Joseph C. Sullivan, III MD...Lumbar lesions can produce mixed UMN and LMN neuron signs in the lower limbs Joseph C. Sullivan, III MD ... C. Bulbocavernosus reflex D. Cremaster reflex

Joseph C. Sullivan, III MD

1. Headache2. Foreign object in the

body3. Skin infection4. Back pain5. Cuts and contusions

Health.Howstuffwoks.com/10most common reason for ER visits

65% increase in spending since

1997. That’s in line with cancer and

diabetes.

Only dwarfed by Heart disease

and Stroke

Web-md.com

Its 1AM, and your ER Doc

has a patient with back

pain, what are they

going to order?

Its 1AM, and your ER Doc

has a patient with back

pain, what are they

going to order?

A. Fall with pain

B. Radiculopathy/Pain

C. Epidural abscess

D. Cauda equina

1. Trauma

2. Infection

3. Tumor

4. Cauda Equina Syndrome


• Real or Assumed (Ass-U-Med)

• Triage or Lack thereof

• Neurological deficits







0. No movement contraction

1. Minimal movement

2. Active movement, but not against gravity

3. Active movement against gravity

4. Active movement against resistance

5. Active movement against full resistance




• Compression fracture

• Mets

• Muscle spasm

• Herniated disc

• Infection

• Ligamentous/muscle


• Cardiac

• Cholelithiasis, Peptic ulcer,

Pancreatitis

• Dissecting AAA

• Pyelonephritis

• PID, Ectopic, Fibroids


• Cancer History (or unexplained weight

loss)

• Trauma

• Immunosuppression (or long term

steroid use)

• Recent serious illness/infection

• IV Drug use


• Atypical pain or tenderness (abdominal or thoracic; 4-6 wks; non-mechanical)

• Severe limited ROM

• Fever; Meningismus; Lhermitte’s

• Muscle atrophy; Loss of sensation or strength (especially saddle)

• Loss of bowel or bladder control

• Abnormal reflexes: Hoffman’s; Babinski sign; Bulbocavernous/Wink


• C2 – Back of skull cap

• C3 – Back of turtle neck

• C4 – T shirt collar

• C5-6 – Thumb

• C7 – Index and Middle fingers

• C8 - Ring and Pinky fingers

• T4 – Nipple

• T5 – Under line

• T6-7 – Xyphoid

• T10 – Umbilicus

• T12 – Pubis

• L1 – Inguinal

• L4 – Knee cap

• L5 - Top of foot

• S1 – Lateral foot


In the absence of acute trauma or

infection, usually associated with

spondylosis or OPLL resulting in

compression of the cord and/or roots












• Insidious onset

• Weak or Clumsy hands

• Lhermitte’s Sign

• May have gait or bowel/bladder dysfunction

• Upper Motor Signs (Hoffman’s, Babinski, hyper-reflexia, clonus)

• Lower Motor Signs (atrophy or hypo-reflexia


• Amyotrophic Lateral Sclerosis

• Multiple Sclerosis

• Spinal Tumors

• Syringohydromyelia


• Cervical lesions can affect all four limbs and risk respiratory paralysis (C3, C4 & C5)

• Cervico-Thoracic junction lesions can cause mixed UMN and LMN signs in upper limbs, while LMN in the lower extremities

• Thoracic lesions can produce spastic paralysis

• Lumbar lesions can produce mixed UMN and LMN neuron signs in the lower limbs


• Discitis/Osteomyelitis; Epidural abscess

• Hematologic spread

• 1/3 may have fever

• Up to 15% present already with neurologic deficit

• Involve the disc and endplate

• Occur in up to 1% of patients

• More often in immunocompromised

• Symptoms can last2-4 weeks after treatment










Sarcoid

Rosai Dorphman


Sarcoid

Rosai Dorphman


Sarcoid

Rosai Dorphman




The cauda equina is a bundle

of spinal nerves and spinal nerve

roots, consisting of the second

through fifth lumbar nerve pairs,

the first through fifth sacral nerve

pairs, and the coccygeal nerve, all

of which arise from the lumbar

enlargement and the conus

medullaris of the spinal cord.

Generally considered to be

comprised of nine pairs of nerve

roots, starting with L2 and

extending to and including S5 (ok,

and the coccyx root as well, so

9+1).

The “Cauda Equina” was so-named by

French anatomist Andreas Lazarius in

the 1600’s.

Cauda Equina Syndrome was first

described by Mixter and Barr in

1934.

A variable presentation consisting

of a constellation of symptoms

which includes lower back pain,

asymmetrical LE paralysis, variable

sensory deficits, and loss of bowel

and bladder control.

