bowel function. Further analysis, in which we considered the time between diagnosis and surgery, revealed that both patients operated within 24 h and after 48 h could benefit from the intervention. Consequently, we were not able to show a correlation between speed of surgical treatment and outcome. CONCLUSION: Although we analyzed a relatively large cohort, we were not able to identify single parameters that were capable of reliably predicting the outcome of patients with CES. Nonetheless, we were able to show that consideration of multiple parameters of symptomatology would enable an improvement in making a prognosis. In conclusion, we propose establishing a simple semi-quantitative clinical score of the main symptoms of CES.

Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction.

BACKGROUND: Even though micturition, defecation, and sexual function are substantially affected in cauda equina syndrome (CES), data on outcome are scarce. METHODS: Medical files of patients operated on lumbar herniated disc were screened for CES and retrospectively analyzed for baseline characteristics, outcome of micturition, defecation, and sexual function and possible predictors. RESULTS: Seventy-five CES patients (52% men) were included with a mean age of 44 years. L5-S1 was the most common affected level. Duration of CES complaints at presentation was, on average, 84 h (median 48 h). Prevalence of symptoms at presentation: sciatica (97%), altered sensation of the saddle area (93%), micturition dysfunction (92%), and defecation dysfunction (74%). Only 26 patients were asked about sexual dysfunction of whom 25 patients experienced dysfunction. Female gender was associated with more defecation dysfunction at presentation than male gender (OR 4.11; p = 0.039). All patients underwent decompressive surgery. Two post-operative follow-up (FU) moments took place after a mean of 75 h and 63 days. Outcomes at second FU moment: micturition dysfunction 48%, defecation dysfunction 42%, sexual dysfunction 53%, sciatica 48%, and altered sensation of the saddle area 57%. A shorter time to decompression was associated with more sciatica at FU 1 (p = 0.042) which effect had disappeared at FU 2. CONCLUSION: This study is unique in (1) displaying the presenting features in a large cohort of CES patients, (2) demonstrating that recovery after decompression is slow and far from complete in the majority of patients with regard to micturition, defecation, and sexual function and (3) evaluating predictors for outcome.

Definitions of traumatic conus medullaris and cauda equina syndrome: a systematic literature review.

STUDY DESIGN: A systematic review. OBJECTIVES: Conus medullaris syndrome (CMS) and cauda equina syndrome (CES) are well-known neurological entities. It is assumed that these syndromes are different regarding neurological and functional prognosis. However, literature concerning spinal trauma is ambiguous about the exact definition of the syndromes. METHODS: A MEDLINE, EMBASE and Cochrane literature search was performed. We included original articles in which clinical descriptions of CMS and/or CES were mentioned in patients following trauma to the thoracolumbar spine. RESULTS: Out of the 1046 articles, we identified 14 original articles concerning patients with a traumatic CMS and/or CES. Based on this review and anatomical data from cadaveric and radiological studies, CMS and CES could be more precisely defined. CONCLUSION: CMS may result from injury of vertebrae Th12-L2, and it involves damage to neural structures from spinal cord segment Th12 to nerve root S5. CES may result from an injury of vertebrae L3-L5, and it involves damage to nerve roots L3-S5. This differentiation between CMS and CES is necessary to examine the hypothesis that CES patients tend to have a better functional outcome.

Ejaculation and sperm characteristics in men with cauda equina and conus medullaris syndromes.

