Conus Medullaris and Cauda Equina Syndromes

Temple University Hospital November 22, 2006

Presented by Darric E. Baty, M.D.

Outline of Discussion
Introduction Anatomical Overview Conus Medullaris Syndrome Trauma As An Etiology Cauda Equina Syndrome Questions

Introduction
Conus medullaris and cauda equina syndromes are clinical entities
Diagnosis based on clinical findings
History and Physical Examination

Diagnosis prompts emergent acquisition of appropriate radiographic workup

Exclude psychogenic causes Identify the pathology to aid in formulation of a treatment plan

Etiology is variable

Introduction
Whats the Difference?
Idealistically
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

Practically
There is much overlap in symptomatology Both require complete evaluation, including imaging, to manage appropriately

Anatomical Overview
For Zak For Bong Soo

Anatomical Overview

Conus Medullaris Syndrome

Definitions
Historically (i.e., in the pure, classic syndrome) defined as signs consisting of:
Paralytic bladder incontinence Bowel incontinence Impotence Perineal sensory changes Absence of lower extremity weakness Bowel dysfunction Bladder dysfunction Sexual dysfunction Poor rectal tone Perianal sensory changes Sometimes, lower extremity weakness

Presently, a constellation of signs and symptoms including:

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

Trauma As An Etiology

Trauma As An Etiology
Acute Spinal Cord Injury Syndromes in Trauma Patients
Complete spinal cord injury
ASIA/IMSOP Grade A Unilevel: no zone of partial preservation Multiple level: zone of partial preservation
ASIA/IMSOP Grades B, C, and D Cervicomedullary syndrome Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown-Squard syndrome Conus medullaris syndrome ASIA/IMSOP Grade A ASIA/IMSOP Grade B, C, and D Cord concussion Burning hands syndrome Contusio cervicalis Hysteria

Incomplete spinal cord injury

Complete cauda equina injury

Incomplete cauda equina injury Reversible or transient syndromes

Trauma As An Etiology
Conus Medullaris Syndrome: Trauma Definition
Combination of upper and lower motor neuron deficits, with initial flaccid paralysis of the legs and anal sphincter

Trauma As An Etiology
Conus Medullaris Syndrome: Trauma Symptoms
Acute Phase
Flaccid paralysis of the legs Paralysis of the anal sphincter

Chronic Phase
Muscle atrophy of the legs Lower extremity spasticity Lower extremity hyperreflexia
Extensor plantar response may be present

Development of a low-pressure, high-capacity neurogenic bladder

Sensory deficits are variable

Cauda Equina Syndrome

Definitions
Historically
Bilateral sciatica
Expanded to include unilateral sciatica

What about a central disc herniation at L5-S1 sparing the motor and sensory roots of the lower extremities but affecting bowel and/or bladder function? The frequency of daily urination is much greater than bowel evacuation, so

Presently
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

Avoid the Trap
Acute central disc herniation at L4-5 or L5-S1
The sacral roots lie centrally within the dural sac Sparing of the lumbar, and even S1, roots may be present
Total preservation of leg strength possible Bowel and bladder may be completely paralyzed Perineal anesthesia present

The sacral roots are very delicate

Recovery may not occur, even with relatively expeditious decompression

Questions
Please give two etiologies of conus medullaris and/or cauda equina syndrome Please recall the most common location for the end of the spinal cord in the adult human