Cytomegalovirus lumbosacral polyradiculitis in patients with long-term use of an oral corticosteroid: a case report.

BACKGROUND: The long-term use of an oral corticosteroid suppresses immunity. Here, we describe a case involving a patient with weakness in the bilateral lower extremities due to cytomegalovirus (CMV) lumbosacral polyradiculitis. CASE PRESENTATION: A 64-year-old man visited a university hospital for symmetric motor weakness in both lower extremities (Medical Research Council grade: 2). Symptoms started 1 month before and gradually aggravated. The patient had been taking oral prednisolone for 10 years in order to control pain in multiple joints due to seronegative rheumatoid arthritis. He also had neuropathic pain on the entire right lower extremity and voiding difficulty. Gadolinium-enhanced magnetic resonance imaging revealed enhancement along the entire lumbosacral nerve roots. In the cerebrospinal fluid analysis (CSF), elevated white blood cell (WBC) count (19 cells/µL) and protein level (142.5 mg/dL) were observed. CMV detection by polymerase chain reaction (PCR) was positive. We diagnosed the patient as having lumbosacral polyradiculitis due to CMV. Ganciclovir (250 mg twice daily) was administered intravenously. Two months after initiating Ganciclovir, in the CSF analysis, CM detection by PCR was negative, and no WBC was found. CONCLUSION: We reported a patient who had symmetric motor weakness in the bilateral lower extremities induced by CMV lumbosacral polyradiculitis. Its occurrence seems to be related to immunosuppresion due to the long-term use of an oral corticosteroid. When a patient who is taking an oral corticosteroid shows motor weakness in the bilateral lower extremities, CMV lumbosacral polyradiculitis is one of the possible disorders to be differentiated.

Cauda equina syndrome-a practical guide to definition and classification.

PURPOSE: International uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians when discussing CES with patients and relatives, and for medicolegal purposes. METHODS: We reviewed published literature using PubMed on definition and classification of cauda equina syndrome since 2000 (21 years). Using the search terms 'cauda equina' and 'definition' or 'classification', we found and reviewed 212 papers. RESULTS: There were 17 different definitions of CES used in the literature. There were three well-defined methods of classification of CES. The two-stage system of incomplete CES (CESI) versus CES with retention (CESR) is the most commonly used classification, and has prognostic value although the details of this continue to be debated. CONCLUSION: We used the existing literature to propose a clear definition of CES. We also drew on peer-reviewed published literature that has helped to amplify and expand the CESI/CESR dichotomy, adding categories that are both less severe than CESI, and more severe than CESR, and we propose clear definitions in a table form to assist current and future discussion and management of CES.

'Scan-negative' cauda equina syndrome: what to do when there is no neurosurgical cause.

Suspected cauda equina syndrome is a common presentation in emergency departments, but most patients (≥70%) have no cauda equina compression on imaging. As neurologists become more involved with 'front door' neurology, referral rates of patients with these symptoms are increasing. A small proportion of patients without structural pathology have other neurological causes: we discuss the differential diagnosis and how to recognise these. New data on the clinical features of patients with 'scan-negative' cauda equina syndrome suggest that the symptoms are usually triggered by acute pain (with or without root impingement) causing changes in brain-bladder feedback in vulnerable individuals, exacerbated by medication and anxiety, and commonly presenting with features of functional neurological disorder.

Acute Aortic Thrombus Presenting as Cauda Equina Syndrome.

