Cauda Equina Syndrome& Spinal disorders

Dafydd LoughranF2 Wrexham Maelor

22nd July 2014

Recap on spinal anatomy and radiographic description

Disc herniation key facts Cauda Equina syndrome presentation &

management Other spinal cord injury patterns

Learning objectives

Bony anatomy

Spinal tracts

Corticospinal = Motor control to ipsilateral muscles

Dorsal colums = Fine touch,

vibration & proprioception

Spinothalamic = Crude touch, pain & temperature

Arterial supply

Anterior spinal artery• Supplies 2/3• Spinothalamic & corticospinal

tracts

Posterior spinal artery• Dorsal columns

Anterior cord syndrome, most commonly due to insufficiencies in the aorta (aneurysm/dissection/trauma), leads to disturbance of spinothalamic & corticospinal tracts.

Very poor prognosis

Cervical Spine – Radiograph lines

Important for describing alignments on radiographs.

Anterior vertebral line

Posterior vertebral line

Spinolaminar line

Posterior spinous line

• Predominantly lower back / leg pain

• Progression from disc protrusion – annulus fibrosus intact

• Tear in annulus fibrosus (outer) allows nucleus pulposus through

• Usually due to age related degeneration

• More rarely due to trauma• Usually resolve within a few weeks

without discectomy

Disc herniation

• Neurosurgical emergency• Based on incidence &

catchment around 5 would be expected yearly at WMH

• Most due to large central lumbar disc herniation at L4/5 or L5/S1

• Three Classic patterns of

presentation1. Acutely as first symptom of

disc herniation2. Endpoint of long history of

back pain due to herniating disc

3. Insidious progression to numbness & symptoms

Cauda Equina Syndrome (CES)

• Red Flag symptoms:• Severe lower back pain• Sciatica type pain• Saddle +/- genital sensory

loss• Bladder, bowel or sexual

dysfunction

• Defined as:1. Incomplete Cauda Equina

syndrome2. Cauda Equina syndrome

with urinary retention• Patients with urinary

retention have worse prognosis

Cauda Equina Syndrome (CES)

• History including time frame & bladder / bowel / sexual dysfunction

• Examination:• Full lower limb neuro including

reflexes• Perianal sensation & anal tone• Catheter tug sensation

• Clinical diagnosis even by neurosurgeons has 43% false positive rate so urgent MRI recommended

• If clinical features & MRI suggest reversible cause of pressure then need transfer to spinal centre for surgical decompression

CES - Management

• Some debate regarding urgency of surgery

• Most recent evidence shows that early (<24hrs) decompression does lead to better outcomes in incomplete CES

• Retrospective study noted that 87% recovered normal bladder function if <24hrs, compared to 43% if >24hrs.

• Inconclusive evidence regarding benefit of surgery & its timing in CES with retention

CES - Outcomes

Other differentials to consider from history: Tumour – either primary bone or metastatic cord

compression Epidural / subdural haematoma Infective pathology

Complete cord injury Due to major trauma Neither motor nor sensory below injury

level Minimal chance of functional recovery

Anterior cord syndrome Due to disruption / thrombosis of flow in

anterior spinal artery Motor, pain & temperature loss

bilaterally Poor prognosis

Other spinal cord injury patterns

Brown-Séquard syndrome Hemi-transection or unilateral compression Ipsilateral motor (corticospinal), proprioception &

vibration (dorsal columns) loss Contralateral pain & temperature (spinothalamic)

loss

Central cord syndrome Commoner following hyperextension in patient

with cervical spondylosis Greater motor weakness in upper than lower limbs Burning sensation in upper extremities common

Other spinal cord injury patterns

Recap on spinal anatomy and radiographic description Disc herniation key facts Cauda Equina syndrome presentation & management Other spinal cord injury patterns

Thank you,Any questions?

Learning objectives