Cauda Equina Research Articles

Fluoroscopy guided teardrop technique for open trans-muscular iliac screw placement and open reduction maneuvers during modified triangular spinopelvic fixation for unstable U-shaped sacral and tile C pelvic traumas: technical note.

Unstable traumas of the spinopelvic junction, which include displaced U-shaped sacral fractures (Roy-Camille type 2 and type 3) and Tile C vertical shear pelvic ring disruptions, occur in severe traumas patients following high speed traffic accident or fall from a height. These unstable traumas of the spinopelvic junction jeopardize one's ability to stand and to walk by disrupting the biomechanical arches of the pelvis, and may also cause cauda equina syndrome. Historically, such patients were treated with bed rest and could suffer a life-long burden of orthopedic and neurological disability. Since Schildhauer pioneer work back in 2003, triangular spinopelvic fixation, whether it is performed in a percutaneous fashion or by open reduction and internal fixation, allows to realign bone fragments of the spinopelvic junction and to resume walking within three weeks. Nevertheless, such procedure remains highly technical and it not encountered very often, even for spine surgeons working in high-volume level 1 trauma centers. Hence, this visual technical note aims to provide a few tips to guide less experience surgeons to complete this procedure safely.

(037) VESTIBULODYNIA SECONDARY TO LUMBOSACRAL ANNULAR TEAR-INDUCED SACRAL RADICULOPATHY

Abstract Introduction Vestibulodynia is a prevalent problem in individuals with vulvas, with as many as 30% reporting complaints consistent with entry dyspareunia. Distinctive vestibulodynia pathophysiologies may include psychosocial factors, pelvic floor muscle dysfunction, dermatologic disorders, inflammatory disorders, hormonal deficiencies, neuroproliferative pathology, and pudendal neuropathy. Sacral radiculopathy is considered an inflammatory irritation of S2-S3 nerve roots in the cauda equina by various pathologies such as lumbosacral annular tear. S2-S3 nerve roots are formed by the convergence of the pelvic, pudendal, and sciatic nerves and genito-pelvic clinical symptoms may result from inflammatory involvement of the sensory fields of these nerves. Vestibulodynia may occur from sacral radiculopathy since the somatic and visceral afferent innervation of the vestibule occurs via the pudendal and pelvic nerves, respectively; however, to the best of our knowledge, there has not been a case series of such patients previously reported. Objective To perform a chart review of patients with vestibulodynia secondary to lumbosacral annular tear-induced sacral radiculopathy. Methods Vestibulodynia patients who presented to our sexual medicine clinic were evaluated by detailed history, vulvoscopy, vestibular anesthesia testing, neurogenital testing and lumbosacral MRI. When these tests warranted it, a transforaminal epidural spinal injection with 1 ml lidocaine 1% was performed to substantiate the diagnosis. If appropriate, spine surgery was performed. Improvement was assessed using the Patient Global Impression of Improvement (PGI-I). Results Four patients, 3 cis-gender women and 1 trans-man, mean age 33 years (range 25-42), were diagnosed with vestibulodynia secondary to lumbosacral annular tear-induced sacral radiculopathy. Concomitant sacral radiculopathy symptoms included: clitoral hypersensitivity (50%), bladder urgency/frequency (75%), umbilical hypersensitivity (75%), vaginal dysesthesia (25%), vulvar itching (50%), low back pain (100%), and sciatica (75%). Vulvoscopy was performed to exclude other forms of vestibulodynia. All patients had: a) positive cotton-tipped swab testing throughout the entire vestibule; b) negative vestibular anesthesia testing; c) abnormal neurogenital testing; d) lumbosacral MRI that revealed surgically treatable lumbosacral annular tear (L5-S1, L4-L5); e) transforaminal epidural spinal injection resulting in clinically significant symptom reduction. Lumbar endoscopic spine surgery resulted in improvement in 75% reporting PGI-I 1-3 (very much better - somewhat better). Conclusions We report the first series of patients with vestibulodynia resulting from lumbosacral annular tear-induced sacral radiculopathy. Clinicians should be aware that bothersome vestibulodynia in patients with vulvas can occur from cauda equina pathology (Region 3) outside the genitals (Region 1) and/or pelvis/perineum (Region 2). Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.

