Cauda conus syndromes
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Transcript of Cauda conus syndromes
CAUDA-CONUS SYNDROMES
DR. ANKUR NANDAN VARSHNEYDEPARTMENT OF GENERAL MEDICINE
IMS, BHU
A 21-yr- old male, unmarried
c/o:-1. Difficulty in urination X 2 ½ year2. Lower back pain X 2 year3. Pain in both lower limb with numbness X 2
year4. Weakness in right lower limb along with
thinning of limb X 1 year
CASE REPORT
Vitals = WNL
General Condition = within normal limit
CNS =1. Higher mental fxn WNL2. Cranial nerves = WNL3. Upper limb = WNL4. Findings confined to lower limb
Sensory1. Pain and temperature lost up to 20% - L2 level.2. In saddle area , sensation lost up to 90%.3. Vibration = 50% reduced right side4. mildly reduced on left side
On examination
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 left2. Mid thigh = 36 cm 37.5 cm3. Leg = 26.5 cm 28 cm
Tone = normal to slight decreased right side , left side WNL
POWER = Right Left
1. Hip flexion wnl wnl2. Hip adduction 4/5 5/53. Knee extension 4/5 5/54. Knee flexion 4/5 5/55. Dorsiflexion foot 3/5 5/5
REFLEXES = 1. Knee - -2. Ankle - -3. Abdominal WNL WNL4. Bulbocavernous - -5. Anal reflex -6. Anal tone reduced
Functional
Anatomical
Pathological
Etiological
Diagnosis
Anatomical Aspects
ETIOLOGIES VERTEBRAL1. Infections = TB2. Tumour affecting spine =
secondaries , multiple myeloma3. Lumbar spondylosis , PID4. Cong lumbar canal stenosis5. Spondylosis , spondyloarthrosis6. Spina bifida , tethered cord
syndrome7. Metabolic = osteoporosis ,
osteomalcia , osteosclereosis
NON VERTEBRAL1. Meningioma2. Neurofibroma3. Ependyoma4. Astrocytoma5. Epidural abscess6. Spinal arachnoiditis7. cyst- dermoid ,
epidermoid , hydatid8. Leukemia ,
lymphoma deposits.9. Intramedullary
deposits10. 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
Conus Medullaris Syndrome
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.
Conus Medullaris Syndrome
Etiologies◦ Tumor◦ Vascular lesion◦ Diabetic neuropathy◦ Trauma◦ Disc herniation
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
Conus Medullaris Syndrome
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
Cauda Equina Syndrome
Etiologies◦ Disc herniation
◦ Disc fragment migration
◦ Iatrogenic epidural hematoma Post LP or spinal anesthesia Postoperatively
◦ Infection
◦ Tumor
◦ Trauma
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
Cauda Equina Syndrome
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
Localistion of lesion
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
What’s the Difference?
CAUDA EQUINA SYNDROME
CONUS MEDULLARIS SYNDROME
CAUDA- CONUSSYNDROME
ROOT PAIN +++asymmetric
_ ++
MOTOR WEAKNESS
++ IN HIGH CAUDA+/- IN LOW CAUDA
+/- ++
SENSORY + SADDLE ANESTHESIA
+
REFLEXES ( knee , ankle, plantar , bulbocavernous)
++ in high+/- in low
visceral ( bladder , anal , bulbocavernous ) impaired
++
Sphinctor involvement
Late early Late/early
CONUS MEDULLARIS SYNDROME
CAUDA EQUINA SYNDROME
Presentation Sudden and bilateral Gradual and unilateral
Reflexes Knee jerk preserved but ankle jerks affected
Both affected
Radicular pain Less More
Low back pain More Less
Impotence Frequent Less
Sensory dissociation Present No dissociation
Numbness Symmetrical Asymmetrical
Motor strength SymmetricHyperreflexicDistal paresis of lower limbs
AsymmetricAreflexiaParaplegia
Sphincter dysfunction Present early Both urinary and fecal incontinence
Present laterOnly urinary retention