Prof. N. K.

Singh
DEPARTMENT OF GENERAL MEDICINE
IMS, BHU
 A 21-yr- old male, unmarried

 c/o:-
1. Difficulty in urination X 2 ½ year
2. Lower back pain X 2 year
3. Pain in both lower limb with numbness X 2
year
4. Weakness in right lower limb along with
thinning of limb X 1 year
 Vitals = WNL

 General Condition = within normal limt

 CNS =
1. Higher mental fxn WNL
2. Cranial nerves = WNL
3. Upper limb = WNL
4. Findings confined to lower limb
 Gait = unable to walk alone
try to avoid weight on right side
no apparent foot drop

 Motor examination =
1. Wasting of thigh and calf muscles.
right left
1. Mid thigh = 36 cm 37.5 cm
2. Leg = 26.5 cm 28 cm

 Tone = normal to slight decreased right

side , left side WNL
 POWER = Right Left
1. Hip flexion wnl wnl
2. Hip adduction 4/5 5/5
3. Knee extension 4/5 5/5
4. Knee flexion 4/5 5/5
5. Dorsiflexion foot 3/5 5/5

 REFLEXES =
1. Knee - -
2. Ankle - -
3. Abdominal WNL WNL
4. Bulbocavernous - -
5. Anal reflex -
6. Anal tone reduced
 Functional

 Anatomical

 Pathological

 Etiological
 VERTEBRAL  NON VERTEBRAL
1. Meningioma
1. Infections = TB 2. Neurofibroma
2. Tumour affecting spine = 3. Ependyoma
secondaries , multiple myeloma 4. Astrocytoma
3. Lumbar spondylosis , PID 5. Epidural abscess
6. Spinal arachnoiditis
4. Cong lumbar canal stenosis 7. cyst- dermoid ,
5. Spondylosis , spondyloarthrosis epidermoid , hydatid
6. Spina bifida , tethered cord 8. Leukemia ,
syndrome lymphoma deposits.
9. Intramedullary
7. Metabolic = osteoporosis , deposits
osteomalcia , osteosclereosis 10. Arterio- venous
malformations
◦ a constellation of signs and symptoms
including:
 Bowel dysfunction
 Bladder dysfunction
 Sexual dysfunction
 Poor rectal tone
 Perianal sensory changes
 Sometimes, lower extremity weakness
 Most distal bulbous part of spinal cord situated at
level of L1-L2 vertebral bodies and comprises of
sacral segments S1-S5.

 Signs shows involvement of:-

1. Saddle anesthesia ( S3-S5)
2. Absent Bulbocavernous reflexes ( S2-S4)
3. Absent anal reflexes ( S4-S5)

 Symptoms include both upper and lower motor

neuron lesions.
 Etiologies
◦ Tumor
◦ Vascular lesion
◦ Diabetic neuropathy
◦ Trauma
◦ Disc herniation
 Symptoms
◦ Back pain
◦ Unilateral or bilateral leg pain
◦ Bladder dysfunction
◦ Bowel dysfunction
◦ Sexual dysfunction
◦ Diminished rectal tone
◦ Perianal sensory loss
◦ Lower extremity weakness
 Cauda equina is the collection of nerve containing nerve roots
from L1-L5 and S1-S5.

 Most centrally located nerve roots are from most caudal

segments.

 Lesions give rise to lower motor neurons symptoms.

 Radicular pain is prominent and symptoms are usually

unilateral.

 Bladder dysfunction with a decrease in perianal sensation

 Etiologies
◦ Disc herniation

◦ Disc fragment migration

◦ Iatrogenic epidural hematoma

 Post LP or spinal anesthesia
 Postoperatively

◦ Infection

◦ Tumor

◦ Trauma
 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
 Distribution of pain / paresthesia in certain
dermatomes.

 Segmental / sensory changes

 Alteration in motor function ( weakness and

wasting )

 Reflex abnormalities

 Site of vertebral deformities and tenderness

 Imaging - X-ray , CT- myelo , MRI

 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”

 There is much overlap in symptomatology

 Both require complete evaluation, including
imaging, to manage appropriately
 CAUDA EQUINA CONUS CAUDA- CONUS
SYNDROME MEDULLARIS SYNDROME
SYNDROME

ROOT PAIN +++ _ ++

asymmetric

MOTOR ++ IN HIGH CAUDA +/- ++

WEAKNESS +/- IN LOW CAUDA

SENSORY + SADDLE +
ANESTHESIA

REFLEXES ++ in high visceral ( bladder , ++

( knee , ankle, +/- in low anal ,
plantar , bulbocavernous )
bulbocavernous) impaired

Sphinctor Late early late

involvement
 CONUS MEDULLARIS CAUDA EQUINA
SYNDROME SYNDROME
Presentation Sudden and bilateral Gradual and unilateral

Reflexes Knee jerk preserved but Both affected

ankle jerks affected
Radicular pain Less More

Low back pain More Less

Impotence Frequent Less

Sensory dissociation Present No dissociation

Numbness Symmetrical Asymmetrical

Motor strength Symmetric Asymmetric

Hyperreflexic Areflexia
Distal paresis of lower Paraplegia
limbs
Sphincter dysfunction Present early Present later
Both urinary and fecal Only urinary retention