BACKGROUND: Occlusive abdominal aortic thrombus is a rare but critical clinical emergency with life-threatening consequences. Clinical presentation may mimic other diagnoses, resulting in a delay in the appropriate investigations for this condition. Spinal arterial involvement is a recognized complication of aortic thrombus and can result in pain, lower limb weakness, and loss of continence. These symptoms are usually associated with local spinal compression or stenosis manifesting as cauda equina syndrome (CES): a clinical finding of disrupted motor and sensory function to the lower extremities and bladder. CASE REPORT: We present a case of a 60-year-old female patient presenting with back pain, leg weakness, paresthesia, and urinary incontinence. She was urgently investigated for cauda equina syndrome via a magnetic resonance imaging scan of the spine, which subsequently demonstrated a large occlusive abdominal aortic thrombus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Nontraumatic acute thrombosis of the aorta is a life-threatening condition that may present with apparent neurological symptoms. In this patient there was both a relevant history and evolving clinical signs pointing toward a vascular etiology; however, the clinical findings were confusing and CES evaluation was prioritized. CES remains a medical emergency requiring urgent investigation and management. However, knowledge of spinal anatomy including vascular supply may help widen the differential. Physicians and associate specialists should consider this at clinical assessment and also when interpreting imaging of the spine. Any delay in diagnosing an aortic thrombosis has the potential for catastrophic clinical consequences.

The lived experience of Cauda Equina Syndrome: a qualitative analysis.

STUDY DESIGN: An exploratory qualitative analysis, using semi-structured interviews to investigate the lived experience of Cauda Equina Syndrome (CES). OBJECTIVES: To address the paucity of psychological research into CES and explore patient experiences of living with the injury. SETTING: The study was conducted in the United Kingdom. Recruitment was via two National Health Service spinal services in the South East of England and an online CES charity. METHODS: An interpretative phenomenological analysis (IPA) methodology was employed. Eleven participants took part in the study and completed an interview consisting of seven open ended questions relating to the psychosocial impact of CES. Interviews were audio-recorded, transcribed verbatim and analysed following an IPA procedure. RESULTS: Three superordinate themes were generated. The first, Dissatisfaction with care: 'I felt very abandoned', captured experiences of feeling neglected and disbelieved by the healthcare system and a wish for symptoms to be validated. The second, Hidden to others: 'Nobody knows. It's horrible', spoke to a struggle to gain a social identity in relation to a hidden disability. The third, Changing identities: 'You become someone totally totally different' versus 'You're still the same person', captured a process of renegotiating identity following CES. CONCLUSION: Findings highlight the importance of improving access to support for people with CES, as well as validating and facilitating disclosure of hidden symptoms. There is a clear need for more research into the psychosocial impact of this injury.

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.

Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals.

INTRODUCTION: Cauda equina syndrome (CES) is a condition with significant implications and medico-legal profile. The literature still lacks large primary studies to provide strong evidence for a robust management pathway. Statements from Neurosurgical and Spinal societies support early diagnosis and imaging but this has not resulted in any noticeable shift in referral pattern. We strongly feel the need for a nationally agreed, evidence-based referral pathway in practice. We present our large series and in-depth analysis of the referral pathway to provide strong evidence for more robust referrals and management. METHODS: We reviewed 250 referrals of suspected CES (sCES) to the regional neurosurgical unit, evaluating the importance of clinical findings and the imaging pathway. RESULTS: After clinico-radiological evaluation only 32 (13%) had confirmed CES requiring urgent surgery. There was no significant difference in terms of clinical presentation between these true cases of CES (tCES) and false cases (fCES). Imaging was therefore the key rate-limiting step. MRI was the most common investigation used. 73 patients presented without imaging out of hours (OOH). In this group, investigation was delayed to the next day in 60/73 (82%) patients while only 13 (18%) patients underwent OOH MRI. Only 2 (3%) were able to have this at their local hospital. CONCLUSIONS:  As with previous studies we conclude that signs/symptoms are insufficient to identify tCES. Taking into consideration the improved outcome with early diagnosis, the importance of early scanning in diagnosing tCES, and the poor availability of OOH MRI scanning outside of neurosurgical units, we recommend a national policy of 24/7 MRI availability for cases of sCES at all hospitals with MRI scanners. This would remove the 87% of patients not requiring urgent surgery from an unnecessary and distracting referral process.

Encephalitis associated with human herpesvirus-7 infection in an immunocompetent adult.

