Conus Medullaris & Cauda Equina Syndrome

Leg weakness is flaccid and areflexic not spastic and hyperreflexic

By: Siti Nurulismah bt Che Haron

23/09/2012

Source: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006

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Source: Keith L. Moore and Anne Agur. Essential Clinical Anatomy, 3rd Edition
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Etiology
Trauma - Fracture, subluxation - Penetrating trauma Herniated disc - 90% at L4-L5 and L5-S1
Spinal stenosis - Developmental abnormality - Degenerative disease
Picture from: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006

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 Neoplasm - Primary (schwannoma, paraganglioma) - Metastatic (intracranial, lung, breast and renal cell ca)
Inflammations and infections - Paget disease, epidural abscess - Pyogenic and non pyogenic
Picture from: http://emedicine.medscape.com/

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 Iatrogenic - Misplaced pedicle screw, laminar hooks - Continuous spinal anesthesia

Picture from: http://www.science-art.com

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Conus Medullaris vs. Cauda Equina Syndromes

Conus medullaris syndrome Cauda equina syndrome

Vertebral level Spinal level

Presentation Radicular pain Low back pain Motor strength

L1-L2 Sacral cord segment and roots

Sudden and bilateral Less severe More Symmetrical, less marked hyperreflexic distal paresis of LL, fasciculation Ankle jerks affected Localized numbness to perianal area, symmetrical and bilateral Early urinary and fecal incontinence Frequent
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L2-sacrum Lumbosacral nerve roots

Gradual and unilateral More severe Less More marked asymmetric areflexic paraplegia, atrophy more common Both knee and ankle jerks affected Localized numbness at saddle area, asymmetrical, unilateral Tend to present late Less frequent
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Reflexes Sensory

Sphincter dysfunction Impotence

Illustration of saddle anesthesia; - The S5, S4, and S3 nerves provide sensory innervation to the rectum, perineum, and inner thigh.
Source: Journal of the American Academy of Orthopaedics Surgeons, http://www.jaaos.org

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Investigation
Radiology MRI Laboratory FBC, ESR Needle electromyography of the bilateral external anal sphincter muscles Lumbar puncture

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Sagittal and axial CT scans of thoracolumbar spine demonstrating an L4 burst fracture with retropulsion of bone into the spinal canal

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Source: Harrop, J. S., G. E. Hunt Jr, et al. (2004). "Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles." Neurosurgical Focus 16(6): 1-23. 23/09/2012

MRI image shows compression of the distal lumbar and sacral nerve rootles

Source: Harrop, J. S., G. E. Hunt Jr, et al. (2004). "Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles." Neurosurgical Focus 16(6): 1-23.
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Sagittal MRI images demonstrating large central disc extrusion at L5-S1 (arrows) with compression on the cauda equina.

Source: Levis, J. T. (2009). "Cauda equina syndrome." Western Journal of Emergency Medicine 10(1): 20.
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Method to Relieve Cord Compression

Discectomy - 1 2 Laminectomy

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Corpectomy
Source: http://www.spinesurgeon.co.uk/media/lumbar-corpectomy.jpg

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Prognosis
Important predictor of recovery - The extent of perineal or saddle sensory deficit Patients with unilateral deficits have a better prognosis than patients with bilateral deficits Females and patients with bowel dysfunction have been reported to have worse outcomes postoperatively
Source: - Shaw A, Anwar H, Targett J, Lafferty K. Cauda equina syndrome versus saddle embolism. Ann R Coll Surg Engl. Sep 2008;90(6):W6-8. - O'Laughlin SJ, Kokosinski E. Cauda equina syndrome in a pregnant woman referred to physical therapy for low back pain. J Orthop Sports Phys Ther. Nov 2008;38(11):721.
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Other references: - http://emedicine.medscape.com/article/1148690 - Oxford handbook of clinical medicine - Oxford handbook of clinical surgery - Apleys consice system of orthopaedics and fractures 3rd edition

THANK YOU

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