cauda equina syndrome and other emergencies€¦ · outcome and relationship to time of onset to...
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Cauda equina syndrome and other emergencies
Mr ND MendozaMr JT Laban
Charing Cross Hospital
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Definition• A neurosurgical spinal emergency is any lesion where a
delay or injudicious treatment may leave……• The patient
• The surgeon
• and the barristers
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Causes of acute spinal cord and cauda equinacompression
• Degenerative– Lx / Cx / Tx disc prolapse– Cx / Lx Canal stenosis– Osteoporotic fracture
• Trauma– Instability– Penetrating trauma– Haematoma– Iatrogenic e.g Surgiceloma
• Infection– Vertebral body– Discitis– Extradural abscess
• Tumour– Metastatic– Primary
• Vascular– Spinal DAVF
• Developmental– Syrinx / Chiari malformation
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Cauda Equina Syndrome
Kostuik JP. Controversies in cauda equina syndrome. Current OpinOrthopaed. 1993; 4 ; 125 - 8
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Lumbar disc prolapse
William Mixter
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Cauda Equina Syndrome : Clinical presentation
• Bilateral sciatica• Saddle anaesthesia• Sphincter disturbance
– urinary retention: check post-void residual• 90% sensitive ( but not specific )• Very rare for pt without retention to have cauda
equina– urinary / faecal incontinence– anal sphincter tone may be reduced in 60 - 80% pts
• Motor weakness / Sensory loss• Bilateral loss of ankle jerk
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Investigations
RadiologicalPlain X-rays
MRI
CT
Myelography
X
You’ll be lucky !
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Central disc prolapse35 yr female acute cauda equina syndrome
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Lumbar Canal Stenosis50 yr female with acute on chronic cauda equina syndrome
Congenital narrow canal + PID
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Management
• Decompression– Lx Laminectomy– Hemilaminectomy– Microdiscectomy
• Complications– Incomplete decomp.– CSF leak
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Outcome and relationship to time of onset to surgery
Cauda equina syndrome secondary to lumbar disc herniation : a meta-analysis of surgical outcomes.
Ahn UM et al . Spine 2000 : 25; 1515 – 1522‘ a significant advantage to treating patients within
48 hrs versus more than 48 hours after the onset of CES’
Loss of bladder function is associated with poor prognosis
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Outcome and relationship to time of onset to surgery
Cauda equina syndrome: the timing of surgery probably does influence outcomeTodd N.V. Br. J. of Neurosurgery. 2005; 19 : 301 – 306
Patients treated earlier than 24hrs after the onset of CES are more likely to recover bladder function than those treated beyond 24 hrs
Patients treated earlier than 48hrs after the onset of CES are more likely to recover bladder function than those treated beyond 48 hrs
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Cervical disc prolapse and spinal cord compression
• Usually traumatic– Axial loading with flexion
• Cord injury– Complete– Incomplete
Anterior cord syndromeCentral cord syndrome
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Acute cervical disc prolapse
33 yr male rugby player with acute tetraparesis following scrum collapse ( in front row but not a prop with contested scrum)
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Anterior Cervical Discectomy
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TumoursIf you are
wondering the scale is cm not
inches
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Tumour - Metastasis• Occur in 10% of cancer patients• 5 - 10% cancer present with cord compression
(the primary is often unknown)• Pain is first symptom in 95% of pts
– Localised, radicular• 75% have neurological deficit at time of
diagnosis• Median time from symptoms to diagnosis is 2
months• Referral is usually 4.59pm Friday night
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MRI : MetastasisSmall cell carcinoma : 60 yr male with acute paraparesiswith 8/52 history of back pain with radiation into abdomen
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Metastasis – can be anywhereBreast carcinoma
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Management
• Medical– Steroids
– Radiotherapy : External beam, Cyberknife
– Conservative
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Management
Acute cord compression and functional deficit
Obtain tissue diagnosisRadioresistant tumourNeurological progression
after DXTContra – indications
Poor prognosisMultilevel diseaseParaplegia > 24 hrs
• Decompressivelaminectomy
• Vertebrectomy• Decompression and
instrumented stabilisation
