Ortho_conus Medullaris and Cauda Equina Syndrome
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07/04/20231
Conus Medullaris &
Cauda Equina Syndrome
By: Siti Nurulismah bt Che Haron
‘Leg weakness is flaccid and areflexic
not spastic and hyperreflexic’
07/04/20232
Source: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006Source:
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
Conus medullaris syndrome
Cauda equina syndrome
Vertebral level L1-L2 L2-sacrum
Spinal level Sacral cord segment and roots
Lumbosacral nerve roots
Presentation Sudden and bilateral Gradual and unilateral
Radicular pain Less severe More severe
Low back pain More Less
Motor strength Symmetrical, less marked hyperreflexic distal paresis of LL, fasciculation
More marked asymmetric areflexic paraplegia, atrophy more common
Reflexes Ankle jerks affected Both knee and ankle jerks affected
Sensory Localized numbness to perianal area, symmetrical and bilateral
Localized numbness at saddle area, asymmetrical, unilateral
Sphincter dysfunction
Early urinary and fecal incontinence
Tend to present late
Impotence Frequent Less frequent
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Conus Medullaris vs. Cauda Equina Syndromes
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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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Radiology – MRI
Laboratory – FBC, ESR
Needle electromyography of the bilateral external anal sphincter muscles
Lumbar puncture
Investigation
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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
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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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.
MRI image shows compression of the distal lumbar and sacral nerve rootles
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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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Discectomy - 1 2 Laminectomy
Method to Relieve Cord Compression
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Source: http://www.spinesurgeon.co.uk/media/lumbar-corpectomy.jpg
Corpectomy
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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
Prognosis
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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THANK YOU
Other references:- http://emedicine.medscape.com/article/1148690- Oxford handbook of clinical medicine- Oxford handbook of clinical surgery- Apley’s consice system of orthopaedics and fractures 3rd edition
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