Lightning strike­induced cauda equina syndrome: a case report.

Peripheral nerve injuries after being struck by lightning have been documented. Here, we report a case of cauda equina syndrome induced by lightning. A 27-year-old man presented with numbness, a burning sensation in the saddle region, and increased urinary urgency after being struck by lightning. He had absent Achilles reflexes and paresthesia in the saddle region upon neurological examination, and magnetic resonance imaging of the spine was normal. Electrophysiological studies indicated involvement of bilateral L5, S1, and S2 myotomes and revealed cauda equina lesions. 
Peripheral nerve injury induced by lightning is rare, and the evaluation of people with neurological complaints using electromyography will help determine the true incidence.

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.

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers.

BACKGROUND: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

Post-traumatic lumbar nerve root entrapment into the spinous process of the lumbar spine.

Thoracolumbar fractures constitute a significant portion of spinal trauma, accounting for 15-20% of the cases. These fractures, caused by high-impact injuries, may involve tears of the posterior ligamentous complex, presenting a high chance of neurological injury ranging from dural tears to spinal root avulsion. This case report discusses a rare occurrence of avulsion of lumbosacral nerve roots posteriorly, becoming entrapped in the fractured spinous process of the L2 lumbar vertebra, leading to cauda equina syndrome following trauma and its implications during surgery.

The failure of subcategorization of cauda equina syndrome.

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. This paper presents a reassessment of the diagnostic and prognostic subcategories of CES the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.

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.

Tarlov cyst with self-healing cauda equina syndrome following combined spinal-epidural anesthesia: a case report.

BACKGROUND: Cauda Equina Syndrome (CES) after Combined Spinal-Epidural Anesthesia (CSEA) is a rare disease that most of the time need surgery to relieve spinal cord compression. CASE PRESENTATION: A 34-year-old male patient underwent a procedure for prolapse and hemorrhoids (PPH) under CSEA. Anesthesia and surgery were uneventful. However, the patient gradually experienced urinary retention, lower abdomen and back pain, changes in bowel habits and neurological dysfunction of the lower limbs when the catheter was removed. It was later determined that the patient had Tarlov cyst at the left S1 level in the sacral canal. Finally, the patient completely recovered 20 days after drug conservative therapy onset. CONCLUSION: This case suggests that CES might occur even after ordinary CSEA. The risk factors are drug neurotoxicity to ropivacaine and Tarlov cyst, which helped to accumulate ropivacaine. The development of ultrasound-guided CSEA and an ultrasound atlas of the spinal canal are required.

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.

Triangular Osteosynthesis as a Treatment of Lumbopelvic Dissociation with Acute Cauda Equina Syndrome in an 11-Year-Old Patient.

This case offers a safe and effective method for treating lumbopelvic dissociation in a pediatric patient with cauda equina syndrome using a triangular osteosynthesis construct. After a high-speed accident, an 11-year-old girl was admitted to the hospital with bowel and bladder incontinence and bilateral lower extremity weakness. The orthopaedic trauma and spine teams elected for surgical treatment with a triangular osteosynthesis construct, a procedure usually reserved for adults. The surgery was uncomplicated, and the patient experienced complete resolution of her preoperative symptoms. She is doing well over 1-year postoperatively, with full neurologic recovery, maintained reduction, bony healing, and subsequent implant removal. To our knowledge, this is the youngest reported case of lumbopelvic dissociation treated in this manner and represents a viable treatment option.

Association of Tarlov cyst with cauda equina syndrome and spinal cord infarction following caudal epidural block: A case report.

