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Conus Medullaris & Cauda Equina Syndrome By: Siti Nurulismah bt Che Haron 06/06/2022 1 ‘Leg weakness is flaccid and areflexic not spastic and hyperreflexic’

Ortho_conus Medullaris and Cauda Equina Syndrome

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Page 1: Ortho_conus Medullaris and Cauda Equina Syndrome

07/04/20231

Conus Medullaris &

Cauda Equina Syndrome

By: Siti Nurulismah bt Che Haron

‘Leg weakness is flaccid and areflexic

not spastic and hyperreflexic’

Page 2: Ortho_conus Medullaris and Cauda Equina Syndrome

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Source: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006Source:

Keith L. Moore and Anne Agur. Essential Clinical Anatomy, 3rd Edition

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Etiology

Trauma- Fracture, subluxation- Penetrating trauma

Herniated disc- 90% at L4-L5 and L5-S1

Spinal stenosis- Developmental abnormality- Degenerative disease

Picture 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 pyogenic

Picture 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

Page 7: Ortho_conus Medullaris and Cauda Equina Syndrome

Conus medullaris syndrome

Cauda equina syndrome

Vertebral level L1-L2 L2-sacrum

Spinal level Sacral cord segment and roots

Lumbosacral nerve roots

Presentation Sudden and bilateral Gradual and unilateral

Radicular pain Less severe More severe

Low back pain More Less

Motor strength Symmetrical, less marked hyperreflexic distal paresis of LL, fasciculation

More marked asymmetric areflexic paraplegia, atrophy more common

Reflexes Ankle jerks affected Both knee and ankle jerks affected

Sensory Localized numbness to perianal area, symmetrical and bilateral

Localized numbness at saddle area, asymmetrical, unilateral

Sphincter dysfunction

Early urinary and fecal incontinence

Tend to present late

Impotence Frequent Less frequent

07/04/20237

Conus Medullaris vs. Cauda Equina Syndromes

Page 8: Ortho_conus Medullaris and Cauda Equina Syndrome

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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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Radiology – MRI

Laboratory – FBC, ESR

Needle electromyography of the bilateral external anal sphincter muscles

Lumbar puncture

Investigation

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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

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.

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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.

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

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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.

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Discectomy - 1 2 Laminectomy

Method to Relieve Cord Compression

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

Corpectomy

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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 postoperatively

Prognosis

Source: - 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.

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THANK YOU

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