Clinical and epidemiological features of Lyme neuroborreliosis in adults and factors associated with polyradiculitis, facial palsy and encephalitis or myelitis.

The clinical course of Lyme neuroborreliosis (LNB) is highly variable. Delayed diagnosis and treatment still remain actual challenges. Moreover, there is a lack of studies analyzing the factors associated with different LNB syndromes. We aimed to analyze clinical and epidemiological features of LNB in hospitalized adults in eastern Lithuania. A retrospective study was performed for patients presenting in the years 2010-2021. A total of 103 patients were included in the study, 100 with early, and three with late LNB. Patients with early LNB most often presented polyradiculitis [75/100, (75%)], which was also the most common initial neurological syndrome. Peripheral facial palsy was diagnosed in 53/100 (53%) patients, in 16/53 (30.2%) cases both facial nerves were affected. Encephalitis or myelitis was diagnosed in 14% of patients with LNB. A total of 76/103 (73.8%) patients were discharged with residual symptoms or signs. One patient presenting encephalomyelitis died because of bacterial complications. The absence of observed erythema migrans (EM) was the predictor of peripheral facial palsy, while female sex and EM untreated with antibiotics were predictors of isolated polyradiculitis. A fever of ≥ 38 ° °C and pleocytosis of ≥ 300 × 106/l were associated with the development of encephalitis or myelitis in patients with early LNB.

Surgical Outcome of Cauda Equina Syndrome Secondary to Disc Herniation Presenting Late in Developing Countries.

Cauda equina syndrome (CES) is a serious neurologic state in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. The nerves of the cauda equine provide the muscles that manage the bladder, bowel and the legs and the dysfunction producing impairment of bladder, bowel or sexual function and perianal or saddle numbness. Identification of CES is not only important to neurosurgeons and spine surgeons, but also to prime care practitioners, emergency room physicians, physiotherapists and allied health care professionals concerned in management of back pain. It is a significant diagnosis from a clinical and medico-legal outlook. Early surgical decompression is endorsed by most authors to best support patient's revival and trim down long term disability. This cross sectional observational study was conducted at Shaheed Suhrawardy Medical College Hospitals, Dhaka, Bangladesh from January 2015 to January 2021 and the aim of this study was to find the predictors and the clinical outcome of cauda equina syndrome after spinal decompression with delayed presentation. Among 680 patients of degenerative disc diseases; 32 cases (4.7%) had CES, those presenting late in course of disease. Time interval between bladder and bowel dysfunction and admission to hospital varied from 2-64 days with mean delay of 15.4 days. The average follow-up was 22.6 months, ranging from 12 to 34 months. There was significant positive correlation (p<0.05) between duration taken for total recovery and delay in surgery and between delayed decompression and a poor outcome. Also there was a clear correlation between the presence of complete perineal anaesthesia and absence of anal wink as both univariate and multivariate predictors of a poor outcome. There was significant association between a slower onset of CES and a favourable outcome. There was no significant correlation found between initial motor function loss, bilateral sciatica and level of the lesions as predictors of a poor outcome.

Lumbar decompression surgery for cauda equina syndrome - comparison of complication rates between daytime and overnight operating.

PURPOSE: To investigate the incidence of complications from lumbar decompression ± discectomy surgery for cauda equina syndrome (CES), assessing whether time of day is associated with a change in the incidence of complications. METHODS: Electronic clinical and operative notes for all lumbar decompression operations undertaken at our institution for CES over a 2-year time period were retrospectively reviewed. "Overnight" surgery was defined as any surgery occurring between 18:00 and 08:00 on any day. Clinicopathological characteristics, surgical technique, and peri/post-operative complications were recorded. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals. RESULTS: A total of 81 lumbar decompression operations were performed in the 2-year period and analysed. A total of 29 (36%) operations occurred overnight. Complete CES (CESR) was seen in 13 cases (16%) in total, 7 of whom underwent surgery during the day. Exactly 27 complications occurred in 24 (30%) patients. The most frequently occurring complication was a dural tear (n = 21, 26%), followed by post-operative haematoma, infection, and residual disc. Complication rates in the CESR cohort (54%) were significantly greater than in the CES incomplete (CESI) cohort (25%) (p = 0.04). On multivariable analysis, overnight surgery was independently associated with a significantly increased complication rate (OR 2.83, CI 1.02-7.89). CONCLUSIONS: Lumbar decompressions performed overnight for CES were more than twice as likely to suffer a complication, in comparison to those performed within daytime hours. Our study suggests that out-of-hours operating, particularly at night, must be clinically justified and should not be influenced by day-time operating capacity.