STUDY DESIGN: Retrospective. OBJECTIVES: The objective of the study was to describe the type of ejaculation in patients with cauda equina (CE) and conus medullaris (CM) lesions, and to analyse sperm quality. SETTING: France. METHODS: One hundred sixty-six patients with CE and CM lesions were included. Diagnosis was based on clinical (no motor responses, sensation or sacral reflexes) and urodynamic assessments (no detrusor activity). Vibromassage (VM) was used to induce ejaculation according to the recommendations for patients with spinal cord injury. If ejaculation did not occur, oral midodrine was administered in progressive doses. Retrograde ejaculation was systematically sought. Sperm parameters were analysed according to World Health Organisation recommendations (2010). RESULTS: Eighty-nine patients were included. Eleven ejaculated on the first VM trial (four anterograde (AE), six retrograde (RE) and one antero-retrograde (ARE)). Five patients continued trials of VM alone, two of whom ejaculated following a mean 1.9 trials (one RE, one ARE). Twenty-six patients underwent trials of VM+ midodrine, 18 of whom ejaculated following a mean 4.4 trials with a mean dose of 22.5 g of midodrine (2 AE, 13 RE and 5 ARE). Fifty-three ejaculates from 26 patients were analysed. Sperm concentration was low in 90.6% of samples; total necrospermia was found in 65% and asthenospermia in 95% of samples. CONCLUSION: Ejaculation is difficult to induce using VM in patients with CE and CM lesions, and requires high doses of midodrine. Sperm counts were generally low, and asthenospermia and necrospermia were found in the majority of specimens. Cryopreservation of sperm should be systematic in case of medically assisted procreation.

Pudendal nerve stimulation for bowel dysfunction in complete cauda equina syndrome.

OBJECTIVE: Pudendal nerve stimulation (PNS) aims to maximize afferent or efferent stimulation from the sacral plexus. BACKGROUND: We hypothesized this may be a promising new treatment for patients with bowel dysfunction in complete cauda equina syndrome (CES). METHODS: Thirteen patients with complete CES [8 constipation predominant (group 1) and 5 incontinence predominant (group 2)] had a 3-week trial of PNS. Patients who showed a 50% or more improvement in symptoms during the trial phase proceeded to permanent neurostimulator implantation. RESULTS: Five (63%) of the 8 patients in group 1 showed a 50% or more improvement in bowel symptoms during the trial phase and were permanently implanted. The mean Cleveland Clinic constipation score, sense of incomplete evacuation (%), and straining during defecation (%) improved from 17 ± 3.2 to 10 ± 4.5, 94 ± 18% to 30 ± 35%, and 81 ± 23% to 44 ± 38%, respectively. All 5 patients in group 2 showed a 50% or more reduction in incontinent episodes during the trial phase. The mean St Mark's score, ability to defer defecation, and the number of incontinent episodes per week improved from 18 ± 1.0 to 3.8 ± 2.5, 2.2 ± 1.8 to 11 ± 5.5 minutes, and 9.4 ± 10.7 to 0.4 ± 0.5 episodes, respectively, per week. During a median follow-up of 12 (10-22) months of permanent implantation, one patient lost efficacy at 6 months due to lead migration and another required removal and reimplantation of the neurostimulator due to wound infection. CONCLUSIONS: PNS is an effective treatment in the short term for bowel dysfunction in some patients with complete CES.

Utility of sphincter electromyography and sacral reflex studies in women with cauda equina lesions.

AIMS: Sacral neurophysiologic studies have demonstrated their utility in men with suspected neurogenic sacral dysfunction. However, no similar studies have been performed in women. The present study aimed to test the utility of sacral neurophysiologic assessment in women with chronic cauda equina lesions. METHODS: Twenty-four women with clinical and radiological signs supportive of chronic cauda equina lesions, and a group of 60 control women without clinical symptoms or signs of sacral neuropathic lesion were included. Clinical examination, including testing of saddle sensation, and neurophysiologic testing, including quantitative anal sphincter EMG and clitoro-cavernosus reflex testing (on single and double electrical, and mechanical stimulation), were performed on each side separately. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS: Respective sensitivities, specificities, positive predictive values, and negative predictive values were 63%, 92%, 83%, and 86% for quantitative anal sphincter EMG, 92-96%, 67-80%, 52-59%, and 95-96% for neurophysiologic testing of the clitoro-cavernosus reflex (using different stimulation techniques), and 96-100%, 62-75%, 50-55%, and 97-98% for their combinations. CONCLUSIONS: This study complements previous reports in men supporting the clinical utility of an neurophysiologic protocol that includes both quantitative anal sphincter EMG and sacral reflex studies for assessment of patients with suspected peripheral sacral lesions. Very high sensitivity and negative predictive value confirm high utility of sacral neurophysiologic studies in confirmation and exclusion of sacral neuropathic lesion.

