Patient-specific CFD modeling of cerebrospinal fluid dynamics in lumbar spinal stenosis using weight-bearing MRI: influence of stenosis severity and postural changes.

Renal cell carcinoma (RCC) metastases to the spinal cord, cauda equina, nerve root, and dorsal root ganglion (DRG) are rare and can mimic benign peripheral nerve sheath tumors. A PRISMA-guided review of the PubMed/MEDLINE, Scopus, Embase, and Google Scholar databases identified 47 studies consisting of 57 patients with intradural extramedullary (IDEM), intramedullary spinal cord, or nerve root/DRG RCC metastases. The mean age was 59.4 ± 12.4 years, 71.9% were male, and clear cell RCC was the most common subtype (59.6%). Lesions involved intramedullary spinal cord metastasis in 57.9%, IDEM disease in 31.6%, and primary nerve root/DRG metastases in 10.5%. IDEM and nerve root lesions most often caused pain and radiculopathy, whereas intramedullary lesions uniformly produced myelopathy or motor weakness and more frequent sphincter dysfunction. Surgery was performed in 71.9% of patients, with gross-total resection in 80.5% of operative cases. The illustrative case was a symptomatic left C6-7 foraminal mass with focal Ga-68 DOTATATE uptake and progressive radiculopathy with mild left upper extremity weakness that mimicked schwannoma but was confirmed intraoperatively as metastatic RCC; resection and stabilization achieved durable symptom resolution. New foraminal or dumbbell-shaped lesions in patients with malignancy warrant tissue diagnosis to guide appropriate metastasis-directed management. https://thejns.org/doi/10.3171/CASE26244.

A 7‐year‐old male intact German shorthaired pointer was referred to a board‐certified veterinary neurologist for further evaluation of a chronic (> 6 months) history of gradually progressive paraparesis, limp tail, and spinal pain despite medical management of these clinical signs and presumptive neurologic disease with the family veterinarian. Radiographs revealed evidence of intervertebral disc space collapse, endplate sclerosis, and bridging spondylosis at L7‐S1, and the patient was presumptively diagnosed with degenerative lumbosacral stenosis (DLSS). Initial medical management included oral analgesics, oral anti‐inflammatories, lifestyle changes, and epidural steroid injections. Ultimately, progression of the patient′s clinical signs resulted in referral to a board‐certified veterinary neurologist. Magnetic resonance imaging revealed marked bilateral L7 nerve root enlargement with L7‐S1 foraminal widening and concurrent L7‐S1 intervertebral disc extrusion, causing moderate to severe left‐sided compression of the cauda equina. Given the marked changes of nerve roots on imaging and foraminal widening, consideration was given to a neoplastic process versus inflammatory neuritis. A lumbosacral dorsal laminectomy, partial discectomy, and left L7 nerve biopsy were performed. Histopathology of the L7 nerve root revealed chronic neural fibrosis with atrophy and mild neuritis, consistent with the chronic, progressive nature of the patient′s clinical signs and severe compression of the cauda equina. These dramatic and irreversible changes may have been avoidable or at least minimized with earlier diagnosis and aggressive surgical intervention, highlighting the importance of developing standardized, evidence‐based recommendations for management of dogs with DLSS similar to the framework that exists in human intervention for treatment of cauda equina syndrome (CES).

To describe the range of symptoms experienced over time following traumatic cauda equina syndrome (CES), the participants' attitudes towards their diagnosis, and to describe how participants managed their bowel and bladder symptoms. Participants were recruited through the Victorian State Trauma Registry. Seven semi-structured interviews were conducted with convenience sampling of participants. Data were thematically analysed using a framework approach. Five main themes were identified: (1) information and communication about traumatic CES, (2) psychological wellbeing in living with a traumatic CES, (3) new physical reality of living with a traumatic CES, (4) realisation of the need to gain independence with bowel and bladder management and (5) adaptation of learning for their body, needs and lifestyle. This study revealed that the majority of participants could not recall the terminology of their injury or receiving information about their prognosis, creating great uncertainty. Most participants independently managed their symptoms however, there was a belief that one must live with their symptoms. Timely provision of information is needed. Whilst participants adapted to their new physical reality, symptom management was not optimised. For clinicians, an awareness of the ongoing effects of this injury is also important.