• Preoperative embolisation
• ? Vertebroplasty
Indications to consider surgery Surgical options
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Vertebrectomy46 yr female with isolated breast metastasis with acute pain and cord compression
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OutcomeDirect decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer : a randomised studyPatchell RA et al. The Lancet 2005; 366 :643-48
• Surgical decompression + / - fixation cf 30 Gy radiotherapy• Entry criteria
– Age > 18 years– Proven met with cord compression– Single lesion on MRI
• Exclusion criteria– Radiosensitive tumours, e.g., lymphoma, myeloma, germ cell– paraplegia > 48 hours– previous spinal irradiation– brain mets– survival < 3 months
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Outcome
Surgery– improves walking (122 vs 13days)– improves continence (156 vs 13 days)– improves Frankel score (functional ability)– need less steroids and opioid analgesia– live longer (126 vs 100 days) ………..– does not prolong hospital stay (median 10
days)
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Tumour - Primary
• Intradural, extramedullary– Schwannoma– Meningioma
• Intradural, intramedullary– Ependymoma– Astrocytoma
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Intradural Extramedullary Tumour : Neurofibroma
35 yr male with 18 / 12 persistant back and leg pain, with 48hr history of leg weakness and sacral anaesthesia
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Spinal intradural tumour : Neurofibroma
30 yr male with 12 / 12 history of arm pain and acute right arm and bilateral leg weakness
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70 yr female with tetraparesis and dysphagia
Delay in diagnosis until it became an acute problem
CRANIO – CERVICAL MENINGIOMA
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Spinal intradural tumour : Ependymoma
30 yr male with 48hr of ‘excruciating’ back pain with background back ache
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INFECTION
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Infection• Vertebral body, disc space, epidural• Risk factors
– Postop, IVDU, DM, haemodialysis, immunosupression, endocarditis• Bacterial ( Staph, E.Coli, Salmonella ) / Mycobacterium• Clinical presentation : Pain ++, neurological symptoms, pyrexia• Imaging – XRay, MRI, CT ( for Bx )• Diagnosis – CT Guided Bx ( 50% pos ), MC+S, AAFB, Gram stain
Treatment• Urgent decompression if cord compression ( esp. bacterial abscess) • Appropriate antibiotics
– Length of time – ask the microbiologists ( and add or subtract 3 months depending on answer! )
– Monitor inflammatory markers– If no response consider diagnosis – tissue and bacteriological, ?pt taking
treatment– Response to treatment - CRP, ESR
• Surveillance imaging– Deformity
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Spinal TB
43 yr female typical mechanical low back ache : Microcyticanaemia and local tenderness
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BEWARE DUAL PATHOLOGY !TB AND B CELL LYMPHOMA
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Bacterial Discitis34 yr female on steroids with renal failure and acute neck pain and rapid tetraparesis
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Epidural Abscess
35 yr male HIV, IV drug abuser with acute back and leg pain, leg weakness and sensory loss
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Trauma
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Cervical Spine Injury
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Cervical laminoplasty
Central Cord Injury
80 yr male hyperextension injury after fall
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Trauma - Penetrating• Gunshot wounds
– mostly handguns– thoracic > cervical > lumbar– instability is rare
• Knife wounds– increasingly common– consider vascular and other organ injury– Brown – Sequard syndrome due to cord hemisection
Contralateral : dissociated sensory loss,loss of pain and temperature (1-2 segments below) preserved light touchIpsilateral : loss of posterior column, motor paralysis
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Penetrating bullet wound to cervical spine
Management
? Value of decompression
Wound debridement and drainage
CSF leak may need Lx drain
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Trauma - PenetratingThere are somethings that cannot be treated……
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Epidural Haematoma
• > 30% associated anticoagulation• Traumatic
– LP, epidural anaesthesia, surgery• Spontaneous (rare)
– AVM, vertebral haemangioma• MRI
– Hypointense T1– Hyperintense T2
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Epidural Haematoma
50yr female with Cx Myelopathy, prev ACDF, CxLaminectomy. 2 hours post op tetraparetic ( on aspirin )
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Thank you