Anatomical and functional enhancements of the insula after loss of large primary somatosensory fibers.

Brain changes associated with the loss of a sensory modality such as vision and audition have previously been reported. Here, we examined the effect of loss of discriminative touch and proprioception on cortical thickness and functional connectivity. We performed structural magnetic resonance imaging and resting-state functional magnetic resonance imaging scans on a 60-year-old female who at age 31 suffered a selective loss of large-diameter myelinated primary afferents and, therefore, relies mainly on her intact thin-fiber senses (temperature, pain, itch, and C-fiber touch) and vision to negotiate her environment. The patient showed widespread cortical thinning compared with 12 age-matched female controls. In contrast, her right anterior insula was significantly thick. Seed-based resting-state analysis revealed that her right anterior insula had increased connectivity to bilateral posterior insula. A separate independent component analysis revealed the increased connectivity between the insula and visual cortex in the patient. As the insula is an important processing area for temperature and C-fiber tactile information, the increased intrainsular and insular-visual functional connectivity could be related to the patient's use of C-fiber (gentle) touch and temperature information in conjunction with visual information to navigate her environment. We, thus, demonstrated plasticity in networks involving the insular cortex following denervation of large-diameter somatosensory afferents.

Complaints of micturition, defecation and sexual function in cauda equina syndrome due to lumbar disk herniation: a systematic review.

PURPOSE: Cauda equina syndrome (CES) is a rare complication of lumbar disk herniation. Although micturition, defecation and/or sexual function are by definition affected, little seems to be known about long-term outcome. Aim of this study is to review current literature on outcome of micturition, defecation and sexual function in CES due to lumbar disk herniation. METHODS: A literature search was done in Pubmed, Embase and Web of Science using a sensitive search string combination. Studies were selected by predefined selection criteria and risk of bias was assessed using a Cochrane checklist adjusted for this purpose. RESULTS: Fifteen studies were included. Risk of bias varied with six studies showing low risk. Mean minimal follow-up time was 17.0 months (range 3-24 months). All studies evaluated micturition and reported dysfunction at follow-up in 42.5% (range 13.3-90.0%). Defecation and sexual function were evaluated in eight and nine studies, respectively, and reported to be 49.6 (range 10.5-90.0%) and 44.3% (range 10.0-76.6%), respectively. Only two studies assessed sexual function in all patients at follow-up. CONCLUSION: This review offers an insight into the extent of micturition dysfunction, defecation dysfunction and sexual dysfunction (SD) in CES after decompression. Our findings show that dysfunction is extremely common, even at long-term follow-up. A condition as invalidating as CES requires proper patient information and the outcomes presented here may help in providing those data. Bias in included studies, lack of universal definitions and incomplete follow-up results qualify these data as the best we momentarily have, but still subject to improvement. Since SD seems to be severely underreported, we recommend further research to explore the extent of this problem, as well as the use of questionnaires in future clinical (prospective) studies to accomplish a more patient-based approach.

Differentiation of neonatal dorsal root ganglion-derived neural stem cells into oligodendrocytes after intrathecal transplantation into a cauda equina lesion model.

Cauda equina syndrome (CES) is characterized by varying patterns of low back pain, sciatica, lower extremity sensorimotor loss, and bowel and bladder dysfunction. The prognosis for complete recovery of CES is dependent on not only the time before surgical intervention with decompression but also the severity of the nerve damage. Delayed or severe nerve compression impairs the capability of nerve regeneration. Transplantation of neural stem cells (NSCs) may facilitate axon regeneration and functional recovery in a spectrum of neurological disorders. Our study shows that the NSCs derived from early postnatal dorsal root ganglion (DRG) are able to proliferate to form neurospheres and differentiate into O4(+) oligodendrocytes but not glial fibrillary acidic protein (GFAP(+)) astrocytes or ßIII-tubulin(+) neurons in vitro. After intrathecal transplantation into the lumbar spinal canal stenosis animal model, most of the GFP-expressing NSCs were induced to differentiate into oligodendrocytes in vivo. Although the recovery of sensorimotor function was not significantly improved in rats with transplantation therapy, our results implied that subarachnoid microinjection of NSCs may promote axon regeneration of DRG neurons in the cauda equina model after nerve injury.