BACKGROUND: Primary Human herpesvirus-7 (HHV-7) infection usually occurs during childhood and causes several clinical manifestations: mainly exanthem subitum (roseola infantum), followed by a lifelong latent state with possible reactivation in case of immunodeficiency. Nevertheless, some considerably different approaches exist regarding the natural history of HHV-7 and the possible consequences of HHV-7 infection in immunocompetent adults. In particular, little is known about its pathogenic role in central nervous system (CNS) disease in nonimmunosuppressed adults. Specifically, in case of encephalitis, it is important to distinguish between infectious encephalitis and postinfectious encephalomyelitis for the management of patients CASE PRESENTATION: We describe here a case of encephalitis associated to human herpesvirus-7 with associated polymyeloradiculopathy in an immunocompetent patient which may contribute to the delineation of the approach to a patient profile with a similar clinical presentation and evolution to those presented in the literature. CONCLUSIONS: This case may alert clinicians to consider this specific etiology in the differential diagnosis of encephalopathy in patients with suspected infectious encephalitis who do not respond to acyclovir or in patients who develop acute polymyeloradiculopathy, considering that HHV-7 may be a pathological factor and that a timely diagnosis is crucial for the early administration of specific treatment.

Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage.

INTRODUCTION: Patients with cauda equina syndrome (CES) are frequently referred late when neurological damage cannot be reversed. National Guidelines for emergency referral, imaging and treatment of CES contain symptoms and/or signs that are those of late often, irreversible CES. Referral at this stage may be too late for that patient. METHODS: Seven sources were reviewed. Advice re emergency referral/imaging/treatment were reviewed. Symptoms/signs were compared with a standard classification of CES. RESULTS: 37 recommendations: 12 (32%) were symptoms/signs of bilateral radiculopathy (treatment usually leads to favourable outcomes). Thirteen recommendations (35%) were described in an imprecise way (could be interpreted as early or late CES). Twelve sets of symptoms/signs (32%) were those of late, often irreversible CES where an unfavourable outcome would be expected. CONCLUSIONS: Thirty-two percent of the so-called "red flag" symptoms and signs of CES in seven sources were definitely those of late, irreversible CES. These could be seen as "white flags" [flags of defeat and surrender]. Thirty-five percent of the recommendations if interpreted pessimistically (e.g. absent perineal sensation or urinary incontinence) would also be white flags; potentially therefore two-thirds of the so-called "red flag" symptoms/signs of CES could be those of late irreversible CES. Only 32% of the symptoms/signs were true "red flags" i.e. they warn of further, avoidable damage ahead. Guidelines should be redrawn to emphasise referral of patients who are at risk of developing CES or who have early CES. It is illogical for these guidelines to emphasise the clinical features of severe, often untreatable, CES. Demand for emergency MRI will increase; MRI is part of triage and should be performed at the DGH.

[Radiation-Induced Radiculopathy with Paresis of the Neck and Autochthonous Back Muscles with Additional Myopathy]. / Parese der Nacken- und autochthonen Rückenmuskulatur durch strahleninduzierte zervikale Radikulopathie mit Begleitmyopathie.

Radiation-induced tissue damage is caused by ionizing radiation mainly affecting the skin, vascular, neuronal or muscle tissue. Early damages occur within weeks and months while late damages may occur months or even decades after radiation.Radiation-induced paresis of the spine or the trunk muscles with camptocormia or dropped-head syndrome are rare but have already been described as long-term sequelae after treatment of Hodgkin's lymphoma. The differential diagnosis includes limb-girdle muscular dystrophy, fascioscapulohumeral muscular dystrophy (FSHD) or lysosomal storage diseases (e. g. Acid Maltase Deficiency). We present the case of a patient with long lasting diagnostics over many months due to different inconclusive results.

Neoplastic cauda equina syndrome: a neuroimaging-based review.

