Cauda Equina Symptoms Research Articles

Nonsurgical therapy for lumbar spinal stenosis caused by ligamentum flavum hypertrophy: A review.

Lumbar spinal stenosis (LSS) can cause a range of cauda equina symptoms, including lower back and leg pain, numbness, and intermittent claudication. This disease affects approximately 103 million people worldwide, particularly the elderly, and can seriously compromise their health and well-being. Ligamentum flavum hypertrophy (LFH) is one of the main contributing factors to this disease. Surgical treatment is currently recommended for LSS caused by LFH. For patients who do not meet the criteria for surgery, symptom relief can be achieved by using oral nonsteroidal anti-inflammatory drugs (NSAIDs) and epidural steroid injections. Exercise therapy and needle knife can also help to reduce the effects of mechanical stress. However, the effectiveness of these methods varies, and targeting the delay in LF hypertrophy is challenging. Therefore, further research and development of new drugs is necessary to address this issue. Several new drugs, including cyclopamine and N-acetyl-l-cysteine, are currently undergoing testing and may serve as new treatments for LSS caused by LFH.

Intradural Extramedullary Spinal Tumors: A Clinical Study and Management without the Aid of Nerve Monitoring

Abstract Background: The incidence of primary spinal cord tumors is less and the true incidence is still not known and various studies are still being done. These tumors are benign and slow growing, and they generally present with pain – either radiculopathy or axial back pain or focal neurological deficits due to the loss of roots, myelopathy from spinal cord compression, or cauda equina symptoms due to chronic compression. Early diagnosis and operation are gratifying as the lesions are mostly benign and can be completely resected as well as preservation of functionality if operated as early as possible. Although rare, an inadvertent neurological injury during surgery is a concerning complication that can potentially be prevented with the assistance of intraoperative nerve monitoring (IONM). This technology enables real-time assessment of spinal cord function by providing feedback from sensory tracts, motor tracts, and individual nerve roots. However, the definitive requirement for IONM in the treatment of a highly curable condition is still under consideration. Objective: our study aims at studying the clinical features of intradural extramedullary tumors and their operative management without nerve monitoring. Material and Methods: Patients with intradural extramedullary (IDEM) spinal cord tumors who fit the inclusion criteria and who were willing to investigations, surgical procedures, and follow up were enrolled in the study, and consent was obtained. Patient assessment was done clinically by McCormick’s Scale and radiologically by magnetic resonance imaging. Patients who underwent operation were followed up. The data was collected and analysed using SPSS software. Results: Nineteen patients were enrolled in the study. The age group ranged from 6 years to 79 years. There were 13 females and 6 males in the study group. The common presenting complaints were backache and upper and lower limb pain. Nine out of the 19 patients underwent operative procedures after thorough radiological and clinical evaluation. Histopathology showed five cases of schwannoma and four cases of meningioma. The mean McCormick’s Scale preoperatively was 4.11, whereas postoperatively, it was 3.10. The operative procedures were performed without the aid of IONM, yet there were no inadvertent intraoperative injuries and postoperative outcomes were good. Our study data were comparable with other studies. Conclusion: IDEM tumors, though technically challenging to operate, have excellent results in terms of outcomes due to their benign characteristics as well as complete resectability. Therefore, it is essential to conduct a comprehensive examination and imaging for patients experiencing backaches and weakness. Following a careful evaluation, early surgical intervention should be considered, as the timeliness of the surgery contributes to enhanced outcomes. The unavailability of nerve monitoring did not portend any added risk of surgery if done meticulously though its aid would make the operative procedure safer and gross resection better.

Unilateral Biportal Endoscopic Laminectomy-Bilateral Decompression Using a Monoportal Scope and Bipolar Coagulator for Lumbar Spinal Stenosis: A Technical Report.

