Cauda conus syndromes

1. CAUDA-CONUS SYNDROMES DR. ANKUR NANDAN VARSHNEY DEPARTMENT OF GENERAL MEDICINE IMS, BHU

2. A 21-yr- old male, unmarried c/o:- Difficulty in urination X 2 ½ year Lower back pain X 2 year Pain in both lower limb with numbness X 2 year Weakness in right lower limb along with thinning of limb X 1 year CASE REPORT

3. Vitals = WNL General Condition = within normal limit CNS = Higher mental fxn WNL Cranial nerves = WNL Upper limb = WNL Findings confined to lower limb Sensory Pain and temperature lost up to 20% - L2 level. In saddle area , sensation lost up to 90%. Vibration = 50% reduced right side mildly reduced on left side On examination

4. Gait = unable to walk alone try to avoid weight on right side no apparent foot drop Motor examination = Wasting of thigh and calf muscles. right left Mid thigh = 36 cm 37.5 cm Leg = 26.5 cm 28 cm Tone = normal to slight decreased right side , left side WNL

5. POWER = Right Left Hip flexion wnl wnl Hip adduction 4/5 5/5 Knee extension 4/5 5/5 Knee flexion 4/5 5/5 Dorsiflexion foot 3/5 5/5 REFLEXES = Knee - - Ankle - - Abdominal WNL WNL Bulbocavernous - - Anal reflex - Anal tone reduced

6. Functional Anatomical Pathological Etiological Diagnosis

7. Anatomical Aspects

8. ETIOLOGIES VERTEBRAL Infections = TB Tumour affecting spine = secondaries , multiple myeloma Lumbar spondylosis , PID Cong lumbar canal stenosis Spondylosis , spondyloarthrosis Spina bifida , tethered cord syndrome Metabolic = osteoporosis , osteomalcia , osteosclereosis NON VERTEBRAL Meningioma Neurofibroma Ependyoma Astrocytoma Epidural abscess Spinal arachnoiditis cyst- dermoid , epidermoid , hydatid Leukemia , lymphoma deposits. Intramedullary deposits Arterio - venous malformations

9. 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

10. 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:- Saddle anesthesia ( S3-S5) Absent Bulbocavernous reflexes ( S2-S4) Absent anal reflexes ( S4-S5) Symptoms include both upper and lower motor neuron lesions. Conus Medullaris Syndrome

11. Etiologies Tumor Vascular lesion Diabetic neuropathy Trauma Disc herniation Conus Medullaris Syndrome

12. 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

13. 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

14. Etiologies Disc herniation Disc fragment migration Iatrogenic epidural hematoma Post LP or spinal anesthesia Postoperatively Infection Tumor Trauma Cauda Equina Syndrome

15. 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

16. 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

17. 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?

18. CAUDA EQUINA SYNDROME CONUS MEDULLARIS SYNDROME CAUDA- CONUS SYNDROME 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

19. 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 Symmetric Hyperreflexic Distal paresis of lower limbs Asymmetric Areflexia Paraplegia Sphincter dysfunction Present early Both urinary and fecal incontinence Present later Only urinary retention

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