Cauda equina syndrome refers to dysfunction of the cauda equina, the collection of ventral and dorsal lumbar, sacral and coccygeal nerve roots that surround the filum terminale. This most commonly occurs as a result of compression by a herniated lumbosacral disc. However, the syndrome may also complicate metastatic cancer or a primary neoplasm within or infiltrating the spinal canal. An accurate and timely diagnosis is critical to avoid irreversible loss of neurological function. The clinician and radiologist must therefore be aware of the many possible causes to guide timely management. Here we review the diverse neoplastic causes affecting the cauda equina nerve roots from a neuroimaging-based perspective. We divide them by location into intramedullary neoplasms at the conus (such as astrocytoma), intradural-extramedullary neoplasms (such as schwannoma and leptomeningeal metastases) and extradural neoplasms (such as spinal metastases from systemic neoplasms). We also discuss the clinical features associated with cauda equina tumours, with special focus on cauda equina syndrome.

Cauda equina syndrome. An emergency, some unexpected severe symptoms and conservative treatment.

An 83 years old physician, doing only office work and no exercise, presented with cauda equine, due to a large intervertebral disk hernia between L1-L2 vertebrae, after an unorthodox movement. He also had a facet syndrome, a muscular spasm in the gluteus, a small fracture in the periphery of the body of the L2 vertebra and pain in the L4-L5, due to a previous vertebral hernia five years ago. All L1-L5 left lateral area was painful. He felt an unbearable pain. He also had a degree of paralysis of the gastrointestinal (GI) and the genitourinary system. He could not take analgesics or anti-inflammatory drugs per os because of the paralysis of the GI system. His pain was relieved only by intramuscular injections of parecoximbe (a cyclooxigenase-2 inhibitor, COX-2). The disc hernia was treated without surgery. After 43 days in bed, he was able to start exercising in order to treat muscles' atrophy.

Common questions about chronic low back pain.

More than 30% of U.S. adults report having experienced low back pain within the preceding three months. Although most low back pain is nonspecific and self-limiting, a subset of patients develop chronic low back pain, defined as persistent symptoms for longer than three months. Low back pain is categorized as nonspecific low back pain without radiculopathy, low back pain with radicular symptoms, or secondary low back pain with a spinal cause. Imaging should be reserved for patients with red flags for cauda equina syndrome, recent trauma, risk of infection, or when warranted before treatment (e.g., surgical, interventional). Prompt recognition of cauda equina syndrome is critical. Patient education should be combined with evidence-guided pharmacologic therapy. Goals of therapy include reducing the severity of pain symptoms, pain interference, and disability, as well as maximizing activity. Validated tools such as the Oswestry Disability Index can help assess symptom severity and functional change in patients with chronic low back pain. Epidural steroid injections do not improve pain or disability in patients with spinal stenosis. Spinal manipulation therapy produces small benefits for up to six months. Because long-term data are lacking for spinal surgery, patient education about realistic outcome expectations is essential.

A rare case of anterior sacral meningocoele presenting as cauda equina syndrome.

The authors present a case of anterior sacral meningocoele demonstrating a clinical picture of cauda equina syndrome. To the best of our knowledge, such presentation has not yet been reported.

Lyme disease -induced polyradiculopathy mimicking amyotrophic lateral sclerosis.

IMPORTANCE: To describe a case of predominantly motor polyradiculopathy secondary to Lyme disease that can mimic motor neuron disease and has been rarely reported. OBSERVATIONS: A 64-year-old man presented with a 1-month history of rapidly progressive weakness involving bulbar, upper limb and lower limb muscles. The physical examination showed widespread weakness, atrophy, fasciculation, and brisk reflexes. The initial electrodiagnostic test showed widespread active and chronic denervation findings. The initial physical and electrodiagnostic findings were suggestive of Amyotrophic Lateral Sclerosis (ALS). However, blood serology indicated possible Lyme disease. Thus, the patient was treated with doxycycline. The clinical and electrodiagnostic findings were resolved with the treatment. CONCLUSION AND RELEVANCE: The diagnosis of Lyme disease can be very challenging and it can mimic other neurological disorders such as ALS or Guillain-Barre syndrome (GBS). Careful and detailed examination and investigation are required to confirm the diagnosis and to prevent misleading inaccurate diagnoses.