The purpose of this study was to introduce the application of a monoportal scope and bipolar coagulator used in full-endoscopic spine surgery (FESS) for unilateral biportal endoscopy-unilateral laminectomy bilateral decompression (UBE-ULBD) in those with central stenosis. A 68-year-old man who presented with cauda equina symptoms underwent UBE-ULBD to improve his central stenosis at the L2/3 level. In this technique, a FESS scope was attached to a camera portal in place of a common arthroscope. A decompression tool was subsequently inserted through the working portal, and the lower border of the vertebral lamina and the lower border of the contralateral lamina were resected. Additionally, the superior border of the L3 level was thinned using a high-speed drill, and the ligament flavum was excised. The operation time was 70 minutes, and his symptoms improved. The patient was discharged from the hospital four days postoperatively. We found three advantages of using a FESS scope and bipolar coagulator, including the ability to 1) stabilize the camera via placement of the sleeve against the bone, 2) minimize the wounded area by irrigating saline on the side of the scope, and 3) provide bipolar tissue hemostasis in an isolated area around the nerves. Therefore, among the UBE techniques, we believe that assisted full-endoscopic spine surgery (AFESS) is a viable option to offer a more minimally invasive surgery for patients with stenosis.

The Red and Yellow Flag Awareness Level of Family Physicians in Low Back Pain

Aim: This study aims to determine the level of attitude and awareness of family physicians about red and yellow flags in patients with low back pain. Methods: A total of 395 family physicians were included in the study between February 2022 and April 2022. A questionnaire that evaluates the physicians’ non-mechanical causes of low back pain, red flag symptoms and findings, yellow flag signs, and the rate of questioning them in clinical practice was created and used. Results: Although 70.1% of the participants specified cauda equina symptoms, 65.3% non-mechanical nature of pain, 63.5% systemic illness findings, 62.5% history of severe trauma and malignancy as red flag symptoms and findings, 71.1% the presence of catastrophic thoughts as a yellow flag sign in low back pain, they could not achieve the same success in other red and yellow flag signs. The rate of questioning red and yellow flags in patients who applied to family physicians with low back pain was 60.7% and 34.5%, respectively. Conclusion: The results of our study show that family physicians have a deficiency in questioning the red and yellow flags. When it is considered that patients with low back pain consult family physicians frequently, we think that training family physicians on red and yellow flags may help to the quick determination of non-mechanical causes of low back pain and to prevent low back pain from becoming chronic. Keywords: low back pain, awareness, physicians, family

Surgical Intervention for Primary B-cell Lymphoma of the Spine: A Systematic Review and Meta-analysis of Clinical Presentation, Treatment, Postoperative Outcomes, and Histologic Markers.

Systematic review and meta-analysis. To perform a systematic review of the clinical symptoms, radiographic findings, and outcomes after spinal decompression in B-cell lymphoma. B-cell lymphoma is a potential cause of spinal cord compression that presents ambiguously with nonspecific symptoms and variable imaging findings. Surgical decompression is a mainstay for both diagnosis and management, especially in patients with acute neurological deficits; however, the efficacy of surgical intervention compared with nonoperative management is still unclear. The databases of Medline, PubMed, and the Cochrane Database of Systemic Reviews were queried for all articles reporting spinal B-cell lymphoma. Data on presenting symptoms, treatments, survival outcomes, and histologic markers were extracted. Using the R software "survival" package, we generated bivariate and multivariate Cox survival regression models and Kaplan-Meier curves. In total, 65 studies were included with 72 patients diagnosed with spinal B-cell lymphoma. The mean age was 56.22 (interquartile range: 45.00-70.25) with 68% of patients being males and 4.2% of patients being immunocompromised. Back pain was the most common symptom (74%), whereas B symptoms and cauda equina symptoms were present in 6% and 29%, respectively. The average duration of symptoms before presentation was 3.81 months (interquartile range: 0.45-3.25). The most common location was the thoracic spine (53%), with most lesions being hyperintense (28%) on T2 magnetic resonance imaging. Surgical resection was performed in 83% of patients. Symptoms improved in 91% of patients after surgery and in 80% of patients treated nonoperatively. For all 72 patients, the overall survival at 1 and 5 years was 85% (95% CI: 0.749-0.953; n = 72) and 66% (95% CI: 0.512-0.847; n = 72), respectively. Although surgery is usually offered in patients with acute spinal cord compression from B-cell lymphoma, chemotherapy and radiation alone offer a hopeful alternative to achieve symptomatic relief, particularly in patients who are unable to undergo surgery.

Spinal epidural lipomatosis (SEL).