1 in 33000 to 100000

Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda

equina syndrome. Brit Med J. 2009;338:b936

1 in 33000 to 100000

ER doc may not see a true one in

there entire career

Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda

equina syndrome. Brit Med J. 2009;338:b936

Incidence of CES in U.S. is estimated between 2 and 4 cases per 10,000 patients with chief complaint which includes LBP.

Estimated to be present to some degree in as many as 2% of patients undergoing surgery for HNP.

High clinical suspicion must be kept in patients presenting with LBP and other symptoms. Good history and physical exam-taking is key!

A. Back pain

B. Bladder and bowel

dysfunction

C. Paralysis

D. Sexual dysfunction

A. Back pain

B. Bladder and bowel

dysfunction

C. Paralysis

D. Sexual dysfunction

A. Motor innervation of the hips but

not the knees

B. External anal sphincter but not

internal sphincter

C. Motor innervation of the

perineum

D. Partial innervations of the para-

sympathetics to the bladder

E. Sensory innervation of the

external sphincter, only

A. Motor innervation of the hips but

not the knees

B. External anal sphincter but not

internal sphincter

C. Motor innervation of the

perineum

D. Partial innervations of the para-

sympathetics to the bladder

E. Sensory innervation of the

external sphincter, only

The nerves that compose the cauda

equina innervate the pelvic organs

and lower limbs to include motor

innervation of the hips, knees,

ankles, feet, internal and the

external anal sphincter.

In addition, the cauda equina

extends to sensory innervation of

the perineum, and partially,

parasympathetic innervation of

the bladder.

Nerve roots of the Cauda Equina are susceptible to injury from compression partly due to a poorly developed epineurium (less protection from “outside stresses” or tension).

Proximal nerve roots are relatively hypovascularizedand are supplemented by increased vascular permeability in this area as well as diffusion from surrounding CSF (which is thought to contribute to swelling and edema in irritated nerve roots).

Unmyelinated, smaller

parasympathetic/pain fibers are

more susceptible to compression

and injury from compressive

forces.

Herniated lumbar disc

Tumor

Trauma

Spinal epidural hematoma

Infection

Other

Basic idea: Severe Canal

Stenosis (narrowing)

Acute presentation is most common,

and is most commonly seen in

patients with a prior history of LBP.

Acute presentation in patients with

no prior history of LBP and/or sciatica

occasionally seen.

Insidious onset and progression of

symptoms is rare, but is associated

with better chance of return of

function (especially bladder

function).

Caused by compression or injury to the nerve roots which descend from the conus medullaris.

Many different possible causes.

Underlying chronic conditions can predispose to CES, as well as cause it in some cases.

The most common symptom in

patients presenting with CES is Low

Back Pain (LBP).

>90% of patients

Nonspecific, yes, but index of suspicion

should be high and appropriate history

should be elicited, especially if

coexisting symptoms/complaints are

present.

The most consistent sign in cauda equina syndrome is urinary retention (incidence approaches 90%).

Check post-void residual – normal is between 50 and 100 mL and >200 is positive for retention.

Overflow incontinence can be seen as the bladder fills.

Anal sphincter tone is diminished in 50-75% of patients with CES.

Fecal incontinence can be seen.

“Saddle anesthesia” is the most commonly observed sensory deficit in patients with CES.

Roughly 75% of pts.

Sensory loss seen around the anus, lower genitalia, perineum, buttocks, sometimes even the posterior thighs.

LBP is a nonspecific finding.

New LBP is rarely seen in cases of

CES without other symptoms

being present.

Sciatica, when present, is usually

bilateral (but can be unilateral).

If Motor weakness – can be severe, and usually involves more than a single nerve root.

May be bilateral, but is rarely symmetric (one side is usually weaker/stronger than the other).

Untreated motor weakness can become permanent disability, and can progress to complete paralysis/paraplegia.

Reflexes are HYPO-active; no long tract signs!

Altered urinary sensation

Loss of desire to void

Poor urinary stream

Strain to micturate

Saddle anesthesia is partial or

unilateral

Painless urinary retention and

overflow

No longer able to execute

micturition

Complete saddle anesthesia

and genital sensory deficit

A. Anal sphincter tone

B. Full bladder on palpation

C. Bulbocavernosus reflex

D. Cremaster reflex

E. Anal wink reflex

A. Anal sphincter tone

B. Full bladder on palpation

C. Bulbocavernosus reflex

D. Cremaster reflex

E. Anal wink reflex

Uff CE (2009) Clinical assessment of cauda equina syndrome and the

bulbocavernosus reflex.

http://www.bmj.com/cgi/eletters/338/mar31_1/b396

http://www.bmj.com/cgi/eletters/338/mar31_1/b396

Herniation of a [typically] massive portion of intervertebral disc material into the spinal canal causing compression of the descending nerves of the cauda equina.