Acute Lymphoblastic Leukemia Masquerading as Guillain-Barré Syndrome.

INTRODUCTION: Neurological manifestations of acute lymphoblastic leukemia (ALL) have been reported as cranial neuropathies or meningeal symptoms most common in children. However, ALL can rarely involve the nerve roots causing symmetrical polyradiculopathy which can present with rapid onset paralysis, mimicking Guillain-Barré Syndrome (GBS). The symmetrical polyradiculopathy can be the earliest manifestation of ALL occurring even before the hematological and systemic manifestations. CASE REPORT: We report a case of a healthy 29-year-old man who presented with subacute bilateral lower extremity weakness and numbness preceded by a respiratory infection. He was initially treated as a suspected (GBS) but cerebrospinal fluid (CSF) findings suggested an alternative diagnosis. His prior TB exposure created a diagnostic confusion. Lumbar spine magnetic resonance imaging revealed nerve root enhancements at L4-L5 and L5-S1 that are seen in GBS and TB arachnoidids. Brain magnetic resonance imaging demonstrated bilateral distention of the optic nerve sheath complexes with CSF suggestive of intracranial hypertension. CSF revealed elevated protein, nucleated cells 2145 leukocytes/mm 3 , numerous atypical lymphoid cells. He was later diagnosed with ALL associated symmetrical polyradiculopathy presenting with GBS-like symptoms. CONCLUSION: Symmetrical polyradiculopathy is a rare complication of ALL and can be confused with acute inflammatory demyelinating polyneuropathy. ALL associated polyradiculopathy in young individuals can be clinically indistinguishable from GBS. Our case highlights that when CSF findings are atypical for GBS, ALL should be considered on the differential diagnosis in patients presenting with GBS like symptoms.

Factors affecting urinary outcome after delayed decompression in complete cauda equina syndrome: "A regression model study".

PURPOSE: To evaluate the recovery of urinary functions and the factors predicting urinary recovery, following delayed decompression in complete cauda equina syndrome (CESR) secondary to Lumbar disc herniation (LDH). METHODS: Retrospective study evaluated 19 cases of CESR due to single-level LDH, all presenting beyond 72 h. Mean delay in decompression was 11.16 ± 7.59 days and follow-up of 31.71 ± 13.90 months. Urinary outcomes were analysed on two scales, a 4-tier ordinal and a dichotomous scale. Logistic regression analysis was used for various predictors including delay in decompression, age, sex, radiation, level of LDH, motor deficits, type and severity of presentation. Time taken to full recovery was correlated with a delay in decompression. using Spearman-correlation. RESULTS: Optimal recovery was seen in 73.7% patients and time to full recovery was moderately correlated with a delay in decompression (r = 0.580, p = 0.030). For those with optimal bladder recovery, mean recovery time was 7.43 ± 5.33 months. Time to decompression and other evaluated factors were not found contributory to urinary outcomes on either scales. Three (15.8%) patients had excellent, 11 (57.9%) had good, while 3 (15.8%) and 2 (10.5%) had fair and poor outcomes respectively. CONCLUSIONS: Occurrence of CESR is not a point of no-return and complete recovery of urinary functions occur even after delayed decompression. Longer delay leads to slower recovery but it is not associated with the extent of recovery. Since time to decompression is positively correlated with time to full recovery, early surgery is still advised in the next available optimal operative setting. LEVEL OF EVIDENCE: IV.

'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.

A Diffuse Leptomeningeal Glioneural Tumor Case Producing Hydrocephalus and Polyradiculopathy

The present report describes the case of a male 17-year-old patient who progressively developed a hydrocephalus and polyradiculopathy due to involvement of central nervous system (CNS) by a diffuse leptomeningeal glioneuronal tumor (DLGNT). The tumor had partial remission in response to the treatment with radiotherapy plus procarbazine, lomustine, and vincristine (PCV) chemotherapy, and the patient had improvement in function and pain levels. The current knowledge about DLGNT, including its clinical manifestations, imaging findings, histological characteristics, and treatment are revised and discussed in the present paper.