Reflex Responses in Muscles of the Lower Extremities Elicited by Transcutaneous Stimulation of Cauda Equina: Part 1. Methodology and Normative Data

Introduction: Transcutaneous electrical stimulation is used to stimulate the dorsal roots of the cauda equina. Multiple elicited responses recorded in the lower extremity muscles are called posterior root muscle reflexes (PRMRs). Normal PRMR values in the muscles of healthy lower extremities have yet to be determined. Methods: Thirty subjects without known lumbosacral spinal root illness were included in this study. Subsequently, they were subjected to transcutaneous electrical stimulation of the cauda equina. Posterior root muscle reflex was recorded in the four muscle groups of both lower extremities. We elicited multiple PRMR and examined their characteristics in order to establish normal electrophysiological parameter values. Results: Posterior root muscle reflex was successfully elicited in the tibialis anterior (96.7%), gastrocnemius (100%), quadriceps femoris (93.3%), and hamstring (96.7%). No statistically significant differences were found in the intensity of stimulation, latencies, or area under the PRMR between the right and left leg muscles. The area under PRMR varied significantly among the participants. Higher body weight and abdominal girth showed a significant positive correlation with stimulation intensity for eliciting PRMR, and a significant negative correlation with the area under PRMR. Older age showed a significant negative correlation with the success of eliciting PRMR and the area under the PRMR. Conclusions: Posterior root muscle reflex is a noninvasive and successful method for eliciting selective reflex responses of cauda equina posterior roots. Obtained values could be used in future studies to evaluate the utility of this methodology in clinical practice. This methodology could improve testing of the proximal lumbosacral nervous system functional integrity.

Surgical Management of Spinal Cysticercosis: 2-Dimensional Operative Video.

Neurocysticercosis is a notorious—albeit relatively rare—parasitic infection of the nervous system caused by ingestion of embryonated eggs or gravid proglottids of the pork tapeworm Taenia solium. 1 Most cases appear intracranially and can present with seizures and/or headache; far fewer affect the spinal canal alone. 1-6 We describe a case of a 66-year-old Hispanic man with isolated spinal cysticercosis presenting to the emergency department initially with axial back pain. After lumbar x-rays and a computed tomography scan failed to find any pathology, he was discharged home without neurosurgical consultation. A week later he would re-present to the same emergency department with worsening back pain and new neurologic deficits, prompting an MRI revealing pathology within the lumbar spinal canal. After consultation, the neurosurgical team discussed management strategies and eventually opted for surgical exploration of the patient's lumbar spine. This exploration eventually culminated in an intradural exploration, revealing an impressive string of interconnected larval cysts of the T. solium tapeworm within the cauda equina. The patient's neurologic condition improved immediately after surgery, and final pathologic examination supported a diagnosis of spinal cysticercosis, prompting the appropriate workup and medical treatment. He would ultimately make a full recovery and continues to follow-up with infectious disease at our institution. The patient consented to the surgical intervention described herein after a discussion of its risks, benefits, and alternatives. Institutional review board and ethics committee approval was not sought because the intervention did not constitute experimental surgery, but rather represented standard of care given the patient's condition on presentation.

Clinical and epidemiological profile of patients with atypical melanomas treated with immunotherapy.