We present a case of an 87-year-old man with spinal epidural lipomatosis (SEL). The patient had been diagnosed with microscopic polyangiitis and treated with prednisone at a 5mg daily dose. He has a 1-week history of progressive low back pain radiating to the posterior of the right thigh. A spinal magnetic resonance imaging scan revealed SEL in L2-L4. SEL is a rare condition with adipose tissue accumulation in the spinal canal's epidural space, leading to spinal cord or nerve root compression. The greatest risk of SEL is corticosteroid use, and corticosteroid reduction may improve the disease. Physicians should list SEL in the differential diagnosis if a patient on corticosteroid therapy presents with back pain and acute cauda equina symptoms.

Influence of the Preoperative Duration of Symptoms on Patients' Clinical Outcomes after Minimally Invasive Surgery-Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Spinal Diseases.

Background and Objectives: The impact of the duration of symptoms (DOS) on postoperative clinical outcomes of patients with degenerative lumbar spinal diseases is important for determining the optimal timing of surgical intervention; however, the timing remains controversial. This prospective case−control study aimed to investigate the influence of the preoperative DOS on surgical outcomes in minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF). Materials and Methods: Patients who underwent single-level TLIF for lumbar degenerative diseases between 2017 and 2018 were reviewed. Only patients with full clinical data during the 1-year follow-up period were included. The patients were divided into two groups (DOS < 12 months, group S; DOS ≥ 12 months, group L). The clinical outcomes, including the Oswestry disability index (ODI) and visual analog scale (VAS) for lower back pain, leg pain, and numbness, were investigated preoperatively and at 1, 3, and 6 months, as well as 1 year, after surgery. Furthermore, postoperative patient satisfaction 1 year after surgery was also surveyed. Results: A total of 163 patients were assessed: 60 in group S and 103 in group L. No differences in baseline characteristics and clinical outcomes were found. The ODI and VAS significantly improved from the baseline to each follow-up period (all p < 0.01). Group S had significantly lower ODI scores at 3 months (p = 0.019) and 6 months (p = 0.022). In addition, group S had significantly lower VAS scores for leg pain at 3 months (p = 0.027). In a comparison between both groups, only the patients with cauda equina symptoms showed that ODI and leg pain VAS scores at 3 months after surgery were significantly lower in group S (19.9 ± 9.1 vs. 14.1 ± 12.5; p = 0.037, 7.4 ± 13.9 vs. 14.7 ± 23.1; p = 0.032, respectively). However, the clinical outcomes were not significantly different between both groups 1 year after surgery. Patient satisfaction was also not significantly different between both groups. Conclusions: Patients with a shorter DOS tended to have a significantly slower recovery; however, clinical outcomes 1 year after surgery were good, regardless of the DOS.

SURG-12. SURGICAL INTERVENTION FOR PRIMARY B-CELL LYMPHOMA OF THE SPINE: A SYSTEMATIC REVIEW AND META-ANALYSIS OF CLINICAL PRESENTATION, HISTOLOGICAL MARKERS, TREATMENTS, AND SURVIVAL OUTCOMES

Abstract B-cell lymphoma is a potential cause of spinal cord compression that presents with nonspecific symptoms and inconsistent imaging findings. Surgical decompression is a mainstay for both diagnosis and management especially in patients with acute neurologic deficits; however, the long-term efficacy of intervention is still unclear. We perform a systematic review of the clinical symptoms, radiographic findings, and outcome after spinal decompression in B-cell lymphoma. The databases of Medline, PubMed, and the Cochrane Database of Systemic Reviews were queried for all articles reporting spinal B-cell lymphoma. Data on presenting symptoms, histological markers, treatment and survival outcomes were extracted. Bivariate and Multivariate Cox survival regression models and Kaplan-Meier curves were generated using R software survival package. In total, 57 studies were included with 72 patients diagnosed with spinal B-cell lymphoma. Mean age was 56.22 (IQR: 45.00-70.25) with 68% of patients being male and 4.2% of patients being immunocompromised. Back pain was the most common symptom (74%) with B symptoms and cauda equina symptoms present in only 6% and 29% respectively. Mean length of symptoms before presentation was 3.81 months (IQR: 0.45-3.25). The most common location was the thoracic spine (53%), with a majority of the lesions being hyperintense (28%) on T2 MRI. Surgical resection was performed in 83% of patients. Symptoms improved in 88% of patients after surgery and 80% of patients treated nonoperatively. OS at one- and five-years was 85% (95% CI: 0.749-0.953; n=72) and 66% (95% CI: 0.512-0.847; n=72), respectively. Age &amp;gt; 70 was associated with poorer OS in bivariate (HR 4.07 [95% CI: 1.328-12.46], p &amp;lt; 0.01; n=72) and multivariate analysis (HR 3.829 [95% CI: 1.158-12.662], p &amp;lt; 0.03; n=72). Primary spinal B-cell lymphoma can have a variety of presentations. Both surgery and nonoperative management may have similar improvement in symptoms. Age &amp;gt; 70 appears to confer poorer OS.