Risk factors for serious underlying pathology in adult emergency department nontraumatic low back pain patients.

BACKGROUND: Nontraumatic low back pain (LBP) is a common emergency department (ED) complaint and can be caused by serious pathologies that require immediate intervention or that lead to death. OBJECTIVE: The primary goal of this study is to identify risk factors associated with serious pathology in adult nontraumatic ED LBP patients. METHODS: We conducted a health records review and included patients aged ≥ 16 years with nontraumatic LBP presenting to an academic ED from November 2009 to January 2010. We excluded those with previously confirmed nephrolithiasis and typical renal colic presentation. We collected 56 predictor variables and outcomes within 30 days. Outcomes were determined by tracking computerized patient records and performance of univariate analysis and recursive partitioning. RESULTS: There were 329 patients included, with a mean age of 49.3 years; 50.8% were women. A total of 22 (6.7%) patients suffered outcomes, including one death, five compression fractures, four malignancies, four disc prolapses requiring surgery, two retroperitoneal bleeds, two osteomyelitis, and one each of epidural abscess, cauda equina, and leaking abdominal aortic aneurysm graft. Risk factors identified for outcomes were: anticoagulant use (odds ratio [OR] 15.6; 95% confidence interval [CI] 4.2-58.5), decreased sensation on physical examination (OR 6.9; CI 2.2-21.2), pain that is worse at night (OR 4.3; CI 0.9-20.1), and pain that persists despite appropriate treatment (OR 2.2; CI 0.8-5.6). These four predictors identified serious pathology with 91% sensitivity (95% CI 70-98%) and 55% specificity (95% CI 54-56%). CONCLUSION: We successfully identified risk factors associated with serious pathology among ED LBP patients. Future prospective studies are required to derive a robust clinical decision rule.

Transverse sacral fractures and concomitant late-diagnosed cauda equina syndrome.

Transverse sacral fractures in young patients occur with high-energy mechanisms. Because of the drawbacks in radiographic and neurologic evaluations of the sacral area in polytrauma patients, misdiagnosis is quite common. In this study, we aimed to report our clinical results in three patients with displaced transverse sacral fractures compromising the sacral canal and concomitant late-diagnosed (at least 48 hours) cauda equina syndrome. Bilateral lumbopelvic fixation, followed by sacral laminectomy and decompression, was performed in all patients. Despite the late- diagnosed cauda equina syndrome, we observed that surgical decompression and lumbopelvic fixation had positive effects on neurologic recovery, pain relief and early unsupported mobilization.

Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome.

Acute aortic occlusion is an uncommon vascular emergency that can present with predominantly neurologic symptoms owing to spinal cord ischemia. We describe a 62-year-old woman who experienced acute thrombosis of an abdominal aortic aneurysm that initially presented as cauda equina syndrome. She was treated operatively with an axillary bifemoral bypass. Our case report is followed by a discussion of acute aortic occlusion.

Inflammatory hypertrophic cauda equina following intrathecal neural stem cell injection.

INTRODUCTION: Potential benefit from stem cell treatments has more patients seeking treatment without understanding possible risks. METHODS: We describe a woman who presented with progressive bilateral leg pain, numbness, and gait difficulties. A prior stroke, macular degeneration, osteoarthritis, and depression, led her to receive intrathecal neural stem cell therapy overseas 1 year before onset of symptoms. RESULTS: Imaging showed marked enlargement of lumbosacral roots of the cauda equina, which was not seen before stem cell treatment. Electrodiagnostic studies confirmed chronic multiple lumbosacral radiculopathies. Biopsy of a lumbar dorsal sensory root showed myelinated fiber degeneration and loss, with endoneurial inflammation. The hypertrophic inflammatory cauda equina syndrome was potentially triggered by the prior intrathecal neural stem cell injection. CONCLUSIONS: Safety of intrathecal stem cell treatments is not routinely regulated in overseas stem cell facilities. We wish to bring this potential complication to the attention of health care providers.