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Ortho_conus Medullaris and Cauda Equina Syndrome

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Conus Medullaris & Cauda Equina SyndromeLeg weakness is flaccid and areflexic not spastic and hyperreflexic

By: Siti Nurulismah bt Che Haron

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Source: Walter B. Greene. Netter's Orthopaedics 1st ed. 20062

Source: Keith L. Moore and Anne Agur. Essential Clinical Anatomy, 3rd Edition23/09/2012

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Etiology Trauma - Fracture, subluxation - Penetrating trauma Herniated disc - 90% at L4-L5 and L5-S1 Spinal stenosis - Developmental abnormality - Degenerative diseasePicture from: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006

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Neoplasm - Primary (schwannoma, paraganglioma) - Metastatic (intracranial, lung, breast and renal cell ca) Inflammations and infections - Paget disease, epidural abscess - Pyogenic and non pyogenicPicture from: http://emedicine.medscape.com/

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Iatrogenic - Misplaced pedicle screw, laminar hooks - Continuous spinal anesthesia

Picture from: http://www.science-art.com

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Conus Medullaris vs. Cauda Equina SyndromesConus medullaris syndrome Cauda equina syndrome

Vertebral level Spinal levelPresentation Radicular pain Low back pain Motor strength

L1-L2 Sacral cord segment and rootsSudden and bilateral Less severe More Symmetrical, less marked hyperreflexic distal paresis of LL, fasciculation Ankle jerks affected Localized numbness to perianal area, symmetrical and bilateral Early urinary and fecal incontinence Frequent7

L2-sacrum Lumbosacral nerve rootsGradual and unilateral More severe Less More marked asymmetric areflexic paraplegia, atrophy more common Both knee and ankle jerks affected Localized numbness at saddle area, asymmetrical, unilateral Tend to present late Less frequent23/09/2012

Reflexes Sensory

Sphincter dysfunction Impotence

Illustration of saddle anesthesia; - The S5, S4, and S3 nerves provide sensory innervation to the rectum, perineum, and inner thigh.Source: Journal of the American Academy of Orthopaedics Surgeons, http://www.jaaos.org

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Investigation Radiology MRI Laboratory FBC, ESR Needle electromyography of the bilateral external anal sphincter muscles Lumbar puncture

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Sagittal and axial CT scans of thoracolumbar spine demonstrating an L4 burst fracture with retropulsion of bone into the spinal canal

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Source: Harrop, J. S., G. E. Hunt Jr, et al. (2004). "Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles." Neurosurgical Focus 16(6): 1-23. 23/09/2012

MRI image shows compression of the distal lumbar and sacral nerve rootles

Source: Harrop, J. S., G. E. Hunt Jr, et al. (2004). "Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles." Neurosurgical Focus 16(6): 1-23.11 23/09/2012

Sagittal MRI images demonstrating large central disc extrusion at L5-S1 (arrows) with compression on the cauda equina.

Source: Levis, J. T. (2009). "Cauda equina syndrome." Western Journal of Emergency Medicine 10(1): 20.12 23/09/2012

Method to Relieve Cord Compression

Discectomy - 1 2 Laminectomy

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CorpectomySource: http://www.spinesurgeon.co.uk/media/lumbar-corpectomy.jpg

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Prognosis Important predictor of recovery - The extent of perineal or saddle sensory deficit Patients with unilateral deficits have a better prognosis than patients with bilateral deficits Females and patients with bowel dysfunction have been reported to have worse outcomes postoperativelySource: - Shaw A, Anwar H, Targett J, Lafferty K. Cauda equina syndrome versus saddle embolism. Ann R Coll Surg Engl. Sep 2008;90(6):W6-8. - O'Laughlin SJ, Kokosinski E. Cauda equina syndrome in a pregnant woman referred to physical therapy for low back pain. J Orthop Sports Phys Ther. Nov 2008;38(11):721.15 23/09/2012

Other references: - http://emedicine.medscape.com/article/1148690 - Oxford handbook of clinical medicine - Oxford handbook of clinical surgery - Apleys consice system of orthopaedics and fractures 3rd edition

THANK YOU

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