Sacral dome resection and single-stage posterior reduction in the treatment of high-grade spondylolisthesis in a young girl

Introduction: The treatment of high-grade spondylolisthesis remains controversial in terms of in situ fusion versus reduction. The aim of operation in this patient is to restore the spino-pelvic alignment, sagittal profile of the spine and prevention of progression of slip with a minimal neurological risk.&#x0D; Case presentation: 18 years old schooling girl referred with a history of backache and right lower limb numbness over lateral aspect of foot for four years duration. She also had intermittent lower back pain, produced by long distant walking and relived by rest. It was aggravated by standing for long duration. There was no radiation of pain, no red flag sign or no cauda equina symptoms. Apart from her right lower limb neurology which was her power MRC grade IV in L5 and S1 myotome, other examinations were normal. X-Ray revealed grade V spondyloptosis. MRI showed evidence of right exiting L5 nerve root entrapment with grade V spondyloptosis. She underwent single stage posterior instrumentation of L4 - S1vertebrae, sacral dome resection, reduction of L5 over S1, interbody fusion of L5 - S1 and posterolateral intertransverse fusion of L4 to S1 vertebrae. She was ambulated on post-operative day one without brace. There was no worsening of neurology.&#x0D; Conclusion: Lumbosacral spondylolisthesis grade V can be treated using posterior approach alone to obtain reduction, decompression, and solid fusion. The sacral dome resection is a shortening osteotomy of the lumbosacral spine which allows a single-stage reduction of L5 without lengthening of lumbosacral region in high-grade spondylolisthesis, which helps to avoid neurological complications.

Delayed arterial symptomatic epidural hematoma on the 14th day after posterior lumbar interbody fusion: A case report

BACKGROUNDDelayed arterial symptomatic epidural hematoma (SEH) on the 14th day after posterior lumbar interbody fusion (PLIF) is rare but it may lead to severe complications if not identified and treated in a timely manner. After diagnosis of the current case, early surgical removal of the hematoma and strict hemostasis treatment was accomplished. This case report highlights the importance of swift diagnosis and treatment in SEH patients.CASE SUMMARYA 41-year-old male patient with a single-segment lumbar disc herniation underwent left-side PLIF. On the 14th post-operative day, the patient complained of lumbar incision pain with sudden onset accompanied by left limb radiation pain and aggravated cauda equina symptoms. Magnetic resonance imaging examination and a puncture blood draw at the incision site confirmed a delayed arterial SEH. Emergency surgical removal of the hematoma and hemostasis was performed. About 70 mL of hematoma was found in the left incision. Continuous bleeding was found in the anterior branch of the transverse process of the 4th lumbar artery in the muscle area about 2 cm below the transverse process of the 4th lumbar vertebra. A blood jet of about 10 cm in height was observed and bipolar electrocoagulation was used to stop the bleeding. Post-operative lumbar incision pain and left lower limb pain were relieved immediately and gradually disappeared. There was no recurrence during the 12-mo follow-up.CONCLUSIONFor delayed arterial SEH on the 14th day after PLIF, preventive measures including pre-, intra- and post-operative prevention should be implemented.

Distinct progression pattern of ossification of the posterior longitudinal ligament of the thoracic spine versus the cervical spine: a longitudinal whole-spine CT study.