Rising Suspicion, Stable Disease: An Eight-Year Analysis of Suspected and Confirmed Cauda Equina Syndrome.

Background/Objectives: Cauda equina neuroendocrine tumors (CENETs) are rare neuroendocrine tumors that predominantly arise in the cauda equina and filum terminale region. Due to their nonspecific clinical and radiological features, preoperative diagnosis remains challenging, and available data are limited to small case series. Methods: This retrospective single-center study included nine patients who underwent surgical treatment for histopathologically confirmed CENETs between 2014 and 2025. Clinical presentation, radiological findings, surgical management, histopathological features, and postoperative outcomes were analyzed. Results: The mean age was 51.2 years, with a slight male predominance. Pain was the most common presenting symptom (77.8%), followed by radiculopathy and sensory disturbances. All tumors were intradural and extramedullary, predominantly located in the lumbosacral region. Radiologically, all lesions were isointense on T1-weighted imaging and demonstrated predominantly homogeneous contrast enhancement. Vascular imaging features, including flow voids (55.6%), eccentric vessel sign (66.7%), and tadpole sign (44.4%), were frequently observed. Gross total resection was achieved in all patients, with no neurological deterioration or major complications. Over a mean follow-up period of 59.6 months, no tumor recurrence was detected. Conclusions: Cauda equina neuroendocrine tumors are rare but surgically curable tumors with excellent prognosis. Although preoperative diagnosis remains difficult, recognition of characteristic vascular imaging features may improve diagnostic accuracy. Gross total resection remains the cornerstone of treatment, providing durable disease control with minimal morbidity.

Duration of intensive care unit admission to maintain mean arterial pressure goals following acute traumatic spinal cord injury.

Krabbe disease is an autosomal recessive leukodystrophy where a deficiency of the galactosylceramide beta-hydrolase enzyme leads to accumulation of toxic substances which cause demyelination in both central and peripheral nervous systems. It is classified into early infantile, late infantile, juvenile and adult types based on the age of presentation. MRI of the brain in patients with Krabbe disease shows bilaterally symmetrical T2 hyperintense signal in the periventricular and deep white matter and in the corticospinal tracts. Patients can have peripheral neuropathy, which, on imaging, is commonly seen in the form of thickening and enhancement of cranial nerves and nerve roots of cauda equina. Our patient, a child aged eleven years, had intracranial lesions along with brachial plexopathy. This is the first described case of juvenile-onset Krabbe disease with brachial plexus involvement.

The evaluation of sexual dysfunction in patients with spinopelvic dissociation underwent triangular osteosynthesis: A single-center retrospective study.

Spinal myxopapillary ependymoma (SMPE) is a common primary tumor of the cauda equina region. Despite its benign nature, SMPE is difficult to resect, and early seeding along the neural axis may necessitate further adjuvant therapy. The aim of this study was to analyze the clinical and MRI characteristics of SMPE to enhance pretreatment diagnosis and outcomes. We retrospectively reviewed patients with SMPE at 2 institutions between 2003 and 2023. Preoperative MRI was reviewed to determine the tumor characteristics. The primary outcomes were progression-free survival and overall recurrence rates, which were analyzed using Kaplan-Meier statistics. A total of 20 patients with SMPE were recruited (mean age: 33.1 ± 14.8 years, 70% male). The follow-up period was 103 ± 70.2 months. "Insects in amber" sign and midline position are the most common characteristics indicative of SMPE on MRI and are observed in 90% and 85% of patients, respectively. Seven (35%) patients experienced tumor recurrence. Younger age (P = .008), tumors >50.2 mm in size (P = .019), conus medullaris involvement (P = .043), the presence of tumor seeding before the operation (P < .001), and incomplete resection (P = .002) were associated with a higher rate of tumor recurrence after the operation. The 5- and 10-year progression-free survival rates were estimated to be 70% and 65%, respectively. SMPE can be diagnosed based on pretreatment MRI findings, such as the "insect in amber" sign and a midline tumor location. We recommend adjuvant therapy and close postoperative follow-up for patients at high risk of tumor recurrence to improve outcomes.

ABSTRACTAPL presenting as an extramedullary mass is exceedingly rare. Here, we describe extramedullary APL causing cauda equina syndrome, underscoring the diagnostic challenges associated with an atypical presentation, highlighting the complexity of distinguishing extramedullary APL from other conditions, and discussing the stepwise approach to diagnosis.