RATIONALE: Caudal epidural block (CEB), which injects drugs into the epidural space through a sacral hiatus, is considered a safer alternative to other approaches. Serious complications, such as cauda equina syndrome or spinal cord infarction, have been reported very rarely, but their coexistence after CEB, which may be related to the ruptured perineural cyst, also known as a Tarlov cyst, was not reported. PATIENT CONCERNS: A 40-year-old male patient presented with bilateral lower extremity radicular pain. CEB was performed without image guidance. The patient exhibited sensory deficits below L2, no motor function (0-grade), hypotonic deep tendon reflexes, and no pathological reflexes. DIAGNOSES: Spinal cord infarction, cauda equina syndrome, and sacral level perineural cyst with hemorrhage. INTERVENTION: High doses of steroids and rehabilitation were performed. OUTCOMES: The patient was discharged after 28 days with persistent bilateral leg paralysis and sensory deficits below the L2 level. The patient demonstrated no neurological improvement. LESSONS: Magnetic resonance imaging, including the sacral area, should be performed before performing CEB, to confirm the presence of a perineural cyst.

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.

A comparison of the safety and efficacy of minimally invasive surgery versus open surgery in treating cauda equina syndrome: A systematic review and meta-analysis.

PURPOSE: To compare the safety and efficacy of minimally invasive surgery (MIS) and open surgery (OS) in treating cauda equina syndrome (CES). METHODS: A systematic literature search was conducted, searching relevant databases for studies investigating MIS and/or OS in treating CES. Pooled outcomes and their 95% confidence intervals (CIs) were meta-analyzed via random-effects models. RESULTS: Ten studies were included in the meta-analysis. Pooled mean operation times were shorter for MIS (75.4 min; 95 %CI: 40.8, 110.0) than OS (155.1 min; 121.3, 188.9). Similarly, mean hospital stay was shorter for MIS (4.08 days; 2.77, 5.39 vs. 8.85 days; 6.56, 11.13). Mean blood loss was smaller for MIS (71.7 mL; 0, 154.5 vs. 366.5; 119.1, 614.0). Mean post-op lumbar/back visual analogue scale (VAS) score was lower for MIS (3.65; 2.75, 4.56 vs. 5.80; 4.55, 7.05). Mean post-op leg VAS score was 1.27 (0.41, 21.4) for MIS and 1.29 (0.47, 2.12) for OS. Mean complete bladder recovery rate was 81.0% (55.0%, 94.0%) for MIS and 75.0% (44.0%, 92.0%) for OS. Mean complete motor recovery rate was larger for MIS (70.0%; 48.0, 85.0 vs. 42.0%; 34.0, 51.0). Mean percentages of "excellent" patient outcomes were equal for MIS (64.0%; 48.0%, 77.0%) and OS (64.0%; 22.0%, 92.0%). CONCLUSION: MIS for CES was associated with reduced operative time, length of stay, and blood loss, compared to OS. MIS was also associated with better post-operative lumbar/back and leg VAS scores and complete motor and bladder recovery rates. MIS and OS produced an equal average percentage of "excellent" patient outcomes.

[Transverse myelitis and cauda equina syndrome followed by varicella in a patient with varicella-zoster virus infection].

A 74-year-old man was admitted to our hospital with complaints of weakness in the lower extremities, urinary retention for 10 days, and generalized vesicular rash for 7 days. Spinal magnetic resonance imaging showed contrast enhancement at the Th12-L1 level of the spinal cord and cauda equina. Serum and cerebrospinal fluid varicella-zoster virus (VZV)-immunoglobulin (Ig) G antibody titers were markedly elevated, and VZV-IgM was detected in cerebrospinal fluid. The patient was diagnosed with VZV transverse myelitis and cauda equina syndrome with subsequent varicella and was treated with acyclovir and prednisolone. Two months later, muscle weakness, and dysuria had almost completely resolved. We hypothesize that latent VZV in the ganglia reactivated and caused transverse myelitis, which subsequently spread to the body via the bloodstream, resulting in the development of varicella.

Diagnosis of cauda equina syndrome in the emergency department.

Cauda equina syndrome (CES) is a spinal emergency that can be challenging to identify from among the many patients presenting to EDs with low back and/or radicular leg pain. This article presents a practical guide to the assessment and early management of patients with suspected CES as well as an up-to-date review of the most important studies in this area that should inform clinical practice in the ED.