Cauda equina syndrome presenting as abdominal pain: a case report.

Cauda equina syndrome (CES) is an uncommon entity. Symptoms include bowel and bladder dysfunction, saddle anesthesia, and varying degrees of lower limb motor and sensory disturbances. The consequences of delayed diagnosis can be devastating, resulting in bowel and bladder incontinence and lower limb paralysis. There is little in literature regarding abdominal pain as a significant feature of the initial presentation of CES. We present the case of a 32-year-old woman with CES who presented to the emergency department with gradually worsening lower abdominal pain.

Cauda equina compression post lumbar discography.

Discography is used as an aid in the diagnosis of back pain related to intervertebral disc pathology. It involves attempting to elicit the patient's pain symptoms by injecting contrast into the suspected pathological disc. The overall complication rate of discography is low, with discitis being the most common complication and acute disc herniation post lumbar discography being reported in a small number of cases. We describe the case of a patient who developed cauda equina compression post lumbar discography.

Intraspinal epidermoid tumor of the cauda equina region: seven cases and a review of the literature.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To investigate the clinical features and surgical outcomes of patients with intraspinal epidermoid tumor of the cauda equina region. SUMMARY OF BACKGROUND DATA: Intraspinal epidermoid tumor of the cauda equina region is very rare, and the majority of the existing literature of this condition comprises case reports with a few case series. METHODS: The clinical features and surgical outcomes of 7 patients (2 males, 5 females; age range, 4-66 y) with intraspinal epidermoid tumor of the cauda equina region were retrospectively studied, and a literature review was performed. All patients complained of neurologic symptoms and underwent microscope-assisted surgery. The mean duration of postoperative follow-up was 126 months (range, 52-209 mo). RESULTS: Antecedent lumbar puncture had been performed on 3 patients, and 4 cases thought to be of congenital origin without a past history of lumbar puncture had no associated anomalies, such as spina bifida or dermal sinus. Postoperatively, complications occurred in 3 patients concerning cauda equina symptom. Two patients (29%) had tumor recurrence, diagnosed 1 and 13 years after surgery, respectively. Immediately after additional surgery for tumor recurrence, both patients had severe paresis of the hemilateral foot. CONCLUSIONS: Complete removal without tear of the tumor was difficult in our case series, because the capsule of the tumor was thin and often adhered to the cauda equina nerve roots or dura mater. However, total resection of the capsule is important, because patients with epidermoid tumor are at risk for recurrence. On the other hand, aggressive resection of the capsule adhering to the neural elements can cause a high rate of neurological complications postoperatively, especially after surgery for tumor recurrence.

Peripheral nerve involvement in a neurofibromatosis type 2 patient with plexiform neurofibroma of the cauda equina: a sonographic vignette.

We report a 20-year-old man with cauda equina syndrome and neurofibromatosis type 2. We discuss the role of sonographic and electromyographic evaluations in the management of our patient and suggest the use of sonographic imaging for visualization of peripheral nerve pathologic states, especially when involvement is widespread.

Pseudomeningocele presenting with cauda equina syndrome: is a 'ball-valve' theory the answer?

Pseudomeningocele is an uncommon complication of spinal surgery. The condition is most often asymptomatic and self-limiting. A proportion of patients may present with lower back pain, dural fistulas, radiculopathy or myelopathy. Cauda equina syndrome due to a pseudomeningocele has been reported due to herniation of the Cauda equina roots through the dural defect. We report a case of large pseudomeningocele causing an impending Cauda equina syndrome by acting as an extradural mass lesion.

Sensory disturbances and pain complaints after brachial plexus root injury: a prospective study involving 150 adult patients.

