Vocal fold paralysis and cauda equina syndrome following spinal-epidural anesthesia: A case report.

RATIONALE: Vocal fold paralysis and cauda equina syndrome are very rare neurologic deficits. This report describes the case of a patient who simultaneously developed both after uneventful spinal-epidural anesthesia with 0.5% hyperbaric bupivacaine. PATIENT CONCERNS: We report the case of a 45-year-old female, who underwent surgery for bilateral hallux valgus developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered. There was no pain or paresthesia during needle placement or drug injection. Surgery was performed uneventfully. DIAGNOSES: Right vocal fold paralysis was diagnosed with flexible laryngoscopy. INTERVENTIONS: Patient was started on the treatment with a surgery for bilateral hallux valgus, who developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered. OUTCOMES: Postoperatively, she had difficulty in urination and defecation. In addition, she developed unilateral vocal fold paralysis characterized by hoarseness, effortful voice production, and choking with liquids. Magnetic resonance imaging performed on the lumbosacral area and computed tomography of the neck, the chest, and the skull revealed entirely normal results. However, flexible laryngoscopy revealed a right vocal fold paralysis. Although cauda equina syndrome can occur due to neurotoxicity of local anesthetics, the exact etiology of vocal fold paralysis is uncertain. LESSONS: The case highlights that 2 rare and serious complications of spinal-epidural anesthesia can even occur in the same patient after uneventful surgery and block performance.

Arachnoiditis Ossificans of the Lumbar Spine: A Rare Cause of Progressive Cauda Equina Syndrome.

Arachnoiditis ossificans of the spine is a rare entity defined as an ossification of the leptomeninges resulting in neurologic decline. We describe the case of a 42-year-old woman, without any obvious predisposing factor, who presented with a progressive cauda equina syndrome. The imaging findings on magnetic resonance imaging were confusing by showing an atypical intraspinal lesion extending from L1 to S1. The computed tomography scan was more specific by showing suggestive images of a huge arachnoiditis ossificans of the lumbar spine. The patient underwent a large lumbar laminectomy with an incomplete resection of the ossified arachnoid. The histologic study confirmed the bony nature of the lesion. This illustrative case highlights the importance of helical computed tomography scan with multiplanar reconstruction for the diagnosis of arachnoiditis ossificans.

Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study.

OBJECTIVE: To describe clinical features relevant to diagnosis, mechanism, and etiology in patients with "scan-negative" cauda equina syndrome (CES). METHODS: We carried out a prospective study of consecutive patients presenting with the clinical features of CES to a regional neurosurgery center comprising semi-structured interview and questionnaires investigating presenting symptoms, neurologic examination, psychiatric and functional disorder comorbidity, bladder/bowel/sexual function, distress, and disability. RESULTS: A total of 198 patients presented consecutively over 28 months. A total of 47 were diagnosed with scan-positive CES (mean age 48 years, 43% female). A total of 76 mixed category patients had nerve root compression/displacement without CES compression (mean age 46 years, 71% female) and 61 patients had scan-negative CES (mean age 40 years, 77% female). An alternative neurologic cause of CES emerged in 14/198 patients during admission and 4/151 patients with mean duration 25 months follow-up. Patients with scan-negative CES had more positive clinical signs of a functional neurologic disorder (11% scan-positive CES vs 34% mixed and 68% scan-negative, p < 0.0001), were more likely to describe their current back pain as worst ever (41% vs 46% and 70%, p = 0.005), and were more likely to have symptoms of a panic attack at onset (37% vs 57% and 70%, p = 0.001). Patients with scan-positive CES were more likely to have reduced/absent bilateral ankle jerks (78% vs 30% and 12%, p < 0.0001). There was no significant difference between groups in the frequency of reduced anal tone and urinary retention. CONCLUSION: The first well-phenotyped, prospective study of scan-negative CES supports a model in which acute pain, medication, and mechanisms overlapping with functional neurologic disorders may be relevant.

A prospective study of the role of bladder scanning and post-void residual volume measurement in improving diagnostic accuracy of cauda equina syndrome.

AIMS: Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. METHODS: A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. RESULTS: The study confirms the low predictive value of 'red flag' symptoms and signs. Of note 'bilateral sciatica' had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed 'low-risk' of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. CONCLUSION: This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677-682.

Recovery after traumatic thoracic- and lumbar spinal cord injury: the neurological level of injury matters.