Data regarding risk factors for the progression of ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine are scarce. Therefore, in this study, the authors aimed to elucidate the difference in the radiographic progression pattern of OPLL and its risk factors between cervical and thoracic OPLL using longitudinally acquired whole-spine CT scans. Overall, 123 patients with symptomatic OPLL who underwent repeated whole-spine CT examinations, with an average interval of 49 months (at least 3 years) between scans, were retrospectively reviewed. Progression of OPLL was assessed to compare the distribution of OPLL over the entire spine on the initial and final CT scans. Patients were divided into a cervical OPLL (C-OPLL) group and a thoracic OPLL (T-OPLL) group according to the location of the main lesion. The progression pattern of OPLL and its risk factors were compared between the two groups using the Student t-test or Mann-Whitney U-test. In the C-OPLL group, 15 (22.1%) of 68 patients had OPLL progression, of whom 12 patients (80.0%) had progression only in the cervical spine and 3 patients (20.0%) had progression in multiple regions (cervical and thoracic/lumbar). In the T-OPLL group, 16 (29.1%) of 55 patients had OPLL progression, of which 3 patients (18.8%) had progression only in the thoracic spine and 8 patients (50.0%) had progression in multiple regions. Young age was a common risk factor for OPLL progression regardless of the location of OPLL, and this trend was more pronounced in the T-OPLL group than in the C-OPLL group. High BMI, male sex, and multilevel, severe T-OPLL were identified as independent risk factors for progression of T-OPLL (OR 1.19, 95% CI 1.03-1.37; OR 10.5, 95% CI 1.39-81.94; and OR 1.24, 95% CI 1.16-1.45, respectively). Patients with T-OPLL are predisposed to diffuse progression of OPLL over the entire spine, whereas patients with C-OPLL are likely to have progression in only the cervical spine. Young age and high BMI are significant risk factors for OPLL progression, especially in patients with T-OPLL. Our study highlights the need for continued follow-up in patients with T-OPLL, especially in young patients and those with obesity, for early detection of spinal cord and cauda equina symptoms due to the progression of OPLL throughout the spine.

Perineural spread of peripheral neurolymphomatosis to the cauda equina.

Neurolymphomatosis (NL) is a rare manifestation of lymphoma confined to the peripheral nervous system that is poorly understood. It can be found in the cauda equina, but extraspinal disease can be underappreciated. The authors describe how extraspinal NL progresses to the cauda equina by perineural spread and the implications of this on timely and safe diagnostic options. The authors used the Mayo Clinic medical records database to find cases of cauda equina NL with sufficient imaging to characterize the lumbosacral plexus diagnosed from tissue biopsy. Demographics (sex, age), clinical data (initial symptoms, cerebrospinal fluid, evidence of CNS involvement, biopsy location, primary or secondary disease), and imaging findings were reviewed. Ten patients met inclusion and exclusion criteria, and only 2 of 10 patients presented with cauda equina symptoms at the time of biopsy, with 1 patient undergoing a cauda equina biopsy. Eight patients were diagnosed with diffuse large B-cell lymphoma, 1 with low-grade B-cell lymphoma, and 1 with mantle cell lymphoma. Isolated spinal nerve involvement was identified in 5 of 10 cases, providing compelling evidence regarding the pathophysiology of NL. The conus medullaris was not radiologically involved in any case. Lumbosacral plexus MRI was able to identify extraspinal disease and offered diagnostically useful biopsy targets. FDG PET/CT was relatively insensitive for detecting disease in the cauda equina but was helpful in identifying extraspinal NL. The authors propose that perineural spread of extraspinal NL to infiltrate the cauda equina occurs in two phases. 1) There is proximal and distal spread along a peripheral nerve, with eventual spread to anatomically connected nerves via junction and branch points. 2) The tumor cells enter the spinal canal through corresponding neural foramina and propagate along the spinal nerves composing the cauda equina. To diffusely infiltrate the cauda equina, a third phase occurs in which tumor cells can spread circumdurally to the opposite side of the spinal canal and enter contralateral nerve roots extending proximally and distally. This spread of disease can lead to diffuse bilateral spinal nerve disease without diffuse leptomeningeal spread. Recognition of this phasic mechanism can lead to identification of safer extraspinal biopsy targets that could allow for greater functional recovery after appropriate treatment.

