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Cauda conus syndromes

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  • 1. DR. ANKUR NANDAN VARSHNEYDEPARTMENT OF GENERAL MEDICINEIMS, BHU

2. A 21-yr- old male, unmarried c/o:-1. Difficulty in urination X 2 year2. Lower back pain X 2 year3. Pain in both lower limb with numbness X 2 year4. Weakness in right lower limb along with thinning of limb X 1 year 3. Vitals = WNLGeneral Condition = within normal limit CNS =1. Higher mental fxn WNL2. Cranial nerves = WNL3. Upper limb = WNL4. Findings confined to lower limb Sensory1.Pain and temperature lost up to 20% - L2 level.2.In saddle area , sensation lost up to 90%.3.Vibration = 50% reduced right side4. mildly reduced on left side 4. Gait = unable to walk alone try to avoid weight on right sideno apparent foot drop Motor examination =1. Wasting of thigh and calf muscles.rightleft1. Mid thigh = 36 cm37.5 cm2. Leg = 26.5 cm 28 cmTone = normal to slight decreased right side , left side WNL 5. POWER =RightLeft1. Hip flexionwnlwnl2. Hip adduction4/5 5/53. Knee extension4/5 5/54. Knee flexion 4/5 5/55. Dorsiflexion foot3/55/5REFLEXES =1. Knee- -2. Ankle- -3. Abdominal WNLWNL4. Bulbocavernous - -5. Anal reflex-6. Anal tone reduced 6. Functional Anatomical Pathological Etiological 7. VERTEBRAL NON VERTEBRAL 1.Meningioma1. Infections = TB 2.Neurofibroma2. Tumour affecting spine =3.Ependyoma secondaries , multiple myeloma4.Astrocytoma3. Lumbar spondylosis , PID5.Epidural abscess 6.Spinal arachnoiditis4. Cong lumbar canal stenosis7.cyst- dermoid5. Spondylosis , spondyloarthrosis , epidermoid6. Spina bifida , tethered cord, hydatid syndrome8.Leukemia , lymphoma7. Metabolic = osteoporosisdeposits. , osteomalcia , osteosclereosis 9.Intramedullary deposits 10. Arterio- venous malformations 8. a constellation of signs and symptoms including: Bowel dysfunction Bladder dysfunction Sexual dysfunction Poor rectal tone Perianal sensory changes Sometimes, lower extremity weakness 9. Most distal bulbous part of spinal cord situated atlevel of L1-L2 vertebral bodies and comprises ofsacral segments S1-S5.Signs shows involvement of:-1. Saddle anesthesia ( S3-S5)2. Absent Bulbocavernous reflexes ( S2-S4)3. Absent anal reflexes ( S4-S5)Symptoms include both upper and lower motor neuron lesions. 10. Etiologies Tumor Vascular lesion Diabetic neuropathy Trauma Disc herniation 11. Symptoms Back pain Unilateral or bilateral leg pain Bladder dysfunction Bowel dysfunction Sexual dysfunction Diminished rectal tone Perianal sensory loss Lower extremity weakness 12. Cauda equina is the collection of nerve containing nerve rootsfrom L1-L5 and S1-S5. Most centrally located nerve roots are from most caudalsegments. Lesions give rise to lower motor neurons symptoms. Radicular pain is prominent and symptoms are usuallyunilateral. Bladder dysfunction with a decrease in perianal sensation 13. Etiologies Disc herniation Disc fragment migration Iatrogenic epidural hematoma Post LP or spinal anesthesia Postoperatively Infection Tumor Trauma 14. Symptoms Back pain Radicular pain Bilateral Unilateral Motor loss Sensory loss Urinary dysfunction Overflow incontinence Inability to void Inability to evacuate the bladder completely Decrease in perianal sensation 15. Distribution of pain / paresthesia in certaindermatomes. Segmental / sensory changes Alteration in motor function ( weakness andwasting ) Reflex abnormalities Site of vertebral deformities and tenderness Imaging - X-ray , CT- myelo , MRI 16. Patients with conus medullaris syndrometypically present with symptoms consistentwith: Spinal cord compression Spinal cord dysfunction Intrinsic pathology Patients with cauda equina syndrome typicallypresent with symptoms consistent with: Lumbosacral radiculopathies Extrinsic pathology There is much overlap in symptomatology Both require complete evaluation, includingimaging, to manage appropriately 17. CAUDA EQUINA CONUS CAUDA- CONUSSYNDROME MEDULLARISSYNDROME SYNDROMEROOT PAIN +++_++asymmetricMOTOR ++ IN HIGH CAUDA +/- ++WEAKNESS+/- IN LOW CAUDASENSORY +SADDLE+ ANESTHESIAREFLEXES++ in highvisceral ( bladder , ++( knee , ankle, +/- in low anal ,plantar ,bulbocavernous )bulbocavernous)impairedSphinctor Late early Late/earlyinvolvement 18. CONUS MEDULLARISCAUDA EQUINASYNDROMESYNDROMEPresentationSudden and bilateralGradual and unilateralReflexesKnee jerk preserved but Both affectedankle jerks affectedRadicular painLessMoreLow back pain MoreLessImpotence FrequentLessSensory dissociationPresent No dissociationNumbnessSymmetrical AsymmetricalMotor strengthSymmetric AsymmetricHyperreflexic AreflexiaDistal paresis of lower ParaplegialimbsSphincter dysfunction Present early Present laterBoth urinary and fecalOnly urinary retention