Represents between 15 and 20% of CES cases.

Ten cases reported in the literature of CES being caused by very large disc fragment[s] which have migrated into the posterior epidural space causing posterior compression.

More than 100 cases of reports of intradural migration of herniated disc fragments.

Some estimates place prevalence of CES as high as 2% of herniated intervertebral discs!

Variability in presentation is a direct result of level of involvement.

Most common level of involvement is L4-5 (57%), followed by L5-S1 (30%), then L3-4 (13%).

Most common presentation of CES secondary to acute disc herniation is males age 30-40 with prior history of LBP. Most have NOT been operated on previously.

Ependymomas account for roughly

90% of primary tumors of the filum

terminale and cauda equina, the

majority of which (~60%) are of the

myxopapillary subtype. Still, CES

from this is rare.

Schwannomas in the area of the

conus or cauda equina can also

occur and cause CES, but are rare.

Tarlov cysts, while rarely

symptomatic, have been described

in the literature as causing CES.

Primary sacral neoplasms, such as

chordoma or a destructive bony

lesion, can cause CES through

collapse of bone and structure.

Again, in all cases, the mechanism

is compression of the nerve roots.

Anything that does this can cause

CES.

Incidence of spinal metastasis is

increasing due to improvements in

diagnostic modalities, imaging, and

treatment regimens.

The most common non-CNS metastatic

tumor causing spinal metastases is lung,

however, CES occurs in less than 1% of

cases involving spinal spread of

metastatic lung cancer.

Drop metastases from inctracranial

ependymomas, germinomas, and

other primary intraneural tumors

can cause CES from seeding via the

CSF space.

Primary genitourinary and

gynecologic tumor extension into

the cauda equina region is a rare

cause.

Mechanical disruption of the spine

from subluxation, spondylolisthesis,

and/or compression of the neural

elements from hematoma, etc.,

can cause CES.

True incidence in the trauma

setting is somewhat unclear due to

coexisting injuries.

Spinal Epidural Hematoma

Infection

Again…Anything that leads to

compression of the roots.

The major point of contention

with Cauda Equina surgical

intervention revolves around

timing – when is it most

appropriate to operate on these

lesions? IS THIS AN EMERGENCY???

Shapiro et al noted that patients who

underwent surgery within 48 hrs of

symptom onset, 95% recovered

continence and normal function within

six months. Conversely, 63% of those

patients whose surgery was delayed

beyond 48 hrs still required

catheterization after 6 months.

Generally, patients show improvement

first in pain, then with motor function –

while autonomic signs are last to

improve (and the least likely).

Shapiro S. Cauda equina syndrome secondary to lumbar

disc herniation. Neurosurgery. 1993;8:317–322

Meta-analysis that came out of Johns Hopkins University in 2000 (total 332 patients) that looked at patients with CES secondary to lumbar disc herniations, Ahn et al determined a significant improvement in outcome for patients operated on within 48 hours of onset of symptoms when compared with those operated on more than 48 hours after onset of symptoms.

Within those respective groups, there was no significant difference in outcomes for earlier or later times.

There is still debate about this in

the literature. In 2004, Radulovic

et al published a retrospective

analysis of their own series of

patients (47) where they found no

significant difference in outcome

regardless of time to operation.

This study, however, did not focus

on onset of symptoms; but rather,

time from presentation.

More recently, McCarthy et al

published their series of 42

patients with CES secondary to

disc herniation and found no

significant improvement in

patients’ outcome regardless of

time to surgery after onset of

symptoms.

Current recommendations outline

a goal of performing surgery within

24 hours of presentation if at all

possible.

A major line of thinking behind

this plan lies in the medical-legal

pitfalls of dealing with CES and the

residual deficits dealt with by the

patients.

The goal of the operation is to

decompress the nerve roots of the

cauda equina.

Instrumentation is rarely used for

acute disc herniations, but is more

commonly used in cases of CES

caused by trauma or severe

degenerative disease of the spine

from which CES has been the result

of instability.

Major point to keep in mind is this: Cauda Equina Syndrome has a variable presentation and is widely thought to be regularly misdiagnosed or just plain missed.

Failure to recognize spinal emergencies is an ongoing issue and the subject of continued litigation in patients who were eventually recognized but in whom deficits remain after surgery.

Appropriateness Criteria


Practice Parameters and

Technical Standards


Presentations can vary – Back Pain

Earlier intervention (before CES-R)

Be suspicious but knowledgeable

Documents

Joseph C. Sullivan, III MD...Lumbar lesions can produce mixed UMN and LMN neuron signs in the lower limbs Joseph C. Sullivan, III MD ... C. Bulbocavernosus reflex D. Cremaster reflex