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Conus Medullaris and Cauda Equina Syndromes

Outline of Discussion. IntroductionAnatomical OverviewConus Medullaris SyndromeTrauma As An EtiologyCauda Equina SyndromeQuestions. Introduction. Conus medullaris and cauda equina syndromes are clinical entitiesDiagnosis based on clinical findingsHistory and Physical ExaminationDiagnosis prompts emergent acquisition of appropriate radiographic workupExclude psychogenic causesIdentify the pathology to aid in formulation of a treatment planEtiology is variable.

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Conus Medullaris and Cauda Equina Syndromes

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    1. Conus Medullaris and Cauda Equina Syndromes Temple University Hospital November 22, 2006

    2. Outline of Discussion Introduction Anatomical Overview Conus Medullaris Syndrome Trauma As An Etiology Cauda Equina Syndrome Questions

    3. Introduction Conus medullaris and cauda equina syndromes are clinical entities Diagnosis based on clinical findings History and Physical Examination Diagnosis prompts emergent acquisition of appropriate radiographic workup Exclude psychogenic causes Identify the pathology to aid in formulation of a treatment plan Etiology is variable

    4. Introduction What’s the Difference? Idealistically Patients with conus medullaris syndrome typically present with symptoms consistent with: Spinal cord compression Spinal cord dysfunction “Intrinsic pathology” Patients with cauda equina syndrome typically present with symptoms consistent with: Lumbosacral radiculopathies “Extrinsic pathology” Practically There is much overlap in symptomatology Both require complete evaluation, including imaging, to manage appropriately

    5. Anatomical Overview For Zak For Bong Soo

    6. Anatomical Overview

    7. Conus Medullaris Syndrome Definitions Historically (i.e., in the “pure, classic” syndrome) defined as signs consisting of: Paralytic bladder incontinence Bowel incontinence Impotence Perineal sensory changes Absence of lower extremity weakness Presently, a constellation of signs and symptoms including: Bowel dysfunction Bladder dysfunction Sexual dysfunction Poor rectal tone Perianal sensory changes Sometimes, lower extremity weakness

    8. Conus Medullaris Syndrome Etiologies Tumor Vascular lesion Diabetic neuropathy Trauma Disc herniation

    9. Conus Medullaris Syndrome Symptoms Back pain Unilateral or bilateral leg pain Bladder dysfunction Bowel dysfunction Sexual dysfunction Diminished rectal tone Perianal sensory loss Lower extremity weakness

    10. Trauma As An Etiology

    11. Trauma As An Etiology Acute Spinal Cord Injury Syndromes in Trauma Patients Complete spinal cord injury ASIA/IMSOP Grade A Unilevel: no zone of partial preservation Multiple level: zone of partial preservation Incomplete spinal cord injury ASIA/IMSOP Grades B, C, and D Cervicomedullary syndrome Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown-Séquard syndrome Conus medullaris syndrome Complete cauda equina injury ASIA/IMSOP Grade A Incomplete cauda equina injury ASIA/IMSOP Grade B, C, and D Reversible or transient syndromes Cord concussion Burning hands syndrome Contusio cervicalis Hysteria

    12. Trauma As An Etiology Conus Medullaris Syndrome: Trauma Definition Combination of upper and lower motor neuron deficits, with initial flaccid paralysis of the legs and anal sphincter

    13. Trauma As An Etiology Conus Medullaris Syndrome: Trauma Symptoms Acute Phase Flaccid paralysis of the legs Paralysis of the anal sphincter Chronic Phase Muscle atrophy of the legs Lower extremity spasticity Lower extremity hyperreflexia Extensor plantar response may be present Development of a low-pressure, high-capacity neurogenic bladder Sensory deficits are variable

    14. Cauda Equina Syndrome Definitions Historically Bilateral sciatica Expanded to include unilateral sciatica What about a central disc herniation at L5-S1 sparing the motor and sensory roots of the lower extremities but affecting bowel and/or bladder function? The frequency of daily urination is much greater than bowel evacuation, so… Presently Bladder dysfunction with a decrease in perianal sensation

    15. Cauda Equina Syndrome Etiologies Disc herniation Disc fragment migration Iatrogenic epidural hematoma Post LP or spinal anesthesia Postoperatively Infection Tumor Trauma

    16. Cauda Equina Syndrome 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

    17. Cauda Equina Syndrome Avoid the Trap Acute central disc herniation at L4-5 or L5-S1 The sacral roots lie centrally within the dural sac Sparing of the lumbar, and even S1, roots may be present Total preservation of leg strength possible Bowel and bladder may be completely paralyzed Perineal anesthesia present The sacral roots are very delicate Recovery may not occur, even with relatively expeditious decompression

    18. Questions Please give two etiologies of conus medullaris and/or cauda equina syndrome Please recall the most common location for the end of the spinal cord in the adult human

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