Can clinical presentation predict radiologically confirmed cauda equina syndrome: retrospective case review of 530 cases at a tertiary emergency department.

PURPOSE: Cauda equina syndrome (CES) may have significant individual consequences if diagnostic delays occur. Our aim was to evaluate the presenting subjective and objective features of patients with suspected CES in comparison to those with radiologically confirmed cauda equina compression (CEC).. METHODS: This was a retrospective analysis of all cases presenting with suspected CES to a tertiary emergency care unit over a two-year period. CEC was defined as radiological confirmation of CEC by Consultant Musculoskeletal (MSK) Radiologist report (MSK-CEC) and by measured canal occupancy due to an acute disc extrusion (> 75%)[measured by a Senior Spinal Surgeon (SP-CEC)]. Routine data collection was compared between categories. Chi square, multivariate regression analyses and ROC analysis of multiple predictors was performed. RESULTS: 530 patients were included in this analysis, 60 (11.3%) had MSK-CEC, and 470 had NO- CEC. Only 43/60 (71.7%) had emergent surgery. Those with MSK-CEC and SP-CEC were statistically more likely to present with bilateral leg pain [(MSK-CEC OR 2.6, 95%CI 1.2, 5.8; p = 0.02)(SP-CEC OR 4.7, 95%CI 1.7, 12.8; p = 0.003)]; and absent bilateral ankle reflexes [(MSK-CEC OR 4.3; 95% CI 2.0, 9.6; p < 0.001)(SP CEC OR 2.5; 95%CI 1.0, 6.19; p = 0.05)] on multivariate analysis. The ROC curve analysis acceptable diagnostic utility of having SP-CEC when both are present [Area under the curve 0.72 (95%CI 0.61, 0.83); p < 0.0001]. CONCLUSION: This study suggests that in those presenting with CES symptoms, the presence of both bilateral leg pain and absent ankle reflexes pose an acceptable diagnostic tool to predict a large acute disc herniation on MRI scan..

An Optimized CT Protocol for Detecting Suspected Cauda Equina Syndrome: A Comparative Analysis with MRI.

BACKGROUND AND PURPOSE: Lumbar disc herniation, potentially leading to nerve root compression and cauda equina syndrome, is typically evaluated using MR imaging. However, the limited availability of MR imaging outside regular hours in certain health care systems poses considerable challenges. This purpose of this study was to prospectively evaluate the diagnostic accuracy of an optimized CT lumbar spine protocol as a potential alternative to MR imaging in assessing suspected neural compression. MATERIALS AND METHODS: Patients presenting to the emergency department with suspected cauda equina syndrome or acute radicular symptoms secondary to lumbar disc herniation referred for MR imaging were prospectively enrolled for an additional CT optimized to assess spinal stenosis. An expert radiologist, blinded to clinical data, graded canal stenosis at each lumbar level on CT. The same grading process was applied to MR imaging after a 4-week interval to maintain blinding. RESULTS: Fifty-nine individuals were included in the final analysis. In 22 (39%) cases, no significant stenosis was identified. In a further 22 (37%) cases, disc pathology was identified that was managed conservatively. Thirteen (22%) individuals proceeded to urgent surgical decompression. In 1 (2%) instance, an alternative diagnosis was identified. Compared with MR imaging, the sensitivity, specificity, and positive and negative predictive values for CT in detecting disc pathology in patients presenting with symptoms suggestive of acute neural compression were 97% (95% CI, 82%-99%), 97% (95% CI, 83%-99%), 97% (95% CI, 92%-99%), and 97% (95% CI, 83%-99%), respectively. CT accurately identified all cases requiring urgent decompression. CONCLUSIONS: CT accurately predicted MR imaging findings in patients with suspected cauda equina and nerve root compression, demonstrating its utility as an adjunct tool for patient triage in emergency settings with limited MR imaging access. This protocol could enhance the allocation of emergency resources by appropriately selecting patients for emergent MR imaging.

Double Level Non-Contiguous Traumatic Lumbar Disc Herniation Presenting With Cauda Equina Syndrome: A Case Report and Literature Review.