STUDY DESIGN: Multicenter prospective cohort. OBJECTIVE: To discern neurological- and functional recovery in patients with a traumatic thoracic spinal cord injury (TSCI), conus medullaris syndrome (CMS), and cauda equina syndrome (CES). SETTING: Specialized spinal cord injury centers in Europe. METHOD: Lower extremity motor score (LEMS) and spinal cord independent measure (SCIM) scores from patients with traumatic TSCI, CMS, and CES were extracted from the EMSCI database. Scores from admittance and during rehabilitation at 1, 3, 6, and 12 months were compared. Linear mixed models were used to statistically analyse differences in outcome, which were corrected for the ASIA Impairment Scale (AIS) in the acute phase. RESULTS: Data from 1573 individuals were analysed. Except for the LEMS in patients with a CES AIS A, LEMS, and SCIM significantly improved over time for patients with a TSCI, CMS, and CES. Irrespectively of the AIS score, recovery in 12 months after trauma as measured by the LEMS showed a statistically significant difference between patients with a TSCI, CMS, and CES. Analysis of SCIM score showed no difference between patients with TSCI, CMS, or CES. CONCLUSION: Difference in recovery between patients with a traumatic paraplegia is based on neurological (motor) recovery. Regardless the ceiling effect in CES patients, patients with a mixed upper and lower motor neuron syndrome (CMS) showed a better recovery compared with patients with a upper motor neuron syndrome (TSCI). These findings enable stratifications of patients with paraplegia according to the level and severity of SCI.

Primary Lumbar Paraganglioma: Clinical, Radiologic, Surgical, and Histopathologic Characteristics from a Case Series of 13 Patients.

BACKGROUND: Paragangliomas are uncommon neuroendocrine tumors, rarely occurring in the lumbar spine. Primary lumbar paragangliomas are prominently vascularized, can present variably, and pose both diagnostic and surgical challenges. We report on a large case series with long-term follow-up and intraoperative footage to characterize the natural history, diagnostic approach, and operative approach to this rare surgical disease. METHODS: This is a single-center, retrospective cohort study including all patients with histologically confirmed primary lumbar paraganglioma treated at our tertiary neurosurgical center between 1997 and 2018. Clinical, radiologic, surgical, and histologic data were collected from medical records. RESULTS: There were 13 cases of primary lumbar paraganglioma (8 men [61.5%], 5 women [38.5%]; mean age, 51.3 years; range, 33.2-68.9 years). Symptom duration correlated with tumor size (Spearman r = 0.735, P = 0.01). The main presenting symptoms were lower back pain and radiculopathy, often long-standing with recent deterioration. Seven patients (53.8%) were admitted as emergency cases, including 3 with cauda equina syndrome. Preoperative differential diagnoses included nerve sheath tumor, ependymoma, meningioma, and disk herniation. The mean Ki-67 mitotic index was 5.7% (range, 1%-10%). Surgical resection improved pain in 8 of 13 patients (61.5%) and weakness improved in 5 of 5 patients (100%). CONCLUSIONS: Primary lumbar paragangliomas are rare neoplasms of the cauda equina that typically progress slowly but may also present acutely. They are often related to the filum terminale, which should be resected prior to other attachments intraoperatively to prevent displacement of the tumor out of view. Total resection can be curative, and long-term follow-up in this series found no recurrence.

Heel lift improves walking ability of persons with traumatic cauda equina syndrome-a pilot experimental study.

STUDY DESIGN: Non-randomized within-subject experimental study. OBJECTIVE: To determine whether the addition of the 1 cm heel lift to the footwear improves the walking ability of the persons with Cauda Equina Syndrome (CES). SETTING: Department of Physical Medicine and Rehabilitation, Christian Medical College, India. METHODS: Fourteen people with bilateral plantar flexor weakness following traumatic CES (mean age 43.7 years) were recruited for the study. Their walking speed, stride length, cadence, and time taken to complete Timed Up and Go (TUG) were measured using footwear with back straps. Then, the 1 cm heel lift was attached to the sole of the footwear. After sufficient practice, all the parameters were reassessed to find out the effectiveness of the heel lift. RESULTS: With the 1 cm heel lift, the participants walked 0.13 m/s (95% CI, 0.08-0.17) faster than their regular footwear. They were able to complete the TUG test 2.6 s (95% CI, 1.4-3.7) earlier than before. There was an increase of 5.2 in. in stride length (95% CI, 2.9-9) and an eight steps increase in cadence (95% CI, 4.9-11.3) observed after the heel lift. CONCLUSIONS: This pilot study has demonstrated that addition of 1 cm heel may be effective in improving the walking performance of persons with Cauda Equina Syndrome. Future studies should investigate the kinetic and kinematic changes of this modification using a randomized controlled trial study design.