After injury of the brachial plexus, sensory disturbance in the affected limb varies according to the extent of root involvement. The goal of this study was to match sensory assessments and pain complaints with findings on CT myelo scans and surgical observations. One hundred fifty patients with supraclavicular stretch injury of the brachial plexus were operated upon within an average of 5.4 months of trauma. Preoperatively, upper limb sensation was evaluated using Semmes-Weinstein monofilaments. Pain complaints were recorded for each patient. With lesions affecting the upper roots of the brachial plexus, hand sensation was largerly preserved. Sensory disturbances were identified over a longitudinal bundle on the lateral arm and forearm. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. If the C7 root also was injured, sensation in the long finger was impaired. Eighty-four percent of our 64 patients with total palsy reported pain, versus just 47% of our 72 patients with upper type palsies. This rate dropped to 29% in the 14 patients with a lower-type palsy. C8 and T1, when injured, always were avulsed from the cord; when avulsion of these roots was the only nerve injury, pain was absent. Hand sensation was largely preserved in patients with partial injuries of the brachial plexus, particularly on the radial side. Even when T1 was the only preserved root, hand sensation was mostly spared. This indicates that overlapping of the dermatomal zones seems much more widespread than previously reported.

Chiari II malformation mimicking partial rhombencephalosynapsis? A case report.

Rhombencephalosynapsis is a rare congenital intracranial malformation with very few cases reported in literature. Partial rhombencephalosynapsis is a variation of this anomaly with fewer reported cases. We present the case of a patient with Chiari II malformation mimicking partial rhombencephalosynapsis.

The accuracy of assessment of walking distance in the elective spinal outpatients setting.

Self reported walking distance is a clinically relevant measure of function. The aim of this study was to define patient accuracy and understand factors that might influence perceived walking distance in an elective spinal outpatients setting. A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and other measures. There are over-estimators and under-estimators. Overall, the accuracy to within 9.14 metres (m) (10 yards) was poor at only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 111 m; mean response 245 m (95% CI 176.3-314.7), Functional test 1 actual distance 29.2 m; mean response 71.7 m (95% CI 53.6-88.9) Functional test 2 actual distance 19.6 m; mean response 47.4 m (95% CI 35.02-59.95). Surprisingly patients over 60 years of age (n = 43) are twice as accurate with each test performed compared to those under 60 (n = 60) (average 70% overestimation compared to 140%; p = 0.06). Patients in social class I (n = 18) were more accurate than those in classes II-V (n = 85): There was a positive correlation between poor accuracy and increasing MZD (Pearson's correlation coefficient 0.250; p = 0.012). ODI, LBOS and other parameters measured showed no correlation. Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate but still poor.

Clinical classification of cauda equina syndrome for proper treatment.

BACKGROUND AND PURPOSE: Cauda equina syndrome (CES) is a severe complication of lumbar spinal disorders; it results from compression of the nerve roots of the cauda equina. The purpose of this study was to evaluate the clinical usefulness of a classification scheme of CES based on factors including clinical symptoms, imaging signs, and electrophysiological findings. METHODS: The records of 39 patients with CES were divided into 4 groups based on clinical features as follows. Group 1 (preclinical): low back pain with only bulbocavernosus reflex and ischiocavernosus reflex abnormalities. Group 2 (early): saddle sensory disturbance and bilateral sciatica. Group 3 (middle): saddle sensory disturbance, bowel or bladder dysfunction, motor weakness of the lower extremity, and reduced sexual function. Group 4 (late): absence of saddle sensation and sexual function in addition to uncontrolled bowel function. The outcome including radiographic and electrophysiological findings was compared between groups. RESULTS: The main clinical manifestations of CES included bilateral saddle sensory disturbance, and bowel, bladder, and sexual dysfunction. The clinical symptoms of patients with multiple-segment canal stenosis identified radiographically were more severe than those of patients with single-segment stenosis. BCR and ICR improved in groups 1 and 2 after surgery, but no change was noted for groups 3 and 4. INTERPRETATION: We conclude that bilateral radiculopathy or sciatica are early stages of CES and indicate a high risk of development of advanced CES. Electrophysiological abnormalities and reduced saddle sensation are indices of early diagnosis. Patients at the preclinical and early stages have better functional recovery than patients in later stages after surgical decompression.