CASE: A 52-year-old man presented with cauda equina syndrome after a motorcycle accident. Magnetic resonance imaging revealed traumatic disc herniation, at L2-L3 and L5-S1 levels without bony injury. He was managed successfully by wide laminectomy and microdiscectomy at both levels with complete neurological recovery at 2-month follow-up. CONCLUSION: With a reported incidence of 0.4%, traumatic disc herniation in the lumbar region is an uncommon occurrence that may resemble a spinal epidural hematoma in acute trauma. Although MRI may not reliably differentiate spinal epidural hematoma from disc herniation, urgent surgical intervention may be required in profound neurological deficits.

A rare case of spontaneous giant pneumorrachis presenting with cauda equina syndrome: a case report.

INTRODUCTION: Pneumorrachis is presence of air in the epidural space. It could be the result of trauma, barotrauma, iatrogenic or spontaneous. The pneumorrachis per se is an underdiagnosed entity as most of the patients are asymptomatic or have subclinical symptoms. The spontaneous occurrence of pneumorrachis has been reported in literature but giant spontaneous occurrence causing cauda equina syndrome has not been reported so far. CASE PRESENTATION: We report a case of 56-year-old male patient who came to our OPD on wheelchair with complains of difficulty in walking for 6 months with dribbling of urine for 2 months with on and off back pain. His perianal sensation was reduced with absent voluntary anal contraction. Imaging revealed giant air pockets in the spinal canal of L5-S1 extending upto L4-L5. It was managed surgically wherein laminectomy without fusion was done. The patient responded well to the treatment. DISCUSSION: There are many causes of pneumorrachis described in literature. Most of the cases of pneumorrachis are asymptomatic and incidentally diagnosed. With the improvement in radio-diagnostic modalities, the diagnosis of pneumorrachis can be easily established. When symptomatic, they can be managed conservatively. Those presenting with neurological deficit may require surgical intervention or other invasive intervention.

Aneurysmal subarachnoid hemorrhage complicating spinal subarachnoid hematoma causing acute cauda equina syndrome: a case report.

BACKGROUND: Spinal subarachnoid hematoma (SSH) is a known but rare entity that can cause cauda equina compression. The occurrence of SSH associated with aneurysmal subarachnoid hemorrhage has rarely been described in the literature. CASE PRESENTATION: A 56-year-old woman presented with subarachnoid hemorrhage secondary to a ruptured middle cerebral artery aneurysm and was managed with coiling embolization without stent assistance. There was no history of either lumbar puncture or the use of anticoagulants. The patient developed severe lumbago radiating to bilateral legs nine days after the procedure. Subsequent magnetic resonance imaging demonstrated a SSH extending from L5 to S2 and wrapping around the cauda equina. The patient was treated with intravenous methylprednisolone (250 mg/day) for four consecutive days, followed by a taper of oral prednisolone (20 mg/day) until complete recovery. Magnetic resonance imaging at one month follow-up revealed complete resolution of the SSH. CONCLUSIONS: Here, we report a case of acute cauda equina syndrome caused by a SSH after aneurysmal subarachnoid hemorrhage, which will facilitate timely intervention of patients with this disorder.

Bladder ultrasonography in the assessment of cauda equina syndrome in the emergency department: a literature review.

For cauda equina syndrome (CES), current clinical assessment in the emergency department usually involves perianal sensation (PAS) and anal tone (AT). Neither reliably predict magnetic resonance imaging (MRI) demonstrating a large central disc prolapse (MRI+). Other clinical examination findings increase the probability of MRI+. Other tests of sacral nerve root function include anal squeeze (AS) and the bulbocavernosus reflex (BCR). If BCR, PAS and AT, and AS are combined and they are all normal, CES can be excluded in almost all cases. Portable bladder ultrasonography is now commonly used to assess bladder function, particularly in measuring the post-void residual urinary volume (PVR). PVR is deemed normal at <50ml. If the PVR is <200ml and there are no objective signs, MRI+ is rare. If the PVR is >200ml, MRI+ is found in 43% of cases. The combined assessment of PAS, AT and AS (and BCR in selected cases) and PVR increases the specificity and sensitivity of a clinical diagnosis of CES (i.e. maximising MRI+ and minimising MRI-). Recommendations for when to perform MRI are made.

