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