SHADES of grey - The challenge of 'grumbling' cauda equina symptoms in older adults with lumbar spinal stenosis.

Diagnosing cauda equina syndrome is challenging in older adults with lumbar spinal stenosis. Understanding these challenges is vital for clinicians who are faced with difficult decisions about when to refer for investigation or surgical management. This is a growing clinical issue because of the escalating prevalence of lumbar spinal stenosis in our ageing population, and increasing demands on healthcare services including imaging and surgical services. This professional issue explores the challenges and evidence gaps relating to cauda equina syndrome in older adults with lumbar spinal stenosis. The degenerative patho-anatomical changes in the lumbar spine that are responsible for lumbar spinal stenosis also have the potential to lead to a gradual compromise of the cauda equina nerve roots. The clinical presentation may be unclear. As a result, there is a risk that slow-onset 'grumbling' cauda equina symptoms may be overlooked or dismissed in older patients with lumbar spinal stenosis. Furthermore, a lack of standardised diagnostic criteria and management pathways add to the challenges for clinicians diagnosing and managing potential cauda equina compromise associated with lumbar spinal stenosis. We recommend careful assessment, appropriate safety netting, and ongoing clinical monitoring and vigilance when assessing and managing this potentially vulnerable patient group.

Are we neglecting sexual function assessment in suspected cauda equina syndrome?

OBJECTIVES: We assessed the documentation rates of signs and symptoms, including sexual function, in patients with suspected cauda equina syndrome and whether they can be improved by increasing local awareness. PATIENTS AND METHODS: We reviewed all electronic records of patients referred with suspected CES who required urgent MRI to our regional service over a 2 month period. We recorded the documentation rates of clinical signs and symptoms. The results were presented locally to increase awareness. A further 2 month period was then re-audited. 120 patients in total were included across both time periods. Chi-squared was used to compare documentation rates between time periods. RESULTS: 25 of 120 patients had radiological cauda equina compression. Lower limb neurology, urinary function and saddle sensation were almost universally documented. After the intervention, there was a significant increase (p < 0.05) in the documentation of bowel function and post-void residual but not sexual function. Sexual function was poorly documented with rates of 3% and 11% throughout the two audited periods. CONCLUSION: Certain clinical features of CES are well documented. Increasing awareness may improve documentation of certain symptoms/signs in patients with suspected cauda equina syndrome. Sexual function was poorly documented and increasing awareness alone is an inadequate intervention.

Evaluation and management of cauda equina syndrome in the emergency department.

BACKGROUND: Cauda equina syndrome (CES) may be a devastating disease with the potential for significant patient morbidity. It is essential for emergency clinicians to be aware of how to effectively diagnose and manage this condition. OBJECTIVE: This article provides a narrative review of the diagnosis and management of CES for the emergency clinician. DISCUSSION: Cauda equina syndrome is a rare but emergent condition associated with back pain. It can result in severe morbidity and can be due to a variety of causes, most commonly vertebral disc protrusion. Diagnosis is often delayed, which may result in a poor prognosis. Red flags and findings consistent with CES include bilateral neurogenic sciatica, reduced perineal sensation, altered bladder function leading to painless urinary retention, loss of anal tone, and loss of sexual function. In isolation, history and examination findings demonstrate poor sensitivity. Symptoms may occur either suddenly or gradually, and most patients do not present with all of these symptoms. Postvoid bladder volume assessments can assist in the evaluation, but the diagnosis typically involves magnetic resonance imaging (MRI) or computed tomography myelography if MRI is not available. Treatment relies upon surgical consultation and operative intervention for decompression. CONCLUSION: Cauda equina syndrome can be a difficult diagnosis. However, knowledge of the history and examination findings, imaging, and treatment can assist the emergency clinician in optimizing management of this condition.

Cauda equina syndrome without motor dysfunction following lumbar spinal stenosis surgery: A case report.