Primary Epstein-Barr virus infection in immunocompetent patients with acute transverse myelitis and a combination of polyradiculitis and anterior horn syndrome as neurological manifestations.

Neurological manifestations of a primary Epstein-Barr virus (EBV) infection are rare. We describe a case with acute transverse myelitis and another case with a combination of polyradiculitis and anterior horn syndrome as manifestations of a primary EBV infection.The first case is a 50-year-old immunocompetent male diagnosed with acute transverse myelitis, 2 weeks after he was clinically diagnosed with infectious mononucleosis. The second case is an 18-year-old immunocompetent male diagnosed with a combination of polyradiculitis and anterior horn syndrome while he had infectious mononucleosis. The first patient was treated with methylprednisolone. After 1 year, he was able to stop performing clean intermittent self-catheterisation. The second patient completely recovered within 6 weeks without treatment.Primary EBV infection should be considered in immunocompetent patients presenting with acute transverse myelitis and a combination of polyradiculitis and anterior horn syndrome. Antiviral treatment and steroids are controversial, and the prognosis of neurological sequelae is largely unknown.

Síndrome de Guillain-Barre. Reporte de un caso / Guillaim Barre Syndrome. Case Report

Antecedentes. El Síndrome de Guillian-Barré (SGB) es una polirradiculopatía aguda, frecuentemente grave, de evolución fulminante sin la asistencia médica oportuna, de origen autoinmunitario. Que es precedida de un antecedente de infección gastrointestinal o respiratoria comúnmente. Se caracteriza por parálisis motora ascendente arrelexica de evolución rápida, con disociación albuminocitológica en líquido cefalorraquídeo. Las principales complicaciones se desarrollan en el 60% de pacientes intubados. Caso Clínico: masculino de 42 años de edad con parestesias en miembros inferiores de cuatro días de evolución, posteriormente a paresias que asciende rápidamente a miembros superiores. Como antecedente enfermedad gastrointestinal aguda hace 4 semanas. A la exploración clínica presentaba tetraparesia, arrelexia, ausencia de relejo tusígeno, y parálisis bulbar con posterior intubación orotraqueal y apoyo ventilatorio. Se realizó punción lumbar con disociación albuminocitológica. Se dio manejo con inmunoglobulina intravenosa (IgIV) por 5 días, siendo la insuiciencia respiratoria, neumonía nosocomial, sepsis y disautónomias como complicaciones más frecuente. Conclusión: el SGB es una entidad de pronóstico grave, que requiere de medidas de soportes esenciales para evitar complicaciones que puedan comprometer la vida del paciente...(AU)

Obesity and spinal epidural lipomatosis in cauda equina syndrome.

BACKGROUND CONTEXT: Although lumbar disc herniations are common, only a small portion of these herniations lead to cauda equina syndrome (CES), which is an uncommon but debilitating disorder. Why some patients with herniation develop CES, when most do not, remains unknown. Preexisting subclinical epidural lipomatosis may limit canal space such that an otherwise benign herniation causes CES. PURPOSE: This study determines whether patients with an acute disc herniation and CES have a greater body mass index (BMI) and greater quantity of epidural fat compared with control subjects with non-CES symptomatic lumbar herniated discs. STUDY DESIGN/SETTING: A retrospective case-control series at a university-based level-1 trauma center was carried out. PATIENT SAMPLE: There were 33 CES and 66 control subjects identified from a prospectively maintained database of patients who underwent surgical management for a lumbar disc herniation between 2007 and 2012. Each CES case had two non-CES control patients matched by gender and age within 5 years except 5 CES cases that matched only one non-CES control. OUTCOME MEASURES: The outcome measures included weight, height, age, gender, and BMI. Radiographic outcome measures included the proportion of lumbar spinal canal occupied by fat and herniated disc on preoperative magnetic resonance imaging. METHODS: Patient charts and preoperative radiographs were retrospectively reviewed. For each patient, a blinded reviewer determined the proportion of lumbar spinal canal occupied by fat, and the maximal proportion of the canal occupied by herniated material at the involved level. Patient demographics and radiographic measures were compared between CES and control groups using chi-square or Student t tests. A second blinded reviewer re-assessed a series of radiographs, and the intraobserver variability was determined by Spearman correlation. Logistic regression was used to model the preoperative factors associated with having an acute disc herniation and CES. RESULTS: The CES cases had higher BMI (31.8 kg/m2, 95% confidence interval [CI] 29.5-34.0 vs. 28.1 kg/m2, 95% CI 26.7-29.5 in controls; p=.007), focally narrower canals (14.6 mm, 95% CI 13.8-15.3 mm vs. 16.4 mm, 95% CI 15.4-17.3 mm in controls; p=.003), and a greater percentage of spinal canal occupied by epidural fat (31.3%, 95% CI 26.1%-36.6% vs. 21.9%, 95% CI 18.7%-25.1% in controls; p=.003) and herniated disc material (54.5%, 95% CI 46.9%-62.0% vs. 34.4%, 95% CI 30.3%-38.5% in controls; p<.0001). Logistic regression confirmed canal width at the involved level, BMI, amount of canal occupied disc, and proportion of canal occupied by fat as independent predictors of having an acute disc herniation and CES. CONCLUSIONS: Obesity is a risk factor for CES from disc herniation. The CES cases also had a greater amount of herniated material, focally narrower canal, and larger epidural fat deposits. The latter may be the mechanism linking obesity with CES.