Cauda equina syndrome in a patient with human immunodeficiency virus and secondary central nervous system lymphoma: a case report.

BACKGROUND: Secondary central nervous system lymphoma (SCNSL) is a known complication of immunocompromised patients with most cases involving the brain parenchyma. Reports of cauda equina syndrome (CES) caused by SCNSL are exceedingly scarce as involvement of this anatomical region is extremely uncommon. CASE PRESENTATION: We report a case of a 46-years-old, African, female patient with human immunodeficiency virus (HIV) who developed CES in the context of SCNSL. There were no blasts present in the peripheral blood smear. We provide a review of the literature, discussion of the clinical evolution of this patient and the radiological/histopathological findings. The patient ultimately responded well to induction chemotherapy and high dose methotrexate. CONCLUSION: This case report demonstrates that CES, while a rare occurrence in this clinical context, should be considered in at-risk patients especially those presenting with abnormal neurological findings. Prompt recognition may prevent permanent neurological injury and obviate the need for more invasive therapeutic interventions.

High-Riding Conus Medullaris Syndrome: A Case Report and Literature Review-Its Comparison with Cauda Equina Syndrome.

INTRODUCTION: Conus medullaris syndrome (CMS) is a distinctive spinal cord injury (SCI), which presents with varying degrees of upper motor neuron signs (UMNS) and lower motor neuron signs (LMNS). Herein, we present a case with a burst fracture injury at the proximal Conus Medullaris (CM). CASE PRESENTATION: A 48-year-old Taiwanese male presenting with lower back pain and paraparesis was having difficulty standing independently after a traumatic fall. An Imaging survey showed an incomplete D burst fracture of the T12 vertebra. Posterior decompression surgery was subsequently performed. However, spasticity and back pain persisted for four months after surgical intervention. Follow-up imaging with single photon emission computed tomography (SPECT) and a whole body bone scan both showed an increased uptake in the T12 vertebra. CONCLUSION: The high-riding injury site for CMS is related to a more exclusive clinical representation of UMNS. Our case's persistent UMNS and scintigraphy findings during follow-up showcase the prolonged recovery period of a UMN injury. In conclusion, our study provides a different perspective on approaching follow-up for CM injuries, namely using scientigraphy techniques to confirm localization of persistent injury during the course of post-operative rehabilitation. Furthermore, we also offered a new technique for analyzing the location of lumbosacral injuries, and that is to measure the location of the injury relative to the tip of the CM. This, along with clinical neurological examination, assesses the extent to which the UMN is involved in patients with CMS, and is possibly a notable predictive tool for clinicians for the regeneration time frame and functional outcome of patients with lumbosacral injuries in the future.

Intraoperative Ultrasound and Findings of Lumbar Intradural Disk Herniation Causing Cauda Equina Syndrome.

Intradural lumbar disk herniation (ILDH) is a rare variant and accounts for 0.33%-1.5% of lumbar disk herniations. Although clues exist on preoperative imaging, they remain subtle and most cases of ILDH are diagnosed intraoperatively. Intraoperative ultrasound is a useful adjunct in diagnosing and managing ILDH. We present a case to demonstrate the features of an intradural herniated disk on ultrasound imaging and highlight the utility of intraoperative ultrasonography in establishing diagnosis, guiding dural opening, and confirming adequate nerve root decompression following diskectomy.

Cauda equina syndrome by extrusion of lumbar disc after lumbar sympathetic neurolysis.

A 56-year-old woman experienced persistent excruciating pain with peroneal nerve injury in the anterior aspect of the lower leg after knee surgery. In our pain clinic, we diagnosed the patient with complex regional pain syndrome and performed lumbar sympathetic neurolysis (LSN) with absolute alcohol at the 3rd lumbar vertebra (L3). After the next follow-up, she complained of continuous dull low back pain, anal dysregulation, and fecal incontinence. We performed magnetic resonance imaging (MRI) to rule out other existing pathologies of back pain. On MRI, the nucleus pulposus was moderately extruded to the central zone with inferior sequestration at L2/3, and moderate central canal stenosis was observed at L2/3. She underwent partial laminectomy with discectomy at L2 level. We were not sure of the cause of disc herniation, but we strongly suspected that LSN at the L3 vertebral level was related to the pathology. Therefore, we discuss this unusual case.