Background/Objectives: Cauda equina syndrome (CES) is a rare but severe complication of lumbar disc herniation (LDH). This study aimed to assess the diagnostic value of the dural sac cross-sectional area (DSCSA) in predicting CES in affected patients. Methods: In this retrospective observational study, we analyzed 99 patients who underwent surgery for LDH, including cases with CES, between 2014 and 2023. The DSCSA was measured at the narrowest level of the dural sac using axial T2-weighted magnetic resonance imaging. Univariable and multivariable logistic regression were performed on DSCSA and other candidate risk factors. Results: Among the patients with LDH, nine (9.1%) had CES. In multivariable logistic regression, DSCSA was associated with CES, with an adjusted odds ratio of 0.79 (95% confidence interval [CI]: 0.62–0.90, p = 0.011). Exploratory receiver operating characteristic analysis identified an optimal DSCSA cut-off of 31.16 mm2, yielding 100% sensitivity, 92.2% specificity, and an area under the curve of 0.974 (95% CI: 0.944–1.000, p < 0.001). Conclusions: Smaller DSCSA was associated with CES in patients with LDH. Patients with a DSCSA of approximately 30 mm2 or less may require closer monitoring for the development of CES symptoms. Given the limited number of CES cases, these findings should be interpreted cautiously and validated in larger studies.

Rationale:While epidural steroid injections (ESI) are a routine component of lumbar disc herniation management, the procedure carries inherent risks. Certain clinical presentations may signal an elevated risk for catastrophic complications, such as cauda equina syndrome. This report examines the significance of severe positional pain as a pre-procedural warning sign.Patient concerns:We present the case of a 65-year-old male who exhibited a critical physical sign: severe low back pain prohibiting a supine position. Despite this red flag, an interlaminar ESI was administered at the L2–3 level without prior definitive magnetic resonance imaging (MRI) evaluation.Diagnoses:Following the procedure, the patient progressed to acute paraplegia. Emergency MRI identified a massive L2–3 disc extrusion with near-total spinal canal occlusion, confirming a diagnosis of cauda equina syndrome.Interventions:The patient underwent emergency surgical decompression. Prior to this, he had received the interlaminar ESI which preceded the neurological decline.Outcomes:At the 4-month postoperative follow-up, the patient demonstrated partial neurological recovery, regaining the ability to ambulate short distances with the aid of a walker.Lessons:The inability to assume a supine position due to pain should be regarded as a marker for severe spinal stenosis or a large disc herniation. Proceeding with ESI without advanced imaging in such contexts poses an unacceptable risk of precipitating permanent neurological deficit. Comprehensive imaging is mandatory; if pain prevents MRI acquisition, alternative diagnostic strategies must be prioritized over blind intervention.

Surgical management for isthmic spondylolisthesis (IS) can be accomplished with either an anterior, posterior, or combined approach. This study compares 90-day medical and surgical complications of anterior, posterior, and combined lumbar fusion for adults with single-level IS. Deidentified patient data were obtained through the PearlDiver database using relevant ICD and current procedural terminology codes from 2015 to 2022. Patients ≥18 years with single-level IS who had undergone either anterior lumbar fusion (ALIF), posterior lumbar fusion (PLF), or combined AP lumbar fusion (CLF) were evaluated. Patients undergoing more than one level lumbar fusion were excluded, and 90-day postoperative complications were compared across cohorts. Of 43,619 patients who underwent surgery for IS, 4,622 (10.6%) had ALF, 35,550 (81.5%) PLF, and 3,447 (7.90%) CLF. At 90 days postoperatively, multivariate analysis controlling for demographics, tobacco use, and obesity reveals that odds of readmission were significantly lower in patients who underwent PLF (odds ratio [OR] 0.81, P < 0.01) compared with ALF. A markedly higher odds of revision surgery was observed in patients undergoing PLF (OR 2.65) or CLF (OR 2.40) compared with ALF. Both PLF (OR 0.35) and CLF (OR 0.62) cohorts had lower odds of developing postoperative ileus. No significant difference was noted in rate of postoperative hematoma, pneumonia, sepsis, cauda equina syndrome, or deep vein thrombosis at 90 days between PLF or CLF cohorts compared with ALF (P value >0.05). Among adult patients with IS undergoing single-level lumbar fusion, 81.5% had posterior surgery while 7.9% had combined AP surgery. Compared with the anterior approach, patients undergoing the posterior approach had lower 90-day readmission rates and postoperative ileus rates. However, patients undergoing posterior or combined surgery had higher odds of requiring revision surgery within 90 days. These differences in complication profile may help surgeons in surgical decision making on which approach to consider in their patients with IS.

Background/Objectives: Lumbar spinal canal stenosis (LSS) is a major cause of neurological disability and is frequently accompanied by neuropathic pain (NeP). Duloxetine is widely used for NeP, but its clinical role in LSS and the determinants of treatment response remain unclear. This study aimed to identify predictors of duloxetine efficacy in LSS. Methods: We retrospectively analyzed 145 patients with LSS who received duloxetine for ≥3 months (median dose 40 mg) with at least 1-year follow-up. Patients were classified into those with radicular pain or cauda equina syndrome. Treatment response was assessed at 3 months. Stenosis severity was evaluated using the Schizas classification. Multivariable logistic regression analysis was performed to identify independent predictors of duloxetine response in patients with cauda equina syndrome. Results: Duloxetine was effective in 29.4% vs. 52.3% in radicular pain and cauda equina syndrome, respectively. Among patients with cauda equina syndrome, Schizas Grade D was more frequent in responders than non-responders and independently predicted duloxetine response. Nearly 90% of responders had been unresponsive to other NeP medications. A subset of patients with severe stenosis avoided surgery following duloxetine treatment. Conclusions: Duloxetine showed greater efficacy in cauda equina-dominant LSS compared with radicular pain. Paradoxically, more severe spinal canal stenosis tended to be associated with a higher likelihood of response. These findings suggest that neurological phenotype and radiological severity may influence duloxetine responsiveness and support a symptom- and imaging-guided pharmacological management for LSS, although these findings should be interpreted with caution and considered hypothesis-generating given the retrospective study design.

Study DesignRetrospective cohort study.ObjectiveTo evaluate the predictive value of intraoperative bulbocavernosus reflex (BCR) monitoring for postoperative bowel dysfunction (PBD) following conus medullaris and cauda equina tumor (CMCET) resection.MethodsA total of 118 patients were analyzed. Neurogenic Bowel Dysfunction Scores >6 at 1 month and 6 months postoperatively defined short- and long-term PBD. The amplitude reduction ratio (ARR) was calculated from bilateral BCR waveforms using the worst-side ARR for analysis. Multivariate logistic regression and ROC curve analysis determined independent predictors and optimal thresholds. Stratified 10-fold cross-validation confirmed threshold stability.ResultsPatients with short-term or long-term PBD had significantly higher ARRs than those without (P < 0.001 for both comparisons, Mann-Whitney U test). Furthermore, ARR emerged as the only independent predictor for either short-term (OR 1.287, 95% CI 1.018-1.627, P = 0.035) or long-term PBD (OR 1.153, 95% CI 1.055-1.261, P = 0.002). The threshold values of ARR for predicting short-term and long-term PBD were 59.6% (AUC = 0.991, 95% CI 0.974-1.000, P < 0.001) and 63.6% (AUC = 0.988, 95% CI 0.971-1.000, P < 0.001), respectively. Cross-validation confirmed these thresholds, with mean AUC values of 0.992 and 0.993 for short-term and long-term PBD, respectively.ConclusionsThe ARR of the intraoperative BCR waveform showed a high predictive value for PBD in patients with CMCET. We propose a 60% ARR reduction on either side of the BCR waveforms as an exploratory, hypothesis-generating early warning criterion for BCR monitoring during CMCET surgery, pending external validation in independent prospective cohorts before clinical implementation.

Background: Concurrent intracranial and spinal chronic subdural hematomas are rare and may be difficult to diagnose. Intracranial CSDH usually presents with headache or neurological deficits, whereas spinal SDH may cause back pain and radiculopathy. Case Presentation: A 57-year-old man presented with 10 days of severe low back pain radiating to both lower limbs, associated with weakness and abnormal gait. Lumbar MRI showed a subdural hematoma extending from T12/L1 to S1/S2 with cauda equina crowding. Brain MRI revealed bilateral chronic intracranial subdural hematomas without significant mass effect or midline shift. The patient was managed conservatively, and his symptoms resolved completely within 2 weeks. Conclusion: Severe lumbar radiculopathy may be the initial presentation of concurrent intracranial and spinal CSDH. Brain and spine imaging should be considered in older patients with unexplained spinal symptoms, especially after minor trauma or anticoagulant use.

Spinal surgery is primarily performed to improve neurological function; compared with intracranial surgery, it is rarely conducted to address life-threatening conditions. As the goal of treatment is functional recovery, postoperative complications must be minimized. Appropriate perioperative management is therefore essential, and includes careful preoperative neurological evaluation; postoperative monitoring of neurological, respiratory, and circulatory status; and early detection and management of complications. Several complications of spinal surgery require attention. Firstly, airway obstruction caused by cervical swelling after anterior cervical surgery, postoperative epidural hematoma leading to neurological deterioration, and cerebrospinal fluid (CSF) leakage are the major complications requiring urgent intervention. Cervical spine surgery has several characteristic complications, depending on the surgical approach; for example, anterior procedures may cause airway compromise, esophageal injury, or recurrent laryngeal nerve palsy, whereas posterior procedures are more commonly associated with C5 palsy and surgical site infection. Thoracic spine surgery requires careful postoperative management as the spinal canal is relatively narrow, while the spinal cord is vulnerable to ischemia. In lumbar spine surgery, symptoms primarily involve the cauda equina, while major complications include epidural hematoma, CSF leakage, and surgical site infection. Appropriate perioperative evaluation and prompt management of complications at the spinal level are essential for achieving favorable surgical outcomes.

Systematic review and meta-analysis. This meta-analysis aims to systematically assess clinical and surgical outcomes of endoscopic spine surgery for cauda equina syndrome (CES). Endoscopic spine surgery has emerged as a minimally invasive alternative for CES treatment, yet its efficacy and safety remain uncertain. A systematic search of PubMed, Embase, and Web of Science was conducted in accordance with PRISMA guidelines. Continuous outcomes were analyzed as pooled means with 95% CIs, while dichotomous outcomes were pooled using a generalized linear mixed-effects model. Pooled estimates were calculated using random-effects models in R software (version 4.5.1). Seven studies (n=107) were included. The mean operative time was 55.6 minutes (95% CI: 42.0-73.5), with an estimated blood loss of 11.9mL (95% CI: 1.2-118) and a hospital stay of 2.33 days (95% CI: 0.86-6.35). The overall complication rate was 7% (95% CI: 1.3-29.8) and the reoperation rate 4.5% (95% CI: 0.7-24.3). Postoperative outcomes demonstrated pooled mean reductions of -5.7 points in visual analog scale (VAS) Back (95% CI: -8.5 to -2.8), -7.7 points in VAS Leg (95% CI: -9.5 to -5.9), and a -57.7 percentage-point decrease in Oswestry Disability Index (95% CI: -74.0 to -41.4). Neurological recovery was also favorable, with pooled recovery rates of 78.3% for motor function (95% CI: 53.6-91.8), 67% for saddle anesthesia (95% CI: 34-89), and 97.8% for bladder/bowel function (95% CI: 15.8-100). Endoscopic spine surgery provides a safe and effective minimally invasive option for CES. Future prospective studies are warranted to further validate its long-term efficacy and safety.

Brucellar spondylodiscitis frequently poses diagnostic challenges due to its atypical early clinical manifestations, which may mimic degenerative spinal diseases. This report described a 42-year-old male patient who initially presented with severe low back pain and acute cauda equina syndrome and was preoperatively diagnosed with lumbar disc herniation. Emergency lumbar decompression was performed; however, the patient later developed fever and systemic symptoms. Repeated serological testing confirmed brucellosis. The early clinical, laboratory, and imaging features were nonspecific, and initial inflammatory markers and bacterial cultures were negative. Empirical levofloxacin may have masked inflammatory responses. This case highlights the importance of maintaining high index of suspicion for brucellar spondylodiscitis in endemic regions, even in the absence of systemic signs of infection. Repeat serologic testing, careful radiological evaluation, and attention to epidemiological exposure are critical for early and accurate diagnosis.