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.

Prediction of the outcome of bladder dysfunction based on electrically induced reflex findings in patients with cauda equina syndrome: A retrospective study.

The evaluation of the electrically induced bulbocavernosus reflex (BCR) using electromyography (EMG) is a useful tool for evaluating the integrity of sacral spinal segments 2 to 4, and that of their afferent and efferent connections in the urogenital region. In the current retrospective study, the value of this technique in predicting the outcome of bladder dysfunction was investigated in patients with cauda equina syndrome (CES). Electrically induced BCR (E-BCR) was evaluated in 40 patients with bladder dysfunction due to CES at the subacute stage (7-90 days). Manually examined BCR, perianal pinprick sensation, and voluntary anal contraction were also investigated. The recovery of bladder function was evaluated 1 year after the onset of CES. All patients with the presence of E-BCR showed successful recovery of the bladder function, while all patients in whom E-BCR was absent showed poor recovery. E-BCR showed a higher positive predictive value than perianal pinprick sensation and voluntary anal contraction, and showed a higher negative predictive value than manually examined BCR. Results show that E-BCR has advantages in predicting the outcome of bladder dysfunction. Thus, this method can be used as a reference to predict the final outcome of bladder dysfunction at the subacute stage of CES.

Motor polyradiculopathy during pembrolizumab treatment of metastatic melanoma.

INTRODUCTION: Pembrolizumab, a monoclonal antibody directed against the immune checkpoint programmed cell death-1 receptor (PD-1), has improved survival in patients with advanced melanoma. Neuromuscular immune-mediated side effects have been rarely reported. METHODS: We describe a 44-year-old man with metastatic melanoma who presented with progressive muscle weakness after 23 doses of pembrolizumab. RESULTS: The patient developed asymmetric, proximal muscle weakness and atrophy in all four limbs. Cerebrospinal fluid examination showed albuminocytologic dissociation. MRI revealed contrast enhancement of the lumbosacral roots. Electrodiagnostic studies demonstrated widespread fibrillation potentials in all four limbs, suggesting a generalized motor polyradiculopathy. Despite pembrolizumab discontinuation and treatment with steroids and intravenous immunoglobulin, limb weakness worsened. Electrodiagnostic studies were repeated, and showed marked and diffuse axonal motor damage. Seven weeks after clinical onset the patient was treated with plasma exchanges. He showed no further deterioration. DISCUSSION: We report a severe motor polyradiculopathy associated with an anti-PD-1 agent that expands the spectrum of neuromuscular complications of this class of drugs. Muscle Nerve 56: E162-E167, 2017.