Facet joint cyst haematoma: a rare cause of cauda equina syndrome.

Facet joint cysts are a feature of lumbar spondylosis and are an uncommon cause of radiculopathy. Facet joint cyst haematoma is a very rare entity and has previously been reported as a subacute cause of leg pain, back pain, sensory deficit and lower limb weakness. We present the unique case of facet joint cyst haematoma presenting as cauda equina syndrome. An 81 year old lady presented with a 7 day history of back pain and left foot drop, a 1 day history of perineal numbness and urinary retention with absent rectal tone, perianal anaesthesia and left leg hypoaesthesia. Emergency MRI scan demonstrated spinal canal stenosis as the aetiology of her cauda equina syndrome. She was taken to theatre for emergency lumbar decompression. At operation a facet joint haematoma compressing the cauda equina was found and extirpated with complete resolution of symptoms. In this case, the aetiology of cauda equina compression was not demonstrated effectively on pre-operative MRI scanning.

Early experience of a local pathway on the waiting time for MRI in patients presenting to a UK district general hospital with suspected cauda equina syndrome.

AIM: This study evaluated the impact of the Salisbury Protocol for Assessment of Cauda Equina Syndrome (SPACES) on the waiting time for MRI in patients presenting with suspected Cauda Equina Syndrome (sCES) within a UK district general hospital. PATIENTS AND METHODS: All consecutive patients undergoing an MRI scan in our hospital, for sCES, over a 12 month period, prior to and following the introduction of SPACES, were identified. Patient's gender, age, MRI diagnosis, time from MRI request to imaging and outcome were recorded. RESULTS: In the year prior to the introduction of SPACES, 66 patients underwent MRI for sCES, out of which 10.6% had cauda equina compression (CEC), 63.5% had other spinal pathology and 25% had a normal scan. In the year after introduction of SPACES, 160 patients underwent MRI for sCES out of which 6.2% had CEC, 70.7% had other spinal pathology and 23% had a normal scan. Despite the referrals for sCES increasing by more than 2-fold following the introduction of SPACES, the median time from MRI request to scan decreased from 9.1 to 4.2 hours (p = 0.106, Mann-Whitney-U) and the number of patients transferred to the regional hub hospital decreased from 7 to 3. CONCLUSION: Implementation of SPACES for patients with sCES resulted in a substantial reduction in waiting time for MRI and decreased the number of transfers to the regional hub hospital. Based on our early experience, we encourage other centres within the UK to introduce such a pathway locally, to improve the management of patients with sCES.

Post-void bladder ultrasound in suspected cauda equina syndrome-data from medicolegal cases and relevance to magnetic resonance imaging scanning.

OBJECTIVE: Post-void residual (PVR) scans of less than 200 ml are increasingly being used to rule out the likelihood of cauda equina syndrome (CES) and to delay emergency MRI scanning in suspected cases. This study was done to review a series of 50 MRI confirmed cases of CES and to test the hypothesis that a PVR of less than 200 ml was unlikely to be present. METHODS: Fifty consecutive medicolegal cases involving CES were audited. Records were reviewed to see if PVR scans were done. MRI scans were reviewed, clinical and radiological diagnosis reviewed, and treatment recorded. RESULTS: Out of 50 CES cases, 26 had had PVR scans. In 14/26 (54%) the PVR scan was ≤ 200 ml. In one case, the CES diagnosis was in question leaving 13/26 (50%) cases where there was a clear clinical and MRI diagnosis of CES despite the PVR being ≤ 200 ml. All 13 were classified as incomplete cauda equina syndrome (CESI) and all proceeded to emergency decompression. CONCLUSIONS: This study is the first in the literature to demonstrate that there is a significant group of CES patients who require emergency decompression but have PVRs ≤ 200 ml. The results demonstrate the existence of a significant group of CESI patients whose bladder function may be deteriorating, but they have not yet reached the point where the PVR is over 200 ml. Given the accepted understanding that CESI is best treated with emergency decompression, such patients are likely to have worse outcomes if MRI scanning and therefore surgery is delayed. We recommend the following: PVR is recommended as an assessment tool in suspected CES. A PVR of ≤ 200 reduces the likelihood of having CES but does not exclude it; clinical suspicion of CES should always lead to an MRI scan. Further investigation of PVR as a prognostic tool is recommended.