e21532 Background: Atypical melanomas, such as acral lentiginous, uveal, mucosal, spitzoid, desmoplastic, meningeal, and primary occult site, represent less than 5% of melanoma cases. Due to their different biological tumor behavior from cutaneous melanomas, their treatment is still challenging. Currently, checkpoint inhibitors are the main treatment based on extrapolations or data from small surveys. Methods: This study aims to describe the epidemiological profile, clinical and pathological characteristics, and treatment of patients with atypical melanomas treated with immunotherapy. It is an observational, descriptive, retrospective study that analyzed 72 medical records of patients with atypical melanomas, ECOG 0-1, > 18 years old, treated with immunotherapy (neo, adjuvant, and palliative lines), between January 2015 and December 2023 at the A.C. Camargo Cancer Center, São Paulo, Brazil. Results: We gathered 72 patients, 61% male and 39% female, with an average age of 58.89 (±13.63) years; 57% were white, 15% African-descendant (black and brown), 8% Asian, and 20% not specified. Regarding primary site, 26% were acral, 24% mucosal, 24% occult primary site, 15% uveal, 8% desmoplastic, 1% amelanocytic, 1% spitzoid, and 1% cauda equina meningeal. Regarding staging, (3%) were stage I, (15%) stage II, (25%) stage III, (47%) stage IV, and (10%) unknown. LDH: 372.5 (±360) mg/dL. Metastases: lymph node 29%; hepatic 23%; pulmonary 21%; bone 18%; central nervous system 15%; peritoneal carcinomatosis 5%; stomach 3%; cauda equina 3%; adrenal 1%; in transit 1%; intestine 1%; bone marrow 1%; parotid 1%. BRAF mutations were present in 23% of cases (variants V660E, V600K, V660R, and G469R); NRAS 6% (codons 13 and 61); KIT 1% (exon 11) and NTRAK 1% (S701F). In relation to treatment, 5 received neoadjuvant anti-pd1 + anti-ctla4 combination, 13 adjuvant with anti-pd1+/- anti-ctla4. About 50 patients received systemic treatment for metastatic disease anti-pd1+/- anti-ctla4. Overall survival: 26 (±14.8) months. Conclusions: Atypical melanoma primary occult site is the most prevalent, with the majority diagnosed at stage IV, with high LDH levels and lymph nodes as the main sites of metastases. Twenty-three percent had a BRAF gene mutation. The majority were treated palliatively with first-line immunotherapy, with median survivals of 14.8 months.

CSP2023: 65 - The experiences, beliefs and practices of MSK physiotherapists regarding safety netting for Cauda Equina Syndrome

CSP2023: 65 - The experiences, beliefs and practices of MSK physiotherapists regarding safety netting for Cauda Equina Syndrome

CSP2023: 370 - Keep calm and carry on: The lived experiences of UK physiotherapists involved in Cauda Equina Syndrome Litigation. A qualitative study

CSP2023: 370 - Keep calm and carry on: The lived experiences of UK physiotherapists involved in Cauda Equina Syndrome Litigation. A qualitative study

Post-Infectious Guillain Barré Syndrome Related to COVID-19: Unusual Case Report

Guillain-Barré Syndrome (GBS) is a rare immune mediated inflammatory disease of the peripheral nervous system that is presumed to be triggered by preceding infections. In the era of pandemic COVID-19 (coronavirus disease), there is an emerging case of para/post infectious GBS associated to COVID-19 that are described worldwide. Here, we report a 55-years-old man who was admitted for fatigue, fever and cough related to covid-19. Later, after disappearing of covid-19 symptoms he began presenting an ascending areflexic tetraparesis. CSF and NCS were in favour of GBS diagnosis, in particular pure motor AIDP subtype. Antigangliosides antibodies were negative. Lumbosacral MRI showed contrast enhancement of cauda equina roots. The outcome was good after receiving intravenous immunoglobulins treatment.

History and evolution of surgical treatment for spasticity: a journey from neurotomy to selective dorsal rhizotomy.

The evolution of neurosurgical approaches to spasticity spans centuries, marked by key milestones and innovative practitioners. Probable ancient descriptions of spasmodic conditions were first classified as spasticity in the 19th century through the interventions of Dr. William John Little on patients with cerebral palsy. The late 19th century witnessed pioneering efforts by surgeons such as Dr. Charles Loomis Dana, who explored neurotomies, and Dr. Charles Sherrington, who proposed dorsal rhizotomy to address spasticity. Dorsal rhizotomy rose to prominence under the expertise of Dr. Otfrid Foerster but saw a decline in the 1920s due to emerging alternative procedures and associated complications. The mid-20th century saw a shift toward myelotomy but the revival of dorsal rhizotomy under Dr. Claude Gros' selective approach and Dr. Marc Sindou's dorsal root entry zone (DREZ) lesioning. In the late 1970s, Dr. Victor Fasano introduced functional dorsal rhizotomy, incorporating electrophysiological evaluations. Dr. Warwick Peacock and Dr. Leila Arens further modified selective dorsal rhizotomy, focusing on approaches at the cauda equina level. Later, baclofen delivered intrathecally via an implanted programmable pump emerged as a promising alternative around the late 1980s, pioneered by Richard Penn and Jeffrey Kroin and then led by A. Leland Albright. Moreover, intraventricular baclofen has also been tried in this matter. The evolution of these neurosurgical interventions highlights the dynamic nature of medical progress, with each era building upon and refining the work of significant individuals, ultimately contributing to successful outcomes in the management of spasticity.