RATIONALE: Cauda equina syndrome (CES) refers to a group of symptoms that occur when the nerves in the cauda equina become compressed or damaged. The most common etiology of CES is lumbar intervertebral disc herniation, but CES following lumbar spinal surgery is rare, especially without motor dysfunction. Herein, we illustrate a case of CES that developed as a complication of spinal surgery and to deduce its possible underlying cause. PATIENT CONCERNS: A 46-year-old man experienced lumbago, bilateral shank pain, and numbness with neurogenic claudication for 3 years due to degenerative lumbar disc herniation and spinal cord stenosis. After a thorough examination to diagnose lumbar spinal stenosis, the patient underwent bilateral decompression and pedicle screw system internal fixation with bone graft. Postoperatively, the patient showed regained strength in his bilateral shanks, and he did not complain of lumbago and shank pain, but CES occurred, which manifested as underpants-type numbness in the perineum without bladder, anal, and motor dysfunction. DIAGNOSES: CES as a postoperative complication of lumbar stenosis. INTERVENTIONS: The patient underwent bilateral laminectomies, partial facetectomies, and pedicle screw system internal fixation and fusion with bone graft. Postoperatively, the patient performed adequate rehabilitation exercises and was expected to recover spontaneously. OUTCOMES: The symptoms of pain and claudication resolved after 3 weeks in the hospital, but an underpants-type hypoesthesia in the perineum without motor dysfunction developed. The patient experienced full recovery from CES 6 months after surgery. LESSONS: CES as a complication of lumbar spinal surgery is very rare. Excessive sensitivity to the traction of the dural sac was, in our opinion, the most possible cause of postoperative CES in this case. When the nerve root is pulled intraoperatively, it is best not to cross the central line of the spinous process. The plane of the nerve retractor needs to be parallel to the dural sac at the pulling point to reduce the formation of shear force. Most importantly, gentle maneuver is required because sensitivity to the traction of the dural sac varies individually.

BET 2: Is sexual dysfunction a recognised sign of cauda equina syndrome in the ED?

A shortcut review of the literature was carried out to examine the association of sexual dysfunction in the context of new-onset low back pain, with cauda equina syndrome (CES). Five papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that clinicians appear to be poor at recording this feature during assessment, but between 12% and 96%, patients with confirmed CES will report the presence of new-onset sexual dysfunction at presentation when asked. It appears that this can also be a single isolated red flag feature in the context of low back pain and as such should be a mandatory part of any clinical assessment that seeks to evaluate the risk of impending CES.

Cauda Equina Syndrome Caused by Epidural Venous Plexus Engorgement in a Patient with May-Thurner Syndrome.

The purpose of this article is to present a case of cauda equina syndrome in a patient with incomplete motor and sensory deficits due to epidural venous plexus engorgement, owing to May-Thurner syndrome successfully treated with venous iliac stenting. A 40-year-old woman, with previous history of deep vein thrombosis and miscarriages, gradually developed right leg and back pain, with functional limitation, perineal hypoesthesia, and sphincter incontinence. Magnetic resonance imaging revealed epidural venous plexus engorgement and cauda equina roots involvement. Phlebography showed perimedullary venous enlargement and left common iliac vein stenosis, leading to the diagnosis of May-Thurner syndrome. Stenting of the left common iliac vein was performed resulting in pain improvement and disappearance of neurological symptoms. Thrombophilia study was positive to heterozygous factor V Leiden. Cauda equina syndrome as the first presentation of a May-Thurner syndrome is very rare. In this case, venous iliac stent placement was an effective and safe treatment.

The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients.

BACKGROUND: The majority of patients presenting with suspected clinical cauda equina syndrome (CES) have no identifiable structural cause for their symptoms ('scan-negative' CES). Understanding these patients aids clinical differentiation and management in CES. METHODS: A retrospective electronic note review was undertaken of patients presenting with suspected CES, defined as ≥ 1 of acute bladder, bowel, sexual dysfunction or saddle numbness, to a regional neurosciences centre. We investigated radiology, clinical features, psychiatric and functional disorder comorbidities and outcome of patients with 'scan-negative' CES and patients with MRI confirmed compression of the cauda equina ('scan-positive' CES). RESULTS: 276 patients were seen over 16 months. There were three main radiologically defined patient groups: (1) 'scan-positive' CES (n = 78, mean age 48 years, 56% female), (2) 'scan-negative' CES without central canal stenosis but with lumbosacral nerve root compression not explaining the clinical presentation (n = 87, mean age 43 years, 68% female) and (3) 'scan-negative' CES without neural compromise (n = 104, mean age 42 years, 70% female). In the two 'scan-negative' groups (no neural compromise and nerve root compression), there were higher rates of functional disorders (37% and 29% vs. 9%), functional neurological disorders (12% and 11% vs 0%) and psychiatric comorbidity (53% and 40% vs 20%). On follow-up (mean 13-16 months), only 1 of the 191 patients with 'scan-negative' CES was diagnosed with an explanatory neurological disorder (transverse myelitis). CONCLUSIONS: The data support a model in which scan-negative cauda equina syndrome arises as an end pathway of acute pain, sometimes with partly structural findings and vulnerability to functional disorders.