Detection of Cauda Equine Syndrome With 18F-FDG PET/CT and Leptomeningeal Metastasis by 68Ga-DOTATATE in the Same Patient With Large Cell Neuroendocrine Carcinoma of Lung.

ABSTRACT: Leptomeningeal metastasis is the metastatic spread of the disease to leptomeninges from solid tumors such as breast, lung cancer, and melanoma. Cauda equine syndrome is a neurological condition caused by compression of the cauda equine. The incidence of large cell neuroendocrine carcinoma in resected lung cancers appears to be 2.1% and 3.5%. The incidence of clinically diagnosed leptomeningeal metastasis in patients with solid tumors is approximately 5%. Here, we present cauda equine syndrome caused by the metastasis of large cell neuroendocrine carcinoma detected by 18F-FDG PET/CT and also 68Ga-DOTATATE PET/CT.

Out of hours magnetic resonance imaging for suspected cauda equina syndrome: lessons from a comparative study across two centres.

BACKGROUND: Cauda equina syndrome, a rare but disabling spinal surgical emergency, requires prompt investigation, ideally using magnetic resonance imaging as patients may require decompressive surgery. Out of hours access to magnetic resonance imaging is only routinely available in major trauma centres and neurosurgical units. Patients in regional hospitals with suspected cauda equina syndrome may require transfer for diagnostic imaging. We retrospectively studied the proportion of patients referred with suspected cauda equina syndrome who required out of hours transfer for magnetic resonance imaging and decompressive surgery. MATERIALS ANDS METHODS: Retrospective cohort study of patients referred using online referral platforms with suspected acute cauda equina syndrome and transferred out of hours between 6pm to 8am on weekdays and all day on weekends to two of the largest neurosurgical units in the UK in Birmingham and Cambridge. RESULTS: A total of 441 patients were referred across both sites with a suspicion of acute cauda equina syndrome; 339 patients were transferred for diagnostic scans and only 16 of them (4.7%) were positive for cauda equina compression, necessitating prompt decompressive surgery. Of the patients with negative magnetic resonance scans, 50% had their discharge or transfer back to referring hospitals delayed by more than 24 hours. CONCLUSIONS: Over 95% of patients who were transferred for imaging did not undergo emergency decompression. The authors propose a greater role for the provision of out of hours magnetic resonance imaging in all hospitals admitting emergency patients to streamline management.

Postoperative spinal epidural hematoma in a biportal endoscopic spine surgery.

ABSTRACT: Biportal endoscopic spine surgery (BESS) is extending its application to most kind of spine surgeries. Postoperative spinal epidural hematoma (POSEH) is one of the major concerns of this emerging technique. Through this study we aim to investigate the incidence of POSEH in BESS comparing to a conventional spine surgery (CSS).The patients who underwent a non-fusion decompressive spine surgery due to degenerative lumbar spinal stenosis (LSS) or herniated lumbar disc (HLD) or both between January 2015 and March 2019 were reviewed retrospectively. The incidence of clinical POSEH that demanded a revision surgery for hematoma evacuation was compared between CSS and BESS. As a second endpoint, the morphometric degree of POSEH was compared between the two groups. The maximal compression of cauda equina by POSEH was measured by 4 grade scale at the T2 axial image and the neurological state was evaluated by 5 grade scale. The indication of hematoma evacuation was more than hG3 with more than nG1. As a subgroup analysis, risk factors of POSEH in BESS were investigated.The 2 groups were homogenous in age, sex, number and level of operated segments. There was significant difference in the incidence of symptomatic POSEH as 2/142 (1.4%) in CSS and 8/95 (8.4%) in BESS (P = .016). The radiological thecal sac compression by hematoma was hG1 65 (61.3%), hG2 35 (33.0%), hG3 5 (4.7%), hG4 1 (0.9%) cases in CSS and hG1 33 (39.8%), hG2 25 (30.1%), hG3 22 (26.5%), hG4 3 cases (3.6%) in BESS. The difference was significant (P < .001). In BESS subgroup analysis, the risk factor of high grade POSEH was bilateral laminectomy (OR = 8.893, P = .023).The incidence of clinical and morphometric POSEH was higher in BESS. In BESS, POSEH developed more frequently in bilateral laminectomy than unilateral laminectomy.