Full-Endoscopic Spine Surgery for the Treatment of Lumbar Ossification of the Ligamentum Flavum: Technical Report

Ossification of the ligamentum flavum (OLF) is a relatively common disease in East Asia. Although surgical decompression using a posterior approach is commonly used to treat OLF, there are several different treatment strategies. The purpose of this study is to clarify the technically important points for the treatment of OLF using full-endoscopic spine surgery (FESS). FESS was performed on 7 patients with lumbar OLF. Patients had a mean age of 62.3 years and single-level involvement. Computed tomography and magnetic resonance imaging were used to classify the OLF. Two different types of spinal endoscope were used for posterior decompression. Interlaminal and translaminal approaches were performed in 6 and 1 patient, respectively. Preoperative and postoperative pain was evaluated using the numeric rating scale score. The mean operation time was 84.1 minutes. Unilateral round-type OLF was treated using a 4.1-mm working channel endoscope. The bilateral type was treated using a 6.4-mm working channel endoscope. A dural tear occurred in 1 patient with beak-type OLF, but no symptoms resulting from the tear were observed. The mean preoperative and postoperative numeric rating scale scores were 7.7 and 1.6, respectively. Posterior decompression using FESS can be used to treat patients with lumbar OLF. Unilateral round-type OLF with ipsilateral radiculopathy can be treated using a 4.1-mm working channel endoscope. Bilateral-type OLF with cauda equina symptoms should be treated using a 6.4-mm working channel endoscope.

Walking-Evoked Erection in Patients with Lumbar Degenerative Diseases: Eight Cases and Review of the Literature.

Study DesignNarrative review with a case illustration.PurposeThe purpose of this study was to evaluate the pathogenesis and outcome of therapy for walking-evoked erection in patients with lumbar degenerative diseases.Overview of LiteratureCauda equina compression due to lumbar degenerative diseases rarely cause a walking-evoked erection; however, no review has been undertaken of walking-evoked erection in patients with lumbar degenerative diseases.MethodsA total of 1,570 male patients with lumbar degenerative diseases, who underwent surgery between April 2003 and June 2017, were evaluated; from these patients, participants with walking-evoked erection were selected. Preoperative clinical data of walking-evoked erection, paresthesia, and bladder and bowel function were assessed. In our study, the neurological status and the erectile function of each participant were retrospectively evaluated before and after surgery using the Japanese Orthopedic Association score and the Overactive Bladder Symptom Score.ResultsAmong the 1,570 male patients screened in our department, eight patients (0.51%, 8/1,570) presented with walking-evoked erection accompanied by cauda equina symptoms. In six of the patients, the erectile symptoms were associated with paresthesia in the genitalia or perianal region. Of the six patients evaluated for bladder dysfunction, all were diagnosed with prostatic hyperplasia, while four were diagnosed with an overactive bladder. In all patients, walking-evoked erection disappeared entirely after surgery.ConclusionsThis study comprises the first review of walking-evoked erection in patients with lumbar degenerative diseases. We speculate that sensory input, such as paresthesia in the genitalia or perianal region stimulates the pelvic or perineal nerves through the pudendal nerve and induces reflexogenic erections.

Disseminated herpes zoster with cauda equina symptoms

Herpes zoster is a common infection resulting from the reactivation of dormant varicella zoster virus in a posterior dorsal root ganglion. The typical dermatomal involvement includes the thoracic region, followed by the face and the cervical and lumbosacral regions, with 1% having disseminated disease. We present a rare case of an immunocompetent 85-year-old man presenting with herpes zoster at the L3-S2 dermatomes, that evolved to disseminated varicella zoster virus (dVZV), with radiologically and laboratory-confirmed lumbosacral plexopathy manifesting with cauda equina syndrome. Here we also discuss the diagnosis and complications of dVZV as well as treatment strategy. By maintaining a high degree of clinical suspicion and initiating early treatment, high-quality patient care and good outcomes are able to be achieved in cases like this.