MRI parameters predict central lumbar spinal stenosis combined with redundant nerve roots: a prospective MRI study.

To observe changes in the cauda equina nerve on lumbar MRI in patients with central lumbar spinal stenosis (LSS). 878 patients diagnosed with LSS by clinical and MRI were divided into the redundant group (204 patients) and the nonredundant group (674 patients) according to the presence or absence of redundant nerve roots (RNRs). The anteroposterior diameter of the spinal canal (APDS) and the presence of multiple level stenosis, disc herniation, thickening of ligamentum flavum (LF) and increased epidural fat were assessed on MRI. Univariate and multivariate logistic regression analyses were performed to explore the predictors of LSS combined with RNRs. Patients with LSS combined with RNRs had thicker epidural fat, smaller APDS and more combined multifaceted stenosis. Female patients and older LSS patients were more likely to develop RNRs; there was no difference between two groups in terms of disc herniation (p > 0. 05). Age, APDS, multiple level stenosis, and increased epidural fat were significantly correlated with the formation of LSS combined with RNRs (p < 0.05). A smaller APDS and the presence of multiple level stenosis, thickening of LF, and increased epidural fat may be manifestations of anatomical differences in patients with LSS combined with RNRs. Age, APDS, multiple level stenosis, and increased epidural fat play important roles. The lumbar spine was measured and its anatomy was observed using multiple methods, and cauda equina changes were assessed to identify the best anatomical predictors and provide new therapeutic strategies for the management of LSS combined with RNRs.

Post-operative epidural haematoma as complication of overconsumption of dried fruit in lumbar spinal surgery: a case report and review of the literature

PurposeMebos, a traditional South Africa confection consisting of dried, pulped, and sugared apricots, is rich in fibre and vitamins, but also contains salicylic acid, flavonoids, and citric acid. We report a case of postoperative surgical site bleeding in a healthy patient who consumed approximately 2 kg of mebos per day prior to his elective spinal surgery.MethodsThe clinical course of a previously healthy 54-year-old male patient with cauda equina syndrome secondary to lumbar spinal stenosis who underwent surgical intervention with subsequent bleeding into the surgical site is discussed. The cause was investigated through biochemical analysis, thromboelastometry (ROTEM®) and mass and absorption spectrometry were applied to assess flavonoid, citric acid, and salicylic acid content.ResultsROTEM® revealed an abnormal clotting profile with an increased clot forming time, suggesting intrinsic coagulopathy. Mass and absorption spectrometry revealed a high total flavonoid content as well as citric acid concentration in the mebos. Salicylic acid was at detection limits of the instrument.ConclusionResults highlighted the effect of flavonoids and citric acid and therefore explain the abnormal clotting profile in this patient. Inhibition of coagulation prior to elective surgery is a known contraindication and may pose great risks in spinal surgery. In the present report, we demonstrated an association between inhibition of coagulation and an excess of the flavonoids content and citric acid concentration in mebos consumed in the days prior to elective spinal surgery.

Treatment Outcomes of Lower Urinary Tract Symptoms due to Fragility Sacral Fractures: A Review of Eight Patients and Literature

Sacral fractures can cause lower urinary tract symptoms (LUTS) due to damage to the cauda equina. While several studies have reported on sacral fractures due to high-energy trauma, those due to fragility fractures have only been reported in case reports and their clinical differences are not well known. This study aimed to investigate the clinical characteristics of LUTS caused by fragility sacral fractures and propose a novel treatment strategy. This study is retrospective, uncontrolled, clinical case series. The inclusion criteria were sole sacral fractures due to low-energy trauma and appearance of LUTS after injury. Patients with additional spinal fractures or combined abdominal or pelvic organ injuries that could cause LUTS were excluded. Improvement in LUTS, period from onset to improvement, and imaging findings were recorded. Eight patients met the inclusion criteria (4 surgical and 4 conservative treatment cases). Six patients showed improvement in LUTS. In surgical cases, the mean period from onset of LUTS to surgery and from onset of LUTS to improvement was 14.5 and 21.5days, respectively. Intraoperative rupture or laceration of the dural sac was not observed. In 2 conservatively improved cases, the period from onset to improvement of LUTS was 14 and 17days. LUTS can improve even with conservative treatment and should be utilized as the primary choice. LUTS caused by severe sacral canal deformity and stenosis can be reversible, and the decision to perform surgical treatment is still timely if LUTS do not improve with conservative treatment for several weeks.