Intracranial Mimics of Cauda Equina Syndrome: Heads or Tails?

BACKGROUND: To report cases of extraspinal mimics of cauda equina syndrome (CES) to enable prompt diagnosis and treatment in the future. CES results from compression of spinal nerve roots. Current practice mandates lumbosacral magnetic resonance imaging (MRI) scanning to diagnose CES. However, it may not reveal compression or provide an explanation for the presentation. We present 3 cases of suspected CES who went on to have intracranial pathology. METHODS: Retrospective review of all patients presenting with CES-type features who were subsequently found to have causative intracranial pathology over a 6-month period. RESULTS: Three cases were found, and these are hereby presented. CASE PRESENTATION: Case 1: A 57-year-old lady presented with urinary retention and bilateral leg weakness. She underwent an MRI spine which showed no evidence of CES. She was diagnosed with haemorrhagic intracranial metastases. Case 2: A 52-year-old lady presented with lower back and right buttock pain, with right-sided leg numbness, saddle hypoesthesia, and bowel and bladder incontinence. MRI spine showed no cauda equina compression. MRI neuraxis revealed a subdural haematoma. Case 3: A 69-year-old lady presented with a 6-day history of urinary incontinence, right foot drop, and leg weakness. MRI spine was negative for CES. She was diagnosed with an intraparenchymal haematoma of posterior left frontal lobe. CONCLUSIONS: Negative lumbosacral MRI will not exclude extraspinal mimics of CES and, although rare, these cases should be considered.

L1/2 Intradural Disc Herniation with Compression of the Proximal Cauda Equina Nerves: A Surgical Challenge.

BACKGROUND: Intradural disc herniation (IDH) in the upper lumbar spine is rare. Preoperative radiologic diagnosis can be difficult, making operative planning challenging. We report on a 74-year-old female patient who was diagnosed with an L1-L2 IDH intraoperatively. This case report aims to highlight and discuss the radiological features of IDH and operative challenges when approaching IDH. CASE DESCRIPTION: A 74-year-old female patient presented to outpatient clinic with a 3-month history of significant intermittent neurological claudication and severe lumbar back pain. Her examination was unremarkable apart from a positive left-sided femoral stretch test. Magnetic resonance imaging (MRI) revealed a large central L1/L2 disc herniation causing significant compression of the thecal sac and proximal cauda equina nerve roots. She underwent an elective posterior L1/L2 lumbar exploration. Intraoperatively, identification of the disc was difficult, which led to inadvertent cerebrospinal fluid leak after incision of what was thought to be a disc bulge. Further exploration revealed an intradural disc that was removed via durotomy. The thecal sac was repaired with sutures and TISSEEL (Baxter, Deerfield, Illinois, USA). Postoperatively, the patient complained of weak left lower limb; MRI revealed residual disc remnants causing compression of the cauda equina. She successfully underwent an urgent revision decompression procedure. She was discharged to rehabilitation on postoperative day 14 with weakness in left knee flexion and extension (MRC grade 4/5) and left ankle plantar- and dorsiflexion (MRC grade 2/5). CONCLUSIONS: Upper lumbar IDH represent a surgical challenge. Intraoperative considerations include identification of the disc, intentional or incidental durotomy, intradural discectomy, and anatomical restrictions of operating at the level proximal to the cauda equina.