Síndrome de cauda equina en paciente embarazada con hernia de disco masiva / The cauda equina syndrome in pregnant woman with a massive disc herniation

La lumbalgia durante el embarazo supone una causa frecuente de consulta médica. Si bien la lumbalgia es muy frecuente, la incidencia de lumbalgia secundaria a hernia discal durante la gestación es baja (1:10.000). El síndrome de cauda equina secundaria a hernia discal representa una complicación muy grave. El retraso en el diagnóstico y en el tratamiento puede suponer una causa de discapacidad crónica secundaria a secuelas neurológicas. Se han comunicado numerosos casos de hernias discales durante el embarazo, sin embargo la asociación de un síndrome de cauda equina por hernia discal es poco frecuente. Presentamos el caso de un síndrome de cauda equina en una mujer embarazada de 12 semanas de gestación (AU)

Low back pain during pregnancy is a common cause of medical consultation. Although back pain is very common, the incidence of low back pain secondary to lumbar disk herniation in pregnancy is low (1: 10,000). Cauda equina syndrome from lumbar disk herniation is a serious complication. The delay in diagnosis and treatment can be a cause of chronic disability secondary to neurological sequelae. Numerous cases of disk herniation in pregnancy have been reported, however the association of a cauda equina syndrome as a result of disk herniation is rare. A case is presented of cauda equina syndrome in a pregnant woman at 12-week gestation (AU)

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.

Intermittent catheterization acceptance test (I-CAT): A tool to evaluate the global acceptance to practice clean intermittent self-catheterization.

AIM: In certain cases, a patient's anxiety, fear, or misconceptions can represent significant obstacles to the learning of Clean Intermittent Self Catheterization (CISC), and little is known about these psychological barriers. The aim of the present study is thus to construct and validate an "Intermittent Catheterization Acceptance Test (I-CAT)" to evaluate the psychological acceptance of CISC. METHODS: A study was carried out in nine neuro-rehabilitation and urology departments in French university hospitals. Fifty-five items were identified, following a comprehensive review of the literature and cognitive debriefing interviews with patients. Following an initial expert panel meeting (EPM) with a French-speaking neuro-urology study group (GENULF), this list was refined and reduced to a draft I-CAT comprising 34 items. The face validity of the draft I-CAT was determined, and the results were then analyzed in a second EPM, leading to the elaboration of a second version of the I-CAT (23 items, 5 dimensions). Psychometric validation of this second version was established from a longitudinal, non-randomized study involving 201 neurological and non-neurological patients. Linguistic validation was carried out in English. RESULTS: Following the construct validity analyses, several items were deleted due to item overlap, ceiling effects, or poor content validity and 14 items were retained. Confirmatory factor analysis shows that this version has 2 dimensions. Cronbach's alpha was 0.93. The ICC demonstrated good test-retest reliability and satisfactory responsiveness. CONCLUSION: The upstream identification and solving of potential psychological barriers prior to the learning of CISC could improve patients' acceptance of this procedure.

Endoscope-assisted oblique lumbar interbody fusion for the treatment of cauda equina syndrome: a technical note.

OBJECTIVE: The goal of this paper was to describe how endoscope-assisted oblique lumbar interbody fusion (OLIF) could remove huge lumbar disc herniation (HLDH) manifested with cauda equina syndrome (CES). METHODS: In this study, the authors made an attempt to treat CES with a direct endoscopic decompression through the OLIF corridor and performed OLIF in two patients with HLDH. RESULTS: Two patients with HLDH were successfully treated using OLIF with spinal endoscopic discectomy. We achieved direct ventral decompression by removal of herniated disc fragments located beyond the posterior longitudinal ligament (PLL). All preoperative symptoms in two patients improved postoperatively. CONCLUSIONS: Endoscope-assisted oblique lumbar interbody fusion (OLIF) could successfully achieve neural decompression without additional posterior decompression in CES and could be used as an alternative treatment in well selected cases.

A case of encephalomyeloradiculopathy in a non-carcinomatous patient associated with P/Q type voltage gated calcium channel antibodies.

The presence of P/Q type voltage gated calcium channel (VGCC) antibodies has been strongly correlated with Lambert Eaton Syndrome (LES), present in 90% of non-immunocompromised patients with LES. However, there have been case reports which have shown its association between paraneoplastic syndrome affecting both central nervous system and the peripheral nervous system causing encephalomyelitis and sensory neuronopathy/neuropathy. We present a case of a young man, who presented with encephalomyelitis, and was further noted to have superimposed cervical polyradiculopathy associated with P/Q type VGCC antibodies.

Cefalea pospunción dural como presentación de síndrome de cola de caballo secundario a meningitis tuberculosa / Postdural puncture headache as presentation of horsetail syndrome secondary to tuberculosis meningitis

No disponible