Cauda Equina Syndrome: Cost Burden After Spinal Decompression.

Observational cohort study. Cauda equina syndrome (CES) is a rare neurologic condition with potentially devastating consequences. The objective of this study was to compare the 2-year postoperative cost-associated treatments after posterior spinal decompression between patients with and without CES. By analyzing a commercial insurance claims database, patients who underwent posterior spinal decompression with a concurrent diagnosis of lumbar spinal stenosis, radiculopathy, or disk herniation in 2017 were identified and included in the study. The primary outcome was the cost of payments for identified treatments in the 2-year period after surgery. Treatments included were (1) physical therapy (PT), (2) pain medication, (3) injections, (4) bladder management, (5) bowel management, (6) sexual dysfunction treatment, and (7) psychological treatment. In total, 3,140 patients (age, 55.3 ± 12.0 years; male, 62.2%) were included in the study. The average total cost of treatments identified was $2,996 ± 6,368 per patient. The overall cost of identified procedures was $2,969 ± 6,356 in non-CES patients, compared with $4,535 ± 6,898 in patients with CES ( P = 0.079). Among identified treatments, only PT and bladder management costs were significantly higher for patients with CES (PT: +115%, P < 0.001; bladder management: +697%, P < 0.001). The difference in overall cost was significant between patients (non-CES: $1,824 ± 3,667; CES: $3,022 ± 4,679; P = 0.020) in the first year. No difference was found in the second year. A short-term difference was observed in costs occurring in the first postoperative year. Cost of treatments was similar between patients apart from PT and bladder management.

A novel approach to expedite emergency investigation for suspected cauda equina syndrome referrals from community and primary care services: A service evaluation

IntroductionAlthough a rare spinal emergency, cauda equina syndrome (CES) can result in significant physical, emotional, and psychological sequalae. Introducing a CES pathway enhances diagnosis but may increase Radiology and Orthopaedic workload. To address this, one NHS hospital in England introduced a novel CES pathway. Utilising a criteria-led pathway, patients were referred directly from community/primary care, via the Emergency Department, for an emergency MRI scan. ObjectiveTo compare the outcomes of patients referred via an original and redesigned Community and Primary Care CES pathway. DesignA retrospective service evaluation was undertaken of all emergency MRI scans investigating suspected CES via either pathway. MethodsTwo 3-month time periods were analysed; pre-(original) and post-implementation of the redesigned pathway; time to surgery was reviewed over two 12-month periods. ResultsIncreased MRI scan utilisation was seen following the implementation of the redesigned pathway: original n = 50, redesigned n = 128, increasing Radiology workload. However, the redesigned pathway resulted in a reduction in time to MRI from 3h:01m to 1h:02m; reduction in time spent in ED 4h:55m to 3h:24m; reduction in time to surgery 18h:05m to 13h:38m; reduction in out-of-hour scanning from 10 to 2 patients during the evaluation period; and a reduction in on-call Orthopaedic involvement by 38%. ConclusionAll timed outcomes were improved with the implementation of this novel pathway. This suggests expediting MRI scans can result in substantial downstream benefits; albeit while increasing MRI scan utilisation. This pathway aligns with the emergency management of suspected CES under the new national CES pathway in England.

Cauda equina syndrome in the emergency department: a 2-year retrospective review

Cauda equina syndrome if a rare but life-changing clinical condition inwhich pressure is exerted on the group of nerve roots known collectivelyas cauda equina.It was first described in 1934. It has an incident ranging from 2.7 to4.0 per 100,000.It is more common in women with a mean age of 42 years.It can lead to loss of control of pelvic organs and legs, with a risk ofpermanent loss of sensory and motor control in the area supplied by thecauda equina.The setting for the study was the emergency department in a LargeUrban Teaching Hospital. A Retrospective Chart Review over 2 yearsfrom January 2022 to December 2023 was conducted. Adult patientsaged 18 years and over presenting with suspected cauda equina syndrome(CES) were included. We found a CES prevalence of 0.07% of all EDattendances or 74 per 100,000. There was a female preponderance of70% versus 30% male. A total of 74% of cases were aged between 24and 65 years at one peak, and a spike after the age of 75 years. Mostcases (92%) were managed conservatively. A total of 100 patients (68%)were admitted or transferred, while 32% were discharged. A total of 140patients (95%) met the National Institute for Health and Care Excellence(NICE) red flag symptoms. In conclusion, CES is rare (&lt; 0.5% of ED presentations). There was anage peak between 25 and 65 years, with a spike after the age of 75 years.It has a large female preponderance in keeping with the observation fromother studies. Ninety five per cent of cases in our cohort met the NICEred flag criteria. Most cases were managed locally and conservatively.

Surgical vs. Conservative Management of Chronic Sciatica (>3 Months) Due to Lumbar Disc Herniation: Systematic Review and Meta-Analysis.

Sciatica, characterized by leg or back symptoms along the sciatic nerve pathway, often manifests as a chronic condition lasting over 12 weeks. Decision-making between nonoperative treatment and immediate microdiscectomy for chronic sciatica remains challenging, due to the complex relationship between symptom duration, severity, and lumbar discectomy outcomes. In this systematic review, we conducted a comprehensive search across Scopus, PubMed, Web of Science, and the Cochrane Library, identifying relevant two-arm clinical trials up to September 2023. Rigorous screening and data extraction were performed by two independent reviewers, with study quality evaluated using the risk of bias 2 (RoB) tool. This meta-analysis incorporated four studies comprising 352 participants. Our analysis revealed that conservative treatment was associated with a significant reduction in leg pain and improvement in, SF mental, and physical scores compared to surgical intervention. However surgical treatment demonstrated significant improvement in back pain. In conclusion, our findings suggest that surgical intervention may be more effective than non-surgical treatment for chronic sciatica-related back pain. Conservative treatment significantly reduces leg pain while improving mental and physical health outcomes. Ultimately, our findings support conservative as the initial approach unless surgery is warranted, particularly in cases with neurological deficits or cauda equina syndrome.

Paradoxical Air Embolism in Spinal Surgery: Case Report and Literature Review

AbstractAir embolism (AE) is a subtype of embolism, caused by the entry of air into the vascular system. It is a predominantly iatrogenic complication, and its symptomatic form is severe, although uncommon. In some cases, a venous thrombi may pass into the arterial system through a venous-arterial shunt, characterizing a paradoxical embolism. Here, we describe the case of a previously healthy 44-year-old female who underwent cauda equina decompression and lumbar epidural abscess drainage. The patient suffered a paradoxical AE intraoperatively and died after 4 days. The occurrence of AE in lumbar spine surgeries in the prone position is rare, but the surgical team must be attentive to its clinical signs and quickly institute initial management when necessary.

6301178 Cauda Equina Syndrome in the third trimester of pregnancy, the importance of shared decision making

6301178 Cauda Equina Syndrome in the third trimester of pregnancy, the importance of shared decision making

Lumbar Epidural Abscess Presenting as Cauda Equina Syndrome: A Rare Case with Literature Review

Abstract Pyogenic epidural abscess is a rare illness that can occasionally present like cauda equina syndrome. It may quickly advance and result in long-term neurological paraplegia. This case involves a 17-year-old female who had been experiencing backache for 2 weeks and weakness in her right lower limb for 1 week. She was managed conservatively. Our case is distinctive in that, despite a magnetic resonance imaging diagnostic of the tuberculosis spine, it was ultimately determined to be of pyogenic origin and was treated as such.

Symptomatic Tarlov Cyst – Case Report and Review of the Literature

Here we describe the case of a 53 year old woman presenting with low back pain with radiation was diagnosed with sacral bilateral Tarlov cyst. She was treated by laminectomy, disintegration of cyst and duroplasty. Histopathological examination of the cyst wall was confirmed the diagnosis. Symptomatic Tarlov cysts are extremely rare, commonly presenting as sacral or lumbar pain syndromes, sciatica or rarely as cauda equina syndrome. Tarlov cysts should be considered in the differential diagnosis of patients presenting with these complaints. Bang. J Neurosurgery 2023; 12(2):125-128