SHADES of grey – The challenge of ‘grumbling’ cauda equina symptoms in older adults with lumbar spinal stenosis

Diagnosing cauda equina syndrome is challenging in older adults with lumbar spinal stenosis. Understanding these challenges is vital for clinicians who are faced with difficult decisions about when to refer for investigation or surgical management. This is a growing clinical issue because of the escalating prevalence of lumbar spinal stenosis in our ageing population, and increasing demands on healthcare services including imaging and surgical services. This professional issue explores the challenges and evidence gaps relating to cauda equina syndrome in older adults with lumbar spinal stenosis. The degenerative patho-anatomical changes in the lumbar spine that are responsible for lumbar spinal stenosis also have the potential to lead to a gradual compromise of the cauda equina nerve roots. The clinical presentation may be unclear. As a result, there is a risk that slow-onset ‘grumbling’ cauda equina symptoms may be overlooked or dismissed in older patients with lumbar spinal stenosis. Furthermore, a lack of standardised diagnostic criteria and management pathways add to the challenges for clinicians diagnosing and managing potential cauda equina compromise associated with lumbar spinal stenosis. We recommend careful assessment, appropriate safety netting, and ongoing clinical monitoring and vigilance when assessing and managing this potentially vulnerable patient group.

Association of MRI findings with clinical characteristics and prognosis in patients with leptomeningeal carcinomatosis from non-small cell lung cancer.

Magnetic resonance imagining (MRI) is helpful for diagnosis of leptomeningeal carcinomatosis (LMC) and localizing LMC symptoms. Goal of this study is how MRI findings of LMC are associated with clinical characteristics or prognosis in patients with non-small cell lung cancer (NSCLC). We retrospectively collected data on 283 patients with LMC from NSCLC, adenocarcinoma based on cerebrospinal fluid cytology. All patients had brain MRI with gadolinium enhancement at LMC diagnosis, and spinal MRI was performed at the physician's discretion. We evaluated the prognostic factors for overall survival (OS) of all patients and subgroup of patients with central nervous system cause of death. Two-hundred sixteen patients (76%) had definite or suggestive LMC findings and 67 had negative findings on brain MRI. Of the 37 patients who presented with cauda equina syndrome, 35 (95%) exhibited typical spinal MRI findings. Median OS of all patients was 3.65months (95% confidence interval, 3.06-4.18). There was no significant difference in median OS between MRI-negative and MRI-positive groups (4.31 vs. 3.48months, p = 0.711), whereas negative MRI finding showed longer median OS significantly in a subgroup of 77 patients with a central nervous system cause of death (p = 0.035). Considering clinical characteristics, progressive systemic disease, and altered mentality were significant prognostic factors associated with poor OS, whereas presenting symptom of headache with nausea/vomiting, intra-CSF chemotherapy, WBRT after LMC diagnosis, and concurrent RTKi treatment were significant for favorable OS in multivariable analysis. Positive MRI findings suggests heavier disease burden than negative MRI findings in patients with LMC who died of a central nervous system cause. Spinal MRI findings in patients with LMC correlate with cauda equina symptoms.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P61. Clinical outcomes of microendoscopic decompression for lumbar canal stenosis: a comparison between patients with and without degenerative lumbar scoliosis

BACKGROUND CONTEXT The operative management of degenerative lumbar scoliosis includes decompression or decompression with fusion. However, there is currently no consensus on the criteria for the role of adjunctive fusion. We have performed microendoscopic decompression in patients with the chief complaint of radicular and/or cauda equina symptoms due to degenerative lumbar scoliosis. Although the surgical procedure almost improved leg symptoms, it seemed that the patients had severe low back pain postoperatively as compared with patients without degenerative lumbar scoliosis. PURPOSE To compare the clinical outcomes of microendoscopic decompression for lumbar canal stenosis between patients with and without degenerative lumbar scoliosis. METHODS A total of 75 patients with lumbar canal stenosis between March 2006 and December 2014 were included in this study. The patients who had disc herniation and foraminal stenosis were excluded. The patients were treated with microendoscopic decompression and followed more than two years after the surgery. Of those, 34 were males and 41 were females. The mean age at the time of the surgery was 73.1years (range, 61–86 year). The mean follow-up period was 48.1 months (range, 24–102 months). Twenty-seven patients had degenerative lumbar scoliosis with coronal curvature of more than 10° measured by Cobb's method (DLS group). The other 48 patients had neither degenerative lumbar scoliosis nor degenerative lumbar spondylolisthesis (nonDLS group). Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score and Short-Form 36 (SF-36) preoperatively and at the final follow-up. Recovery rate of the JOA score was calculated as (postoperative score − preoperative score)/(29 − preoperative score)×100%. The visual analogue scale (VAS) for low back pain was also measured at the final follow-up. RESULTS In the DLS group, the JOA score significantly improved from 13.7 preoperatively to 23.4 postoperatively. Also in the nonDLS group, the preoperative JOA score of 15.7 significantly improved to 25.0 postoperatively. Recovery rate in the DLS and nonDLS group were 62.5% and 69.0%, respectively. There were no significant differences in preoperative and postoperative JOA scores between the two groups. At the final follow-up, VAS for low back pain in the DLS group (45.4 mm) was significantly higher than that in the nonDLS group (25.4 mm). As for the preoperative SF-36 score, there were no significant differences in all 8 subscales between the two groups. In the DLS group, a significant improvement was observed only in bodily pain scores after surgery. In the nonDLS group, all subscales except general health perception significantly improved after surgery. All postoperative subscales except social role function and mental health in the DLS group were significantly lower than in the nonDLS group. CONCLUSIONS This study showed that the patients with lumbar degenerative scoliosis had higher VAS for low back pain and lower QOL scores after microendoscopic decompression as compared with the patients without lumbar degenerative scoliosis. We might consider other surgical options in patients with lumbar canal stenosis due to degenerative lumbar scoliosis.

Perineal pain: Think beyond gynaecological reasons

Introduction: Perineal pain is multifactorial in nature. Gynaecological consultation is the first point of contact in females with perineal pain for diagnosis and treatment. Case description: Three females above 60 years presented with non-radiating perineal pain and bladder disturbance. Magnetic resonance imaging revealed severe L5 S1 dural compression, which was released by posterior laminectomy. Patients felt relief in perineal pain, though bladder symptoms persisted for several months. Conclusion: Sacral roots compression leading to pain along pudendal nerve distribution may present with cauda equina symptoms with pain radiating to legs. Awareness of this condition can prevent the delay and lead to better prognosis after the surgery.

Clinical application of modified inverted L-shape incision by extraperitoneal approach to lumbosacral tuberculosis

To explore the clinical effects of one-stage posterior transpedicular screw system internal fixation combined with anterior debridement and bone grafting with modified inverted L-shape incision by extraperitoneal approach in treating multiple lumbosacral tuberculosis. The clinical data of 15 patients with multiple lumbosacral tuberculosis underwent operation from February 2008 to December 2014 were retrospectively analyzed. There were 9 males and 6 females with an average of (47.0±13.9) years old. The lesions involved L₄-S₁ in 12 cases, L₄-S₂ in 1 case, L₃-S₁ in 2 cases. Five cases complicated with nerve root symptoms and 2 cases with cauda equina symptoms. All patients were treated with posterior transpedicular screw system internal fixation combined with anterior L₄,₅, L₅S₁ debridement and bone grafting with modified inverted L-shape incision by extraperitoneal approach. Operation time, blood loss, incision length, first passage of gas by anus were recorded. The condition of bone fusion and focus absorption were observed by lumbar CT and MRI; and ESR and CRP were regularly rechecked. Fifteen patients were followed up for 18-24 months with an average of (20.0±2.73) months. All lumbosacral pain obtained improvement, and no hardware loosening, breaking, or bone graft block loosening was found. The operative time of anterior-posterior approach surgery was 210-250 min with an average of (231.0±12.1) min; the blood loss was 320-705 ml with an average of(495.0±130.3) ml; the incision length was 15-21 cm with an average of (16.4±3.4) cm, and the extended length of inverted L-shape incision was 6 to 9 cm with an average of (7.1±2.6) cm. The time of first passage of gas by anus was 14 to 40 h with an average of (24.1±7.4) h after operation. All bone graft obtained fusion at final follow-up, and spinal cord symptoms got recovery, ESR and CRP restored normal level with no recurred at 3 months after drug withdrawal. The treatment of multiple lumbosacral tuberculosis with posterior transpedicular screw system internal fixation combined with anterior debridement and bone fusion with modified inverted L-shape incision by extraperitoneal approach is feasible and practical. This method has advantages of little trauma